Staying Sane in Quarantine

by Dr. Jim Raines


Introduction

Like most of the world right now, I’m in quarantine to avoid contracting the COVID-19 virus. I’m one of the people in double jeopardy – I am over 65 and I have chronic asthma. My wife works in a high-risk occupation as a nurse in a clinic. Despite my age, I’m still working full-time, but doing it from home. Most of my students are minority and poor and live in complex family situations. Several have struggled with mental health problems during the quarantine.



Psychological Effects of Quarantine

First, we have to recognize that, for youth, COVID-19, is a new adverse childhood experience (ACE). It will be more strongly felt by those with pre-existing ACEs, such as child abuse, divorce, domestic violence, neglect, substance use, etc. As the original ACE study discovered, most adults have at least one ACE, but the effects of ACEs are not just additive, they’re exponential. For those who had experienced four or more, they were 4 to 12 times more at risk for alcoholism, drug abuse, depression, and suicide attempt (Felitti, et al., 1998). That original finding has been backed-up by more recent research showing that youth who have poor coping skills are more likely to respond by yelling, crying, or ruminating on negative thoughts (Vaughn-Coaxum, et al., 2018).


Brooks and colleagues (2020) just completed a literature review on the effects of quarantine and found that people were more apt to exhibit post-traumatic stress symptoms, be confused about their disease status, worry about infecting others, and demonstrate irritability and anger. These effects were even stronger among those who were poor, involuntarily separated, had pre-existing mental conditions, and quarantined for long periods. It’s easy to understand why, with the unemployment rate now at 20% and rising, some families have had to consolidate living quarters and home-school children of family members lucky enough to still work. For school mental health providers, it important to recall that the DSM-5 has a parenthetical note on its first criterion for major depressive disorder, that in children and adolescents, depression may exhibit as an “irritable mood” (APA, 2013, p. 160). Put all these risk factors together under one roof exacerbates the risks for everyone in the household.


While most of us shake our head in disbelief about young people who host COVID-19 parties, congregate on packed beaches during spring break, or join adults in protesting the quarantine, it’s more helpful to see these behaviors as a manifestation of death anxiety that Ernest Becker (1973) talked about in his Pulitzer prize-winning work of nonfiction, the denial of death. Burke and associates (2009) conducted a meta-analysis of this theory and found that people were more likely to engage in riskier decision-making when they were reminded of their own mortality. Males may be especially prone to this problem due to cultural injunctions about masculinity or machismo. Pollack (1998) talked about how boys are raised to never show weakness, “give ‘em hell,” be the big wheel, and avoid “sissy stuff” such as admitting feelings of depression or anxiety (pp. 23-24).


Social Effects of Quarantine

When people live in cramped conditions for long periods of time, it’s understandable that they can get on each other’s nerves. Seddighi and colleagues (2019) conducted a systematic review and found that child abuse increases during natural disasters and prolonged conflicts (like war). The risk was heightened for families with lower socioeconomic status, facing greater social and economic pressures. Likewise, Rao (2020) found that intimate partner violence also goes up during natural disasters. It’s not hard to understand why, Lowe and others (2017) found that use of alcohol and substance use, both disinhibitants, also increased during natural disasters. So those of us who care about youth, must also be concerned about how to help the adults in their lives cope with the stress of quarantine.



How to Help

In my webinar on ethics in an epidemic (Raines, 2020), I pointed out that despite our physical separation from students, we must continue to provide social connection. (It’s the reason I refuse to use the term “social distancing.”) Even if we feel incompetent with technology, it’s important to overcome our own insecurities and learn new ways to connect. There are some distinct benefits of connecting electronically. It can be like a virtual home visit, where you can see (and meet) other family members, their home, and even their pets. The one thing we cannot do is resort to clinical abandonment during a national emergency (Barsky, 2020).


Youth thrive under two conditions: nurture and structure (Cline & Fay, 2006). First and foremost, let students know that you care about them more than their schoolwork. Be human and let them see your technological weaknesses, but do your best to have some face-to-face contact. Mehrabian (2008) hypothesized that, during emotional communication, the actual words account for only 7% of the speaker’s meaning, with paraverbal cues being 38% and nonverbal cues 55%. Even if his numbers are exaggerated, it’s hard to tell how someone is really feeling via text message or emails. Like it or not, seeing your face can be comforting to a student who has lost contact with so many others. Second, recommend to both parents and students, that they maintain a schedule during the quarantine. The schedule may need to be modified from the one when they’re at school with shorter periods of work mixed with short period for breaks and require more adult supervision. Furthermore, breaks should be non-electronic rather than just a switch to social media or video games.


Now that students are spending far more time looking at screens, it’s even more important to digitally disconnect. As Price (2018) says in her bestselling book, how to break up with your phone, we can turn off the constant notifications, keep the phone away from the dining table, create “phone free” zones in the house, such as bathrooms or bedrooms, and leave the phone at home when going on walks or bike rides. Encourage family socializing through board games, cards, charades, or jigsaw puzzles. Pick up a book to read or reread. Play a musical instrument or do an art or craft project.


Finally, remember the basics of self-care (for both yourself and your students). First, it’s important to eat well and have a balanced diet of fruits, vegetables, and protein. Second, it’s important to get some physical exercise everyday and it will help stave off that “quarantine 15.” Third, it’s important to socialize with supportive peers or adult caregivers. This might mean phoning an old friend across the country or “face-timing” distant relatives. Finally, good sleep hygiene is important to mental health, so a regular bedtime should be maintained even when students are “off” from school.


Managing Emergencies

Mental health emergencies can happen at any time, including pandemics. If a student or family member is feeling suicidal, be sure you know their location. Then do a simple assessment for the following warning signs: persistent suicidal ideation, strong suicidal intention or plan, poor impulse control, or a recent suicide attempt or preparatory behavior (McGinn, et al., 2019). While you maintain (visual) contact, be sure that someone dials 911. If you deem that the risk for suicide is high, try have non-family members (police or EMTs) do the transportation to the hospital so the student is unable to dissuade them. Be sure to get verbal permission (and document it) to talk to emergency personnel or community mental health providers. Follow-up with the family more frequently than before the emergency to make sure that after-care recommendations are being followed.


Conclusion

Very few of us ever imagined being in these circumstances. Even my nearly 99-year-old mother doesn’t remember the 1918 Spanish flu. We all have different capacities to serve at this point. Some of us are in sandwich generations, caring for children and older adults at the same time. So, it’s helpful to remember what Reamer (2014) says about the standard of care: it’s what an ordinary, reasonable, and prudent professional with similar training would do under similar conditions. The word that I want you to underline above is the word, ordinary. We’re just ordinary people trying to do our best in extraordinary times. Stay safe and stay well.



Bio

James C. Raines, Ph.D., calls himself an accidental academic with the heart of a practitioner. He has been President of the Illinois Association of School Social Workers, Midwest Council of School Social Workers, and the School Social Work Association of America. He has written four books published by Oxford University Press, most recently Evidence-based practice in school mental health: Addressing DSM-5 disorders in schools. He was the Department Chair of Health, Human Services and Public Policy at California State University Monterey Bay from 2010 - 2016. He is currently a full professor of social work and teaches courses in ethics and social work practice.

References


American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.


Barsky, A. (March, 2020). Ethical exceptions for social workers in light of the COVID-19 pandemic and physical distancing. The New Social Worker.


Becker, E. (1973). The denial of death. New York: Simon & Schuster.


Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (March 14, 2020). Psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395(102237), 912–920.


Burke, B. L., Martens, A., & Faucher, E. H. (2009). Two decades of terror management theory: A meta-analysis of mortality salience research. Personality and Social Psychology Review, 20(10), 1–41.


Cline, F., & Fay, J. (2006). Parenting with love and logic. Colorado Springs, CO: NavPress.


Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study. American Journal of Prevention Medicine, 14(4), 245–58.


Lowe, S. R., Sampson, L., Young, M. N., & Galea, S. (2017). Alcohol and nonmedical prescription drug use to cope with posttraumatic stress disorder symptoms: An analysis of Hurricane Sandy survivors. Substance Use & Misuse, 52(10), 1348-1356.


McGinn, M. M., Roussev, M. S., Shearer, E. M., McCann, R. A., Rojas, S. M., & Felker, B. L. (2019). Recommendations for using clinical video telehealth with patients at high risk for suicide. Psychiatric Clinics of North America, 42, 587–595.


Mehrabian, A. (2008). Communication without words. In D. C. Mortensen (Ed.),

Communication theory (2nd ed., pp. 193-200). New Brunswick, NJ: Transaction Publishers


Pollack, W. (1998). Real boys: Rescuing our sons from the myths of boyhood. New York: Henry Holt & Co.


Price, C. (2018). How to break up with your phone. New York: Crown Publishing.


Raines, J. C. (April 3, 2020). Ethics in an epidemic. SSWAA webinar.


Rao, S. (2020). A natural disaster and intimate partner violence: Evidence over time. Social Science & Medicine, 247, Article 112804


Reamer, F. G. (May, 2014). The concept of the standard of care. Social Work Today.


Seddighi, H. et al. (2019). Child abuse in natural disasters and conflicts: A systematic review.

Trauma, Violence, & Abuse, doi: 10.1177/1524838019835973


Vaughn-Coaxum, R. A., Wang, Y., Kiely, J., Weisz, J. R., & Dunn, E. C. (2018). Associations between trauma type, timing, and accumulation on current coping behaviors in adolescents: Results from a large, population-based sample. Journal of Youth & Adolescence, 47(4), 842-858.

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