Long Covid is very far from ‘all in the mind’ – but psychology can still help us treat it
As the UK nears what will hopefully be the end of lockdowns and high death tolls, our doctors and nurses are left to deal with a worrying secondary aspect of the pandemic in the shape of long Covid. There are more than 1 million people with long Covid in the UK alone, amounting to a human and medical emergency, with potentially a huge impact on society and the workforce. A clinical picture is emerging, with many patients reporting similar symptoms including shortness of breath, difficulty in concentration, body aches, persistent fatigue and other symptoms. The illness has been recognised in the US, Europe and elsewhere. Moreover, long Covid has parallels with CFS/ME, a debilitating condition that has similar symptoms.
Unfortunately, in the face of all this suffering, advances in science and clinical care are being jeopardised by an antiquated and unhelpful debate on whether these symptoms are “in the mind”, as if they were a fantasy or a dream. Of course, long Covid and CFS/ME symptoms are not in the mind. No symptoms are. Unfortunately some people with CFS/ME or, more recently long Covid, have been dismissed by health professionals. Some patients might have felt not taken seriously by their doctor while others might have lost the opportunity to benefit from a broader, psychosocial approach.
I am a medical researcher and clinician who specialises in the biological communication between the body and the brain. I can assure you that every symptom and every disorder, regardless of whether it is called mental or physical, is characterised by measurable biological changes in the body and in the brain. We may not know yet if these changes are the cause of the symptoms, but these biological changes are very real even if we cannot fully understand them.
Interestingly, the same biological mechanisms can often be triggered by diverse events. Both life eventsand infections activate the immune system, with common effects on the brain and the body, resulting in both depression and fatigue. It is not at all surprising that most patients with CFS/ME recognise either a severe life event or an infection at the onset of their illness.
Indeed, even the historical distinction between a mental and a physical disorder is fuzzy when we look at individuals rather than clinical labels. This distinction was never intended to explain the cause of a disorder but rather to describe its main manifestations: that is, abnormal emotions or behaviour for mental disorders versus abnormal functions of the heart, the lungs or other organs for physical disorders.
Moreover, mental and physical disorders are often present together in the same person. Many people with cardiovascular disease and diabetes also have depression, and there are many other similar combinations of diseases. Mental disorders, such as anxiety, depression, schizophrenia or bipolar disorder, have measurable biological changes not only in the brain but also in the body: changes in the blood, saliva and urine, in the heart and the digestive systems. The idea that there is a clear mental health versus physical health distinction has changed in recent years toward treating the health of the person as a whole.
The fact that all symptoms and disorders have underlying biological changes does not diminish the strong evidence that symptoms and disorders can be influenced by “psychological factors”. Many people fully acknowledge that our health can be influenced by what happens in our lives and how we feel about those things – both negative and positive.
Stressful life events, such as bereavement, unemployment, incidents of abuse and violence, poverty or discrimination, can precipitate or exacerbate both mental and physical disorders. These events can lead to hypertension, an autoimmune flare-up, a cardiovascular problem or depression. Why would we want to separate these health impacts and put depression, or any mental disorder, in a separate box to the rest?
Conversely, changes in lifestyle and behaviour, and psychological therapies (which work by challenging unhelpful ways we think about ourselves and world around us), have been shown to help patients with physical disorders including cancer, irritable bowel syndrome, diabetes, multiple sclerosis and stroke, to name just a few.
This point is particularly important in the context of CFS/ME and, more recently, long Covid. Offering lifestyle changes or psychotherapeutic approaches to these patients does not mean that their symptoms are “not real”. Medics routinely help cancer patients with these approaches every day, yet I never hear anyone accusing doctors of suggesting cancer is all in the mind.
There is also good evidence that all types of symptoms can be influenced by anticipation and beliefs, as has been demonstrated many times with the powerful placebo and “nocebo” effects. Being offered something believed to be positive (for example, an empty capsule that we believe to contain a medication) or negative (an empty capsule we believe to contain a toxin) will make our symptoms better (placebo) or, respectively, worse (nocebo). This is not snake oil for the gullible: these are biological effects based on measurable changes in the brain and the body, and can occur in everybody. This is why the standard evaluation of a novel treatment for any disorder – including the very real Covid infection – requires a comparison with a dummy treatment, so that our expectations, positive or negative, do not influence the results. This concept is particularly relevant in the context of the recent controversy around a Guardian article on this topic, and the response it has received.
Patients being told their symptoms are in their mind is completely unacceptable to every doctor I know, and such attitudes have no place in modern medicine. But this dismissive approach has nothing to do with the important clinical understanding that psychological factors and approaches can influence these conditions, as they do any other illness. Those who reject the notion that psychological approaches can help us better understand and treat physical symptoms are themselves falling, perhaps inadvertently, into the trap of differentiating and stigmatising mental illness.
We need every tool in the box to treat long Covid – and it must be hoped that the new focus and funding on this condition may also provide us with new and useful insights into treating CFS/ ME patients.
Carmine M Pariante is professor of biological psychiatry at King’s College London and editor of the blog platform Inspire the Mind
and other inhuman acts” as systematic attacks on the Black community that meet the definition of such crimes.
They also call on the prosecutor of the international criminal court (ICC) in The Hague to open an immediate investigation with a view to prosecutions.
“This finding of crimes against humanity was not given lightly, we included it with a very clear mind,” Hina Jilani, one of the 12 commissioners who led the inquiry, told the Guardian. “We examined all the facts and concluded that that there are situations in the US that beg the urgent scrutiny of the ICC.”
Among its other findings, the commission accuses the US of:
violating its international human rights obligations, both in terms of laws governing policing and in the practices of law enforcement officers, including traffic stops targeting Black people and race-based stop and frisk;
tolerating an “alarming national pattern of disproportionate use of deadly force not only by firearms but also by Tasers” against Black people;
operating a “culture of impunity” in which police officers are rarely held accountable while their homicidal actions are dismissed as those of just “a few bad apples”.
The commissioners also charge that African Americans are frequently subjected to torture at the hands of police. They assert that the use of chokeholds and other violent restraints during arrests are tantamount to torture – also a crime against humanity under international law.
Jilani, who is president of the World Organisation Against Torture, said that last week’s guilty verdict in the Floyd killing substantiated the commission’s views. “It clarified for us that the use of force during the arrest of an individual is not just dehumanizing, it clearly amounts to torture and potential loss of life.”
The report arose directly out of the foment that swept the country in the wake of Floyd’s murder last May. As protests erupted across the nation and around the world, the families of Floyd and other Black people killed by police in recent years petitioned the UN to set up an official inquiry into the shootings.
Under intense pressure from the Trump administration, however, the UN shrank from being drawn into the debate. A coalition of three leading lawyers’ organizations – the US-based National Conference of Black Lawyers and the National Lawyers Guild, and the worldwide International Association of Democratic Lawyers – stepped into the breach, joining forces to stage their own independent inquiry into US police brutality.
A panel of commissioners from Africa, Asia, Europe, Latin America and the Caribbean was assembled to look into police violence, and the structural racism that underpins it. Virtual public hearings were held earlier this year, with testimony from the families of the victims of some of the most notorious police killings in recent times.
Among the 44 black people who died or were maimed by police and whose cases were put under the commission’s spotlight were: Floyd; Sean Bell, killed on his wedding day in 2006 after police fired 50 bullets; Eric Garner, who died in a chokehold in 2014 crying “I can’t breathe”; Tamir Rice, the 12-year-old playing with a toy gun shot in 2014 seconds after police arrived; Michael Brown, the unarmed 18-year-old whose killing ignited the Black Lives Matter movement; Freddie Gray who died in 2015 after enduring a “rough ride” in a police van; and Breonna Taylor, killed as she was sleeping in a police raid on her home in March 2020 in Louisville, Kentucky.
On Monday, the US Department of Justice announced that it was holding a civil rights inquiry into police practices in Louisville.
Jilani told the Guardian that as a native of Pakistan who has participated in many UN investigations probing human rights abuses, she is familiar with accounts of extreme brutality by law enforcement. “But even I found the testimonies we heard in the US extremely distressing. I was taken aback that this country, which claims to be a global champion of human rights, itself fails to comply with international law.”
She added that as she listened to relatives of police shooting victims relate their stories, “it became clear that this was no longer an account of individual trauma, it was an account of trauma inflicted on a whole section of the US population.”
The commission’s report puts the human impact of systemic discrimination against African Americans in stark terms. It says that the US is operating two systems of law.
“One is for white people, and another for people of African descent,” it said.
In the course of the public hearings held in January and February, relatives gave a more personal impression of what such trauma entails. Nicole Paultre Bell, the wife of Sean Bell, testified: “Imagine living in a world where you must explain to your children that their father, an unarmed bridegroom on the morning of his wedding, can be justifiably killed in a hail of 50 police bullets.”
One of the most visceral accounts was given by Dominic Archibald, the mother of Nathaniel Pickett who was gunned down by a police officer in 2018 for doing nothing other than walking unarmed across the street. In her testimony, Archibald began by explaining that “Nate” was her only child.
“He was my legacy, my faith in the present moment, and my hope for the future. Can I ever put this impact into words? Would anyone ever understand?” she said.
Answering her own question, she went on: “That answer is no. Nate was my perfect gift from God. When he was killed, every hope and dream in my head was destroyed, taken and relegated to a statistic.”
The report gives its own searing figures. Unarmed Black people are almost four times as likely as their white equivalents to be killed by police.
Since 2005, about 15,000 people have been killed by law enforcement – a rate of about 1,000 every year. During that same period only 104 police officers have been charged with murder or manslaughter in relation to the incidents, and of those only 35 were convicted of any crime.
The commissioners make a number of demands on the US government and Congress. They want to see demilitarization of local police forces, and prohibition of no-knock warrants that allow officers to raid the homes of Black people like Breonna Taylor’s without warning and often without cause.
They also want an end to qualified immunity through which police officers avoid civil lawsuits. The commissioners say the loophole “amounts to condoning brutal police violence”.
But the most contentious demand is likely to be the call on the ICC prosecutor to launch an investigation against the US for crimes against humanity. It is questionable how effective that tactic would be even were such an inquiry started, given that the US has refused to recognize the international criminal court.
Jilani said she hoped that the US government would see that such an action would support much needed change. “We felt that the US would benefit were individual police officers further deterred from resorting to unjustified force, knowing that some kind of international criminal responsibility might be held against them.”
I was taken aback that this country, which claims to be a global champion of human rights, itself fails to comply with international law
Hina Jilani
something of an unknown quantity but it’s being released by A24 (who have had awards success with Moonlight, Lady Bird and, most recently, Minari) and in telling the story of a soldier returning from Afghanistan with a brain injury yet from young, well-respected theatre director Lila Neugebauer, it has the potential to deal with a serious issue yet from an intriguing, un-gungho viewpoint.
Ruth Negga
During 2020’s traditional in-person Sundance film festival, stacked with bigger movies, we’d seen three of the best picture nominees, a major result even on a normal year but with it all stripped back to a modest virtual lineup this time around, it was harder to predict many nominees-in-waiting. The most likely of which would appear to be Ruth Negga, who ever since she nabbed a nod for best actress for her indelible performance in Loving, has been somewhat quiet on the big screen (just a small role in Ad Astra to speak of). While small screen work (she’s starred in four seasons of Preacher) and a major role as Hamlet on stage have kept her busy, it could be a supporting turn in Rebecca Hall’s directorial debut Passing that thrusts her back into the spotlight. It’s a vibrant, alluring performance that steals the film away from her co-stars and a thrilling reminder of Negga’s magnetic yet underused presence.
Kristen Stewart
We’re now far past the rather patronising astonishment that yes an actor from a major teen franchise could spend most of her career since starring in well-respected indies but while Kristen Stewart has accumulated a great deal of acclaim post-Twilight, she’s yet to make the leap from critics circle prizes to the Oscars. If anything were to change that it would be Spencer, the much-anticipated new drama that sees her taking on the role of Princess Diana, teased already in a set of promising new images. The accent remains a concern for anyone who’s seen Snow White and the Huntsmen (Stewart herself referred to it as “intimidating as all hell”) but with Pablo Larraín at the helm, who previously led Natalie Portman to a nomination for Jackie before producing the best international feature Oscar-winning A Fantastic Woman, it’s safe to be cautiously confident in the execution.
Paul Thomas Anderson
The arrival of a new Paul Thomas Anderson project is usually something to get excited about, especially within a season that can often be without surprise, his films continually upending any expectations we might have. The Academy fawns over him, with eight nominations to date (from Boogie Nights to Magnolia to There Will Be Blood), and with many considering his last, Phantom Thread, to be his best, expectations are high for what’s coming next. As with most of his films, little is known, but the intriguingly titled, and soon-to-be ridiculed, Soggy Bottom will follow a high schooler who dreams of being an actor in the 70s with help from a director played by eight-time nominee Bradley Cooper. Anderson is an awards-magnet even without a film about film at play (something the Academy cannot help but fall for) so expect this one to feature in a number of categories.
Denzel Washington
There’s so much love for Denzel Washington within the Academy that even when the actor is having a widely agreed upon off-day, as with 2017’s under-appreciated legal drama Roman J Israel (note: Washington’s off-day is better than most when they’re on), he’s still able to secure a nomination. In his career, the multi-hyphenate has won two Oscars and been nominated for seven others (he remains the most nominated black actor of all time) and this year offers him two major opportunities both in front of and behind the camera. Firstly, he’s taking on the lead in The Tragedy of Macbeth, an intriguingly mysterious black-andwhite adaptation also starring recent winner Frances McDormand and directed by her husband Joel Coen, the first time he’s worked without his brother Ethan. Secondly, he’s directing Michael B Jordan in emotive fact-based drama A Journal for Jordan about a soldier in Baghdad leaving behind instructions on how his son should live a life without a father. While his work as a director has yet to reach even a shred of the support that his work as an actor has, this could be the film to change that.
Jane Campion
It may have been one of the most predictable wins of the night but Chloé Zhao making Oscars history with her best director trophy for Nomadland was also arguably the most deserved. She became the first woman of colour to win and only the second woman ever, following on from Kathryn Bigelow, and in a year when she was nominated alongside another female film-maker (also a first), it provided a welcome jolt to a category that sorely needed it. Years prior, Jane Campion was helping to pave the way, becoming the first (and frustratingly still, only) female winner of the Palme d’Or at Cannes and only the second nominee at the Oscars, both for The Piano. She’s not made a film since 2009’s criminally unrewarded Bright Star but is primed for a major return with an adaptation of Thomas Savage’s novel The Power of the Dog about two brothers at war after one of them gets married. The cast is promising – Benedict Cumberbatch, Thomasin McKenzie and reallife couple Jesse Plemons and Kirsten Dunst – and with Netflix onboard, it’s likely to receive a hearty awards push later this year.
Sandra Bullock
A winner back in 2010 for The Blind Side and a nominee four years later for Gravity, Sandra Bullock is the kind of well-loved movie star the Academy would probably celebrate even more if she decided to make more movies but the actor picks and chooses, in recent years more wisely, and often with a more commercial sensibility than they would like. Her next project sounds like a more conventional awards play though one with promising heritage: an as-yet-untitled remake of Happy Valley creator Sally Wainwright’s miniseries Unforgiven, where Bullock will play a woman struggling to adjust to life after being released from prison. It’s not exactly groundbreaking stuff on paper but with Oscar mainstay Viola Davis as Bullock’s co-star (whose one win and three nominations have allowed her to be more discerning with what she chooses to make) and with acclaimed German director Nora Fingscheidt, winner of multiple awards in her home country including at the Berlin film festival, at the helm, this could be a winner.
Oscar Isaac
Now free from an increasingly thankless three-film arc in the retooled Star Wars franchise, Oscar Isaac has a far more challenging year ahead, his most publicised role being a return to sci-fi, albeit of a far stranger hue, in Denis Villeneuve’s Dune. But his less high-profile film of 2021 could well be the game-changer, perhaps scoring him his first Oscar nomination. Isaac has skirted close to one before, most notably with his lead performance in Inside Llewyn Davis but buzz is slowly swirling around his work in Paul Schrader’s First Reformed follow-up The Card Counter. The bleak Ethan Hawke-led drama was a bracing return to form, scoring Schrader a best original screenplay nomination, and leading him to his biggest film in years, a gambling drama picked up by Focus Features and also starring Willem Dafoe and Tiffany Haddish. Reportedly, Venice film festival (a reliable launchpad for Oscar movies) is battling with those at Cannes for premiere rights.
Richard Jenkins
As the sort of character actor who has spent years quietly but effectively working in the background, an Oscar for Richard Jenkins would also double as a lifetime achievement award. He’s already respected by the Academy – he scored a best actor nod for The Visitor and one for best supporting actor for The Shape of Water – and with two big films on the way, that might turn into something more substantial by this time next year. His first shot comes from the last director to secure him a nomination, Guillermo del Toro, with his creepy psychological thriller Nightmare Alley, packed with Oscar favourites from Bradley Cooper to Cate Blanchett to Rooney Mara to Toni Collette (the entire cast has 24 noms and two wins in total), based on William Lindsay Gresham’s 1946 novel. The more likely option might be his role in The Humans, released by A24 and based on Stephen Karam’s Tony-winning oneact play, starring alongside recent nominee Steven Yeun and Amy Schumer. While stage adaptations don’t often make their way into the best picture category (recent snubs for Ma Rainey’s Black Bottom and One Night in Miami were examples of this), it’s a surefire way to get attention for actors (this year saw four nominations and one winner from play-based movies).
based in London, hot vax summer means going back to carefree sexual encounters. Being in an open relationship, Dan is looking forward to dancing in a sweaty, dingy east London gay bar, kissing someone – anyone – before devouring a McDonald’s on the way home. He wants to let himself be happy, without bounds, pressure or judgment.
Even so, we should manage our expectations for this summer wisely and be gentle with ourselves as we ease back into society. “This summer has been put on a pedestal because we all needed to get through the winter. But we also can’t forget that accepting going back to ‘normal’ isn’t the goal. Building something new and better is,” says Wright.
New dating expectations
Based on her work, Wright expects people to have a lot of casual sex, and thinks there will be a lot of relationships being redefined. Her single or non-monogamous clients are slowly starting to be able to meet new people again and, she says, it’s a “wild emotional experience” for a lot of them.
“Folks are already starting to get back on [dating] apps stating that they’re half-vaxxed, with the date they’ll be fully vaccinated,” she says. “On one hand, this helps us to have easier STI conversations, and on the other, the perceived safety of the vaccine may encourage people to forget to have that conversation, because we’re out of practice,” she says.
When it comes to bringing up the topic, Wright recommends saying something like: “I’ve been vaccinated, and it’s important to me that anyone I’m going to be intimate with is too. What’s your vaccination status?”
“Be open, honest and courageous
– and ask them,” the therapist says. “Personally, I wouldn’t meet someone in person if I didn’t know they were fully vaccinated. I’d recommend asking them questions about their experience of Covid; in listening to their response, you’ll hear what precautions they took and how seriously they take their health and the health of those around them.”
Light on the horizon
Margaret is excited about the warmth of summer, seeing people out, being dressed in next to nothing, and going out again. “I want to drink and get sunburned at the beach, to be surrounded by my friends. Even just getting looked at twice on the street has me preening,” she says.
Alexa Mendez, a client management coordinator at Christie’s in Miami, is looking forward to proper dates, hopefully with people being more direct and honest than before, and hopes that Covid-19 will give women a new language to say no without feeling guilty.
For Maheshwari-Aplin, who uses they/them pronouns, it’s the little things that count. They want to enjoy youth and partying without scolding, and “hazy, lazy days on the grass, surrounded by friends.” They even miss the worst parts of going out: like drinking too much and running through the rain to stand in queues. “Sharing whispered secrets with friends of friends I might never meet again, bubbling, overlapping conversations, eyes flitting around the room,” they say.
But before you get started on joyfully planning your summer plans, make sure to keep health guidelines in mind. According to the CDC, Covid-19 vaccines are effective at protecting you from getting sick and, based on what we know so far, people who have been fully vaccinated can ease back into normal daily activities.
But people who are dating should continue taking precautions – like wearing a mask, and avoiding crowds and poorly ventilated spaces – until we know more. While the vaccination will keep the person who received it safe, we still do not know whether that person can continue to pass on the virus.
This summer has been put on a pedestal but going back to ‘normal’ isn’t the goal