Resilience and Growth in the Face of a Pandemic

Eight weeks ago, we kept hearing in the US: “Prepare yourselves. Where Italy is now with COVID-19, the US will be in 2 weeks.” Sure enough, in the last 6 weeks, we have seen New York hospitals inundated with cases, resorting to the distressing reality of refrigerator trucks being used as makeshift morgues.

Now that cases in Italy have begun a slow decline, it appears that there is a new storm brewing: the mental health impact of COVID-19. The combination of the protracted shelter-in-place requirements, the significant number of deaths, and grief compounded by many of these deaths occurring without family present or without the ritual of a funeral, has led to a combination of anxiety, listlessness, depression, and demoralization. Compounding matters is the mounting economic toll, with job loss at record numbers and small business owners hurting without the safety net of an unemployment system. Here in the US, this has led to armed protestors convening on the steps of state capitols, demanding the reopening of businesses and an end to shelter in place orders.

In the middle of a crisis, it is difficult to plan ahead, but that is what we must do now, not only for those impacted by this current wave of the COVID-19 pandemic, but also to build inner resilience to care for those who may be impacted by a coming wave in the fall (if the virus should behave as the 1917-18 influenza disease did, with the second half of the pandemic far more consequential than the first half). Not only will this resilience help us with future challenges, it will help to create the space in which meaning and post-traumatic growth can emerge.

MORE: The Search for Acceptance and Meaning in COVID-19

Most of us in mental health are used to working in tertiary care roles—that is, we treat people after prevention and self-treatment failed to work. This is important work, but there is a lot we can do before that. Primary prevention attempts to address problems before they begin. This will be important to help prevent people from developing psychiatric problems. The secondary level is focused on preventing impact on more vulnerable populations. Tertiary care begins with primary care providers and is backed up by psychiatric specialists. It is through bolstering the primary and secondary levels of care that we can begin to build the resistance we need to prevent post-traumatic stress from this pandemic.

Primary prevention seeks to prevent illness and wellness practices are an important component for building resilience. It’s easier to practice resilience when we’re starting from a base of our basic needs being met, and right now, some people are struggling with things like the loss of an income or their health. Here’s what I’m doing, and while I’m not necessarily prescribing these steps for anyone else, perhaps they can get you thinking about what works for you to build your own resilience.

• I’m meditating: not very much, and probably not very well, but after I wake and before I get pulled into the busyness of my day, I sit on my cushion for a few minutes and try to allow a slow emergence between the nighttime sea of sleep and the daytime terra firma. Steven Batchelor, author of Buddhism Without Beliefs, recently described in an interview how the intentional practice of solitude that we get from meditation creates the possibility of autonomy from being controlled by the events of the world. It is in this meditative space that we can practice this autonomy.

• I get out and ride my bike. I was an avid bike commuter before all of this started. Riding my bike home along the ocean is one of the best little joys in the week. Sadly, my bike was stolen in the midst of all of this, but I’m looking forward to getting back out on the road soon with the wind in my face.

• I’m taking long walks; the kind where you leave the house and you don’t know exactly where you’re going, but they allow for the ruminative thoughts to drop off and for novel ideas to rise to the surface.

• I’m noticing beautiful things and sharing them. I have been taking photographs on my walks and sharing them with friends on social media. It’s a nice change from the drumbeats of bad news.

• I’m sleeping more. This is more of an unexpected benefit of not having access to the pool where I do my morning laps. I’m allowing myself to wake up without an alarm. As such, I’m more rested and I notice my dreams more.

• I’m cooking more. While I miss a good restaurant meal with friends, I’m enjoying seeing what I can make in the kitchen. My latest effort was a nasturtium hot sauce from some flowers I picked while out walking. It’s pretty good on eggs.

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• I’m spending more time with family. Every night, we eat together, and then walk a mile around the neighborhood. It’s good for body and soul.

• I’m reading more. When the events of the world become too much, getting lost in the pages of a book is a welcome comfort. But not all my reading is escapism—recent reads: Rebecca Solnit’s A Paradise Built in Hell and Albert Camus’ The Plague, provided a historical and a fictional perspective on times of tremendous peril and great promise. It is through these journeys that I remember that my house may be small, but my confines of the mind are only as small as you make them.

• I’m more connected to friends and colleagues than ever. This was surprising. While I haven’t seen friends or colleagues outside of a Zoom window for weeks now, my email is buzzing with conversations about ideas and projects. This has both nourished me and given me hope for the future.

These routines and rituals have helped me create the containers I have lost with my daily routines now disrupted by sheltering in place and working and learning from home. I want to continue them when we have returned to “normal life.” Strengthening secure attachments will help us weather this storm. We can become mindful of how the stories we tell ourselves about the pandemic influence how we think and feel. Resiliency research and Acceptance and Commitment Therapy have shown that people who feel like they were able to use their core values—their identity—to feel that they had more control, were impacted less by traumatic events.

Secondary prevention targets those who are most at risk for negative outcomes. Those who are at higher risk for developing mental health complications will need additional care during and after the pandemic. Creative programs such as the one announced by California Governor Gavin Newsom to pay restaurants to cook meals for homebound seniors is the kind of novel thinking that addresses multiple at-risk groups—small business owners hurt by shelter-in-place orders and seniors who might not otherwise have contact with others (as noted in the Italian video above, the visits from delivery volunteers were as psychologically nourishing as the food that was being brought to them). Other populations who need special attention are children who have lost the structure of school, our homeless who cannot shelter in place, and those stuck at home in abusive relationships. 

Sadly, the American mental health infrastructure was stretched thin before this crisis ever began and the system will not be sufficient, unless significantly expanded, to meet the mental health needs created by COVID-19. Even if that happens, there will be a lag time between the emergence of the need and the meeting of that need by the mental health system. Mental health care is a specialized skill, and specific training is required to manage the most severe cases.

Emergency medicine also requires significant training, but this does not preclude first responders and good Samaritans from helping in an accident. In the same way, lay people can learn to deliver the basics of psychological first aid. So how can we bolster the skills of our communities to prevent mental illnesses in the first place and to treat the early impacts of this calamity themselves, so that tertiary mental health services that we deliver in our clinics and hospitals can be reserved for the people who need them the most?

Psychological first aid can get us through the start of the crisis, but we will need to do more than just stop the emotional bleeding. We need to think about how we can grow and be stronger from this event. We need to be thinking about post-traumatic growth (PTG). PTG occurs when we are able to take an adverse event and turn it into a deeper appreciation for life and our relationships. Finding meaning in a trauma is an important component of PTG and is often created through increased openness and willingness to connect with others. It is through openness to new experiences and perspectives that we can be surprised by what we learn from adverse events.

In some ways, it feels premature to try to understand how I will grow through this event. I struggled deeply to try to answer this question. I think what I came to in struggling with writing this blog was that we can’t really know what our post-traumatic growth will look like, but that we can—through resilience exercises that include exercise, connection, meaning, intellectual and aesthetic stimulation, meditation, and sensory enjoyment—create a container into which the answer to that question can emerge. That’s why wellness and resilience is so important, because it keeps that space open. If the space is crushed, or filled with detritus, nothing can grow into it. Each person will have to figure out what that growth looks like, but the means of maintaining resilience are similar. Many, understandably, are doing all they can just to cope and get by. What I realized is that the point is not yet to answer this question, but rather to maintain ourselves and create the space for the answer to that question to naturally emerge. We can, as Rainer Maria Rilke encouraged his young poet, live into the questions.

In what ways do you think you are growing from this experience? What is keeping you resilient in these difficult days? I encourage you to share in the comments below.

Andrew Penn, RN, MS, NP, CNS, APRN-BC was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.