Patterns of pain: what Covid-19 can teach us about how to be human

We can expect psychological difficulties to follow as we come out of lockdown. But we have an opportunity to remake our relationship with our bodies, and the social body we belong to.

By Susie Orbach

When lockdown started, I was confused by bodies on television. Why weren’t they socially distancing? Didn’t they know not to be so close? The injunction to be separate was unfamiliar and irregular, and for me, self-isolating alone, following this government directive was peculiar. It made watching dramas and programmes produced under normal filming conditions feel jarring.
Seven weeks in, the disjuncture has passed. I, like all of us, am accommodating to multiple corporeal realities: bodies alone, bodies distant, bodies in the park to be avoided, bodies of disobedient youths hanging out in groups, bodies in lines outside shops, bodies and voices flattened on screens and above all, bodies of dead health workers and carers. Black bodies, brown bodies. Working-class bodies. Bodies not normally praised, now being celebrated.

We are learning a whole new etiquette of bodies. We swerve around each other, hop into the near-empty street, calculate distances at entrances to parks, avoid body contact, even eye contact, and keep a look out for those obliviously glued to their phones, whose lack of attention threatens to breach the two-metre rule. It’s odd and disconcerting and isn’t quite second nature.
Until the pandemic arrived, many of us were finding texting, email and Whatsapp more suitable to our speeded-up lives. But now we are coming to reuse the telephone, and to enjoy the sounds in our ears and the rhythm of conversation, instead of feeling rushed and interrupted. A few of my sessions as a psychoanalyst are now conducted on the phone but, for the most part, I am spending my time looking into a screen, and seeing faces rather than whole bodies. Until I learned to turn off the view of myself, I, like others, was disconcerted by the oddness of catching sight of myself – a view I don’t think we are meant to see.

Conversations in therapy defy many of the customs of social intercourse. There are silences, repetitions, reframings, links across time, reminiscences of fragments, rushes of emotion, shards of dreams, things told and then disavowed. There can be fidgeting or absolute stillness. These form the idiosyncratic and personal ambience between each therapeutic couple. As a therapist, I am also alert to how the dilemmas that beset the person or the couple I am seeing are brought to our relationship.

The conundrums that brought the person to seek therapy in the first place can be replayed right here. For example, a person fearful of intimacy can experience the therapy relationship or the therapist as too close. Someone else who worries they are too needy may be reluctant to show their longings directly to the therapist, although well able to talk about how things go wrong for them in other relationships. The therapy relationship and the sessions are our petri dish. The field of study is the human subject (and her, his or their ways of being able to develop and change).

The therapist works to understand an individual’s personal psychological grammar – to help the person take the risk of unlearning and then learning anew, finding ways to not be in so much hurt. So too with the body. Those with troubled bodies bring them to the session. They may sit too close, for example, or seem to be concave, or dress incongruously, as though presenting a different persona in each session. In the course of therapy, such an abject body experience can be addressed, and, in unlearning and then learning anew, the person finds a more comfortable way to sit in their body.

How is the dematerialisation of bodies affecting us and going to affect us? Me, my patients, you – all of us? For some of my patients, their screen or home is a prison. Their experience is full of woe and worry. Therapy keeps them just about on the border of sane, but it’s a sanity that hurts: isolation can maraud all of us as we miss the interactions, intimate or casual, that confirm our sense of our value, our place in our community, our work and the world.

Some of my clinical preoccupations centre on how we acquire a physical, corporeal sense of self. Although psychoanalysis is a theory of mind and body, its main emphasis has drifted to the development of the mind and its structures: what we call defences, and the relationship patterns we have absorbed. Bodies have been very much the bit player to the main drama of the mind, even when mental processes or disturbance have resulted in bodily symptoms such as eczema or a non-biologically induced paralysis. As therapists, we traditionally read back into the mind the troubles visited on the body, seeing them as the result of mental conflicts. And of course, they often are, but I have long been keen to understand body troubles and body difficulties in their own terms, and to build a theory about the development of the body.

Bodies have always been bound and marked by social rules. Different societies make different sense out of similar bodily actions or gestures. The variety of body adornment and transformations around the world, from rings around the neck to the recent upsurge in labial reductions and penis enlargements, has made it ever more apparent that the body is not simply the product of DNA. The body we inhabit develops within relationships to other bodies. Usually it is within the maternal orbit where, to take an obvious example, we first apprehend gender-based forms of comportment. When I grew up, being told to sit like a girl and not to climb trees were some of the ways we were treated differently to boys. Research across many cultures show that baby girls are weaned and potty-trained earlier, fed less at each feed, and held less, than boys. There may be no biological basis to this, but rather a social, unconscious basis that then informs how we personally experience our particular embodiment.

We have very few verified reports of humans growing up outside of human culture but the feral child Victor of Aveyron, who was discovered living wild in the woods of southern France in 1800, did not have body movements that were recognisably human. The body-to-body relationship that was foundational for him was with the bodies of the wolves he apparently grew up among. He seemingly mimicked their gait and moves, their posture and their vocalisations. Of course, we know this more familiarly, and less dramatically, from when youngsters develop their group identities by adopting the mannerisms of film actors or musicians.

Through screens, billboards and photoshopped images, we reduce the wide variety of bodily expression. It’s as though we are losing body diversity just as we are losing languages. The digitised, westernised body image predominates, and in the last two decades has spawned a cosmetic surgery industry worldwide – from leg-lengthening surgery using steel rods in China (now banned), to rhinoplasty in Iran (which has the highest rate of nose surgery per capita in the world) to double-eyelid surgery and jawbone reduction in South Korea. In the west, surgeons resculpt cheekbones, breasts and calves, and offer day procedures for facial ‘thread lifts’. Cosmetic surgery tourism hubs in Hungary, South Korea and Singapore were thriving until the lockdown.

One Chinese smartphone app allows the selfie-taker to adjust their portrait to bring it closer to a very specific standard of beauty known as wang hon lian, or “internet celebrity face”. It’s very popular: billions of wang hon lian images are uploaded every month.
The richest Europeans are not in tech, but in the business of beautifying bodies – the owners of fashion, luxury and cosmetics brands such as LVMH, L’Oreal and Zara. Increasing automation has led us to move from using our bodies to make things to turning our bodies the site and the product of our labour, through diet and exercise regimes, clothing and cosmetics. The surface body is meant to be on display.

Paradoxically, the sweating, smelling, holding, stroking body of the other becomes, for those socially distancing, too distant – while for others, such as those sharing a house with teenage boys, it’s all too present. All is on show for families and housemates, while all is hidden for those living alone during lockdown.

The experience of the body on FaceTime or Zoom contrasts with the pulsing, breathing, weeping, sighing, tired, achy or indeed springy and enthusiastic bodies we inhabit. We no longer have social communion in the flesh, the handshake or the hug, the pleasure of eating in a restaurant with a friend or lover while seated near strangers. Afraid of infection, for our protection, we collapse our social space.

During the second world war, the psychiatrist René Spitz studied orphan babies in care. He discovered that those closest to the nurses’ station thrived, while those at the end of the ward did not do so well. The difference was touch: the nurses would casually touch and interact with those closest to them, and this gave those infants the essential food for physical and psychological development. They absorbed the will to live. A decade later – in research now considered controversial for the way in which he removed baby monkeys from their mothers – the American psychologist Harry Harlow discovered that baby monkeys given ersatz mothers in the form of basic cloth puppets would find some crucial security and comfort even in this simulation of maternal touch; those baby monkeys deprived of any kind of maternal touch at all became highly disturbed, and many died.

Touch, feel and proximity are central to survival. Consider the genius of premature infants’ capacity to regulate their own and, extraordinarily, their parent’s body temperature, if they are held skin-to-skin in a pouch. The gaze – the search to be seen, to recognise and to influence the other – is also crucial to human subjectivity. In a fascinating video made by the developmental psychologist Edward Tronick, he instructs a mother playing with her baby to keep a still face and refrain from interacting with her infant for a minute or two. We observe as the infant girl seeks to engage the mother. When she is unable to, the baby collapses psychologically and physically until contact is restored. What is so shocking is how fast the collapse is.Trauma Therapy (EMDR)

I’ve been thinking of how impossibly difficult and challenging our quasi-dematerialised life through the Zoom screen is, whether chatting with friends or being in a meeting. Conflict and harmony become cartoonish as subtle gestures collapse and the conversations we have with our eyes are shut down.

Reading each other well enough is a new skill in the therapy room, too, for both people. By now we are used to the screens and the telephone, and the occasional technical blips. We are seeing a physical interior – a study, bedroom, shed or kitchen, and being surprised by an occasional child that floats in. We hear the suddenly hushed voice of someone not wanting their partner to get a drift of the conversation we are having. It illuminates aspects we didn’t see before. Is it better? No. Is it worse? Marginally. I miss noticing how people enter the therapy room – the subtle difference from the session before, or the way they may hold their face and body; above all, the animate body in the room. I suspect that I am more animated to make up for the loss of that precious physicality.

Former hostages Terry Waite, John McCarthy and Brian Keenan have all written and spoken eloquently about solitary confinement and their struggles to find a way through and back – or should I say forward – to familial and social life. It was tough. And although many of us are not self-isolating alone, unless one is able to do interesting or valued work during this period, or have enough people to hang out with, we can expect considerable psychological difficulties to follow as we come out of lockdown. How will we re-establish social interaction with other bodies? What kind of rhythms will we want and be able to have going forward?

Many have been ultra-busy with home schooling, working from home, managing three generations and so on. Time has bent and contracted in perplexing ways. Busyness has increased for some, while others, for whom slowing down is a foreign concept, have had idleness forced on them. Empty time feels alien – or at least did at the beginning. For many it has been an unexpected pleasure. No need to rush to social occasions. No need to dress. No need to get everything done and more. Being wanted, being needed, being in demand have been psychological supports that have melted away. Finding new ways to nourish one’s needs in this new reality – especially in the absence of touch and gaze, which we unknowingly rely upon to recognise ourselves – can be tricky.

Today, there is a frightened, wary, social body. A body that is tense, in which avoidance is the watchword. The covered face, whether by a hoodie or a veil, which formerly some found challenging, now offers reassurance. Indeed, many public places – from Eurostar trains to the streets of New York, Prague, Dubai, Havana and many more – now demand it. Meanwhile, much of society is now paying attention to bodies that had been scandalously overlooked. The bodies of working women, the carers who go in and out of the houses and homes of the people they look after. The faces of vast numbers of black, Asian and minority-ethnic bodies, particularly in the health service, who are finally being recognised for their value, and the shockingly disproportionate number of their losses.

Before Covid-19, the ruling party were happy to slash social and health funding, to put money into management in the NHS, and not into professional carers, doctors and nurses. Now society is waking up to the value of care and medical expertise that comes from the hospital floor – that is to say, from the doctors and nurses who are reorganising what occurs there. The people keeping society going in every sector – transport workers, small shopkeepers, workers in food production and delivery – are often first-generation immigrants. More people are seeing a more nuanced social landscape. The opportunity is here for reframing how we represent the social body. It is of necessity differently hued, and that needs acknowledging, as does the shame of our previous marginalising. Covid-19 is cleaning the lens, so we can see more clearly.

From the individual to the social body, and how it is being challenged by the pandemic, we turn to the corporate body – the body of state – and what we have been learning about how it has functioned. On 17 April, Prof Anthony Costello, a former director of the Institute for Global Health at UCL, told the select committee on health and social care that he feared Britain might have the highest number of deaths in Europe, which has now been confirmed. Costello had estimated 40,000 deaths; on 5 May the official UK death toll was just over 32,000, but the Financial Times reported the same day that the true figure had likely already surpassed Costello’s estimate. London and the north-west of England are showing higher rates of death than other regions, while according to the ONS, people in the most deprived areas of England and Wales are dying at twice the rate of the most affluent areas.

Costello argued for this figure because we were slow off the mark to take precautionary moves early on. He spoke to the chair of the committee, Jeremy Hunt, who has spent this period appearing to stress about the lack of testing, ventilators and PPE equipment. This is the same Hunt who, as the longest serving health secretary in British history, also had social care in his portfolio, and the pay of doctors, nurses and social care workers. Even more damningly, he was the minister in charge during Exercise Cygnus, the UK government’s drill to test our preparedness for a pandemic, carried out in 2016.

The full review of Exercise Cygnus has never been officially published, but leaks have revealed that it showed the UK’s health system and local authorities were woefully unprepared for such an eventuality. The exercise showed hospitals and mortuaries being quickly overwhelmed, and shortages of critical care beds, ventilators and personal protective equipment for hospital staff.
Cygnus, and other such exercises, are meant to show the government what they need to do to be prepared – which was not, as Hunt was doing, cutting beds. On 28 March of this year, when the Cygnus debacle came to light, we were told that the projections were not remedied because of worries that beds, ventilators and PPE would become outmoded or obsolete and that the government had worked on securing reliable supply chains. (As we have seen, in a pandemic, reliable supply chains become very quickly overwhelmed.) A 2018 Red Cross conference report on Cygnus and infectious diseases stated: “The financial and human cost of an outbreak can be staggering and early response reduces the cost.” Our government chose not to act.

Fund for Peace, the Washington-based NGO that publishes the annual Fragile States Index, lists criteria for a failed state. I think we have come dangerously close to fulfilling two of their criteria: the inability to provide public services for the poor, and the inability to interact with other states as a full member of the international community.

As these last months’ farcical developments show – the question about the independence of the Scientific Advisory Group for Emergencies (Sage), the alleged missing communications with the EU on PPE, the political decision not to cooperate with the EU, the posting out of tests without return envelopes, and the expired dates on PPE equipment – the government is in Fawlty Towers territory.

Plans for British companies to design new ventilator machines, detailed by the Financial Times, went belly up. Our government chose to source new ideas rather build to the existing plan under licence. Why, one must ask? Could it be Brexit hubris?

I don’t want to contrast the UK’s response with that of the EU, because the latter has not always covered itself in glory during the pandemic. The ethics of cooperation in Europe and the ethics of transparency and honesty have been mightily tested in the past months. Perhaps now though we can be encouraged by the joint project of the European Investment Banks and WHO to bolster global healthcare systems. Will the UK state be contributing? I think not. So much depends on the actions of citizens now to move things forward. In this light, it is encouraging to see the formation of a new independent panel of experts – a “rival” to Sage – led by the former UK government chief scientific adviser David King, whose deliberations are on YouTube for us to watch.

I am not sure how we characterise the following failure of the state, because it is in part the expression of public good: of the 750,000 people who signed up to volunteer to help the NHS, invited by the government, fewer than 100,000 have been deployed. As citizens, we want to contribute. This squandering of people’s generosity is disturbing. Fortunately, people such as Capt Tom Moore or the many making masks and contributing 3D printers keep on going. And the programme Feed NHS, in which the restaurant chain Leon and other chefs are prepping to feed patients, doctors, nurses, hospital porters and ambulance workers, is now in train. This voluntary work, in which groups of people self-organise, is outstanding, and yet it is in contrast to the inability of our state to mobilise those who wanted to help.

The Gates Foundation’s contributions to seven different vaccine programmes, and Twitter CEO Jack Dorsey’s donation of $1bn, are impressive. Will hedge funds in the UK such as Ruffer investment, which pocketed £2.4bn in March, or Somerset Capital (the fund Jacob Rees Mogg used to run) who see Covid-19 as a “once or twice in a generation” opportunity for investment, make a contribution, too?

There are several dozen UK-based hedge funds managing assets worth £1bn or more. Could the mood of the country be such that hedge fund investors and managers might be persuaded to donate some of their obscene profits to the coronavirus response or to sponsor migrants from beyond Europe (who work here as cleaners, carers, drivers), who do not earn the £30,000 currently demandedfor a work permit?

Covid is a sad story. It is also a story of resilience. The body of state has failed us. We need to grow up and recognise that. Covid-19 has exposed unforgivable systemic failure. In the years leading up to this, we’ve seen a reduction in the status of civil servants and a downgrading of health workers. We have seen teachers, doctors and academics hidebound in a managerial economy. At least it seems that micromanagement has been temporarily overturned in hospitals, thank goodness, because right now doctors and nurses need to be running the show.
And to return to our bodies – the live ones, so many devoid of touch and gaze, facing a long period of isolation, and frightened. How can I conclude?

In a way, I can’t. We are far from the other side of this crisis. Psychological therapies are going to have a huge part to play in the remaking of body and soul. I don’t much like the word trauma, because it has become so overused, but we are a society that is in trauma. A societal trauma gives opportunities for people to go through things together, rather than suffer alone, as long as we don’t bury or make light of what we have experienced and continue to experience. We will have to find new ways to live with our fears and discomforts, to overcome Covid-minted social phobias, with what we project on to other people’s bodies and the fears we have about our own vulnerabilities. We will need all the help we can get in reshaping our relationship to our own and each other’s bodies, to find a way to build bonds of attachment and respect.

What started with the dematerialisation of the individual body has now morphed into the dematerialisation of the body of state. The economist Joseph Stiglitz reminds us that, with the stripping back of the state under Ronald Reagan and Margaret Thatcher, we lost capacity. This needs to be addressed.

There is a lively debate from a range of economists on how to get to a more equitable economy. Moneyweek editor-in-chief Merryn Somerset Webb’s call for a sovereign wealth fund, with the government owning shares in bailed-out companies, is interesting, as is political economist Will Hutton’s idea of expanding the British Business Bank and the Future Fund. UCL economics professor Mariana Mazzucato insists that the state must invest in innovation.
We began trying to make a different kind of society after the second world war. We will have to do that again. Principally, we will need to recognise the contributions and the losses of the UK’s minority and working-class people, above all. Our governments have shamed themselves through creating divisions in society, particularly since austerity was imposed under David Cameron’s government. Now we have an unexpected chance to redress the divisive fallout of Brexit.

The impact of remote working and the need to balance domestic and work life, allied with dire warnings on mass unemployment, gives us an opportunity to write a social contract in which we divide work more fairly. At both ends of the pay scale, people overwork. The evidence for a more balanced relationship between work and home is compelling.

Since the crisis began, the outpourings of artists, musicians, programmers, cultural and scientific workers at all levels has been outstanding. The talent, the will, the desire is there to remake our world. The urgency is not in question. Globalism can’t simply be a celebration of “just-in-time” deliveries. It will need to be recast as mutuality – local and global mutuality – so that we learn from each other, including those who’ve been in lockdown in war zones.
Therapy under lockdown: 'I’m just as terrified as my patients are'

Our institutions will need to be rebuilt with transparency, with heart and by learning from the people who have been staffing them, not just the managers and owners. Doctors, nurses, carers and delivery people have things to say about how their institutions could be better run. The body politic and the politics of the bodies that make up our world must be reconfigured, and we need to start thinking about that now.

I conclude with Freud: “The aim of psychoanalysis is to turn hysteria into ordinary human unhappiness.” That is an accomplishment for an individual and for a society. We cannot escape unhappiness. It is constitutive of being human, just as are creativity, courage, ambition, attachment and love. Let’s embrace the complexity of what it means to be human in this time of sorrow as we think and feel our way to come out of this, wiser, humbler and more connected.

What Meditation Does To The Brain
May 1, 2020

by Betty Vine
https://brainworldmagazine.com/what-meditation-does-to-the-brain/

Anyone who has ever attempted to meditate can vouch for the fact that while it is theoretically simple, it is extremely challenging in practice. In fact, its simplicity is what makes it difficult, and it is also what makes it worthwhile.

“Mindfulness meditation” (the practice most popular in the United States) requires a steady observation of one particular object or sensation. As we find ourselves increasingly surrounded by modern distractions and the hustle and bustle of everyday life, focusing our attention on something very basic can have indelible effects on the brain. Let’s explore some of these effects.

As research published in Frontiers in Human Neuroscience found, meditation increases gyrification in the cerebral cortex — that is to say, the brain’s surface has more folds, and is therefore thicker. As UCLA’s Dr. Mark Wheeler explains, “Presumably then, the more folding that occurs, the better the brain is at processing information, making decisions, forming memories, and so forth.” Further, researchers have drawn a positive link between the number of years someone has practiced meditation and the amount of cortical folding.

Larger amounts of grey matter are found in the orbitofrontal and hippocampal regions when compared to nonmeditating controls, as a study in NeuroImage discovered. These portions of the brain are related to “emotional regulation and response control.” As such, this could help explain and contribute to the balanced, rational, and resilient demeanor of many meditation practitioners. Further, it allows one to see his- or herself in a more objective light, sans bias, as a study in Perspectives on Psychological Science proposed.

Neural connections between the ventromedial prefrontal cortex and the insula/amygdala begin to diminish, as research in Social Cognitive and Affective Neuroscience found. In layman’s terms, this means that one is less likely to associate “gut feelings” and inappropriate fear-based responses with catastrophic ideas of self; ultimately, it can explain the ostensible decrease in anxiety in those who meditate.

On the other side of the coin, neural connections between the lateral prefrontal cortex and the insula/amygdala are strengthened. Again, this allows one to have a more logical and collected response to pain or discomfort. As Dr. Rebecca Gladding clarifies in Psychology Today, “when you experience pain, rather than becoming anxious and assuming it means something is wrong with you, you can watch the pain rise and fall without becoming ensnared in a story about what it might mean.”

Researchers from Brown University suggest in a study in Frontiers in Human Neuroscience that frequent meditators have the ability to control cortical alpha rhythms. In other words, they can more easily devote their attention away from physical and emotional pain.

As the evidence above proves, a consistent meditation practice can foment beneficial alterations in brain structure and functioning — and this list doesn’t even begin to touch on all of the other health benefits for your body, your spiritual well-being, and your interpersonal relationships.

"The Guardian":

For Those of Us With Depression, Coronavirus Is a Double Crisis

by Andrew Solomon

From now on, when someone who hasn’t experienced clinical depression and anxiety asks me what they feel like, I won’t have to resort to florid comparisons. I’ll say: “Remember when the Covid-19 pandemic hit town?” and they will understand. Except that for people with depression and related conditions, the present moment is one of escalated distress. For this is a double crisis, of physical and mental health, and those living the psychiatric challenges need not only acknowledgment but also treatment. I have had dozens of letters and Facebook messages from people who are anxiously upping their doses of antidepressant and anxiolytic medication.

My depression and anxiety share a lot of territory with how most other people feel now: fear of getting sick and dying, fear of losing people I love, fear of unpredictable shortages and economic disaster. Others worry whether their cough is a symptom of Covid-19 or just an allergy. I am in the sizeable part of the population who must seek to distinguish between ordinary fear and the beginnings of a breakdown. I’ve had to alert the doctors who oversee my mental health that I am Code Fragile and will count on them to help me discern whether I cross over from ordinary unhappiness into neurotic paralysis. I have had to cancel my planned withdrawal from a medication that makes me sleepy and fat; lowering my dose would leave me unsettled for a spell, and that’s more than I’m up for now.

In March, I experienced the whole panoply of Covid-19 symptoms: a racking cough that kept me up all night but was not accompanied by any congestion, a fever that soared over 103F (39.4C), aching joints and trouble breathing into lungs that felt like they couldn’t expand all the way. Despite pulling every string I could muster, I was unable to get a test. My doctor diagnosed flu at first; when I couldn’t breathe, I had a chest X-ray and he diagnosed pneumonia. I took Tamiflu, then azithromycin. I quarantined myself at home and rigidly kept distance even from my husband and our son. Now I am fine, and nobody who was in contact with me has been infected. But the unavailability of tests was terrifying and the circumstances seemed to invite in psychic decay.

Quarantine is the oldest medical technology out there: isolation of the sick dates to the ancient world. While it protects those who are not ill, it is toxic for the patients, who show elevated rates of depression, anxiety and post-traumatic stress disorder. Physical recovery is slower for those cut off from friends and family. Quarantine is often necessary for people with incurable or highly contagious infections such as MRSA, Sars or H1N1, but it comes at a terrible cost. No one wants to die alone.

Sheltering inside when you have no symptoms, however, is essentially a new phenomenon: it happened in Toronto during the Sars outbreak of 2003, and many authorities felt its costs far exceeded its benefits. Richard Schabas, formerly Ontario’s chief medical officer of health, wrote: “In the unlikely event of another Sars outbreak in Canada, public health officials should quarantine no one.” His intent was not to dismiss the physical dangers, which were real then as they are now, but to illuminate the psychiatric ones.

This is a bizarre time, and people are dying – but people are always dying, I remind myself. One acquaintance of mine died yesterday of the virus, and another has died tonight of cancer. The first death terrifies me; the second merely saddens me. Social distancing is staunching the proliferation of new cases, but some of us are overreacting and some of us are underreacting and no one knows which are which; it is unlikely that many have hit the sweet spot of appropriate caution. The need for caution must also take into account the effect of isolation on mental health, as anyone knows who has seen The Shining or Cast Away. When I lived with the Greenlandic Inuit, I found that their high rates of depression and suicide were tied not to the sunless winter, but to the intimacy it forced. Whole families gathered in small houses and were stuck with one another and no one else for months because it was too cold and dark for anyone to leave or visit. Emotional repression was the natural consequence, and it was calamitous.

I was on holiday with my extended family when the idea of social distancing was introduced into the popular vocabulary, and had to come home early when the place we were visiting sealed its borders. I have since been sheltering with my husband, my son and my father-in-law in upstate New York. Two weeks ago, I set out for New York City to pick up our family dog, get my 10-year-old son’s school books and pay some bills. I didn’t recognise the empty city where I had grown up. I perched in my office thinking grimly that I would never be able to live at home again. I lie awake with my mind running and have to remind myself that this is how my mind runs when it is in bad shape. I saw my elderly father today and we met outdoors and kept a 6ft distance. I suffered anew the collapse of that feeling of safety he had created in earlier crises, a role he cannot fill at nearly 93. Intellectually I know that my father could never have solved this crisis; that I will eventually live at home again; that I am probably safe in the house upstate. It is my project to keep up a good face for my son, and it is utterly exhausting, sometimes impossible and profoundly redemptive.

Yet, as always, at the bottom of depression’s box there is hope. The very feeling of frailty gives me a window into the suffering of friends who are waiting out this terror by themselves. The feeling of isolation awakens me to the ongoing plight of older people who are alone all the time. I feel singularly well-placed to comfort those who are taking their first deep plunge into depression. I can help them assess what is pathological and treatable.

I am in pretty good shape. I had a bad depression two years ago, and I feel much better now, which seems bizarre given how much worse things are than they were then. I am not all by myself, and I have not lost my job. I don’t feel sorry for myself and I don’t think I am suffering more than others are, but I am suffering a bit differently. The second-guessing all the time is burdensome. Am I proportionately or disproportionately having these particular feelings in this particular moment? Depressives find that our intense sadness and fear easily become intense depression and anxiety. People with pre-existing pulmonary illnesses drop dead of this thing. People with previously existing mood disorders will die of it, too, if mostly in a slower and less obvious ways.

Feeling Anxious? Here’s What You Can Do About It Now
By Lucie Zhang

April 14, 2020

As those of us in New York are coming up on one month of life “on pause,” feelings of anxiety and unease have only become more layered. We’re facing entirely new fears. We cry at unpredictable times. We crave intimacy and connection.
Keeping mounting anxiety under control is an increasingly challenging task during unprecedented times, and it is top of mind for many. Since Laurie Santos, a Professor of Psychology at Yale University and host of The Happiness Lab podcast, uploaded her popular Yale course, The Science of Well-Being, to Coursera two years ago, she’s had over 500,000 people enroll. In the last three weeks of March alone, 800,000 new learners signed up for the lecture series.

“People are worried about their physical health, but we know what we need to do [there], like wash your hands, socially distance six feet from other people. We have stuff we can do to protect our physical health, but I think people are searching for evidence-based things they can do to protect their mental health during this time,” says Santos about the recent surge in sign-ups. “This situation is unprecedentedly scary and anxiety-provoking and uncertain. It’s causing us to face our mortality in a way that I think most Western, first-world-problem people haven't had to face in a long time. And I think we’re forced to do it without the one coping skill that most of us use during a crisis, which is to be more social.”

Below, Santos gives advice on how to recognize and cope with anxiety amid the coronavirus pandemic.

Notice How Your Body Responds to Stress
Because many have had their sense of normalcy and safety upended during this pandemic, Santos says the resulting stress has activated our sympathetic nervous system, which is our “fight or flight” mode that’s basically preparing us for a tiger that’s going to jump out from a bush. Our “tiger” is doorknobs, other people, not washing our hands after getting the mail, and so on.
“It’s flooding our body with stress hormones. It’s actually causing us to tighten our muscles so they’re prepared to run away. Being in a constant state of that can lead to things like muscle problems, digestive problems, even sexual health functioning problems. The ‘fight or flight’ system is meant to be activated in tiny, short bursts when there is a real emergency, and many of us are activating it chronically right now.”
To assuage our sympathetic nervous system, Santos says we must consciously activate our parasympathetic nervous system, which is “our ‘rest and digest’ system.” She notes, “Naturally, it’s not turning itself on because we’re flooding our autonomic nervous system with cues that everything is threatening.”
But one simple (and free) thing to do is to take deep, calming, “belly” breaths whenever you begin to feel signs of anxiety, such as chest-tightening.

Give Yourself a Mental Break
“I think the thing to notice is: If you get a moment free, is it like all the anxiety pours in at that point?” Santos says. She recommends making a habit of taking breaks in order to allow feelings to emerge. "That can feel really scary, especially if you’re not the kind of person who’s mindful normally, to sit there and feel what it feels like,” she acknowledges. “But those things are going to come out naturally and if you’re not letting them out in some form, that’s when you get the neck troubles and the sleep troubles and the digestive stuff that a lot of us are facing. If you’re feeling that, it might be a sign that you need to do some paying attention and really give yourself explicitly some time to notice that you’re feeling anxious, or notice that you’re feeling sad or scared, and just kind of be with that for a little bit.”

Create a New Social Routine
Santos says everyone, including introverts, should make a point to reach out to people for virtual time together. “In fact, it’s a great time to reconnect with people you might not normally interact with. I’m realizing that if I have to Zoom with my lab, who I would normally see every day, I can also Zoom with my friend in Seattle who I haven’t seen in forever, or my college roommates who are all in different states,” she says. “In theory we could’ve done that all the time before, but it would have been weird. But now it’s not weird, because it’s our only way of connecting.”

Our bodies and minds are creatures of habit, so creating a routine can add structure to your life, Santos says; but you may have to reevaluate old habits and schedules in the process. So-called workaholics, for instance, should recognize if they are burying themselves in busyness in order to avoid feeling their emotions.
In particular, Santos notes, it’s important to schedule in informal social time–i.e. social interactions that are casual and without an agenda–into your routine, to fill in for those types of spontaneous exchanges that we are now missing.
“One thing that we don’t notice as part of our routine but core to our normal day is we also run into lots of people,” she explains. “Those can be our coworkers, our friends, but even just a barista at a coffee shop, who you don’t notice you’re having a conversation with, [but] your mind notices. There is research showing that we’re happier when we have those quick interactions with a person on our commute or someone in the coffee shop or something like that. And we’re really missing those right now.”

Be Self-Compassionate, Not Just Self-Aware
Santos cautions against defaulting to filling a social void with social media, warning: “This might be a time to wean off the social media more than you think, for a couple of reasons. That tends to be a really easy, low-cost, go-to, fix-our-boredom strategy, but the content on that is going to be different right now. Especially if you’re a person who experiences anxiety—you’re not going to see as many baby videos or cat videos or good recipes. It’s going to be doom and gloom. I think limiting that is important. I also think that those kinds of moods–when you’re bored and feel the need for social [interaction] and the easy thing to do is to click on Facebook or something–can come at an opportunity cost for putting in that little bit of extra effort to call a friend or call your mom.”
Another thing to keep in mind is that everyone is going to react very differently to this unprecedented situation. “Some are going to be like, ‘This is my time to get the perfect abs in the next three weeks and I’m just going to show off my ab videos.’ That’s a way of coping, not my way of coping, but it’s someone’s way of coping. Whereas other people are going to be like, ‘I’m going to watch Netflix and eat my entire cartons of ice cream that I bought for three weeks in one night,’ and that’s also a way of coping. That’s fine. I think we just need to chill out with ourselves,” says Santos. “...Realize that we’re all doing it in our own way–and what counts as our own way is going to change because this is going to be a long process. There is going to be ups and downs.”

Find Gratitude
This is not the first time that people have faced uncertainty, but we have never been as technologically advanced as we are now, says Santos. “As a species, we’ve faced pandemics. We made it through the 1918 flu, which was as bad as this and required as much socially distancing, and we did that without Netflix or Zoom meetings or even really good telephone technology. In some ways, we’re so grateful,” she says. “Even relative to 9/11, which wasn’t that long ago, technology-wise we couldn’t be doing this back then. So I think we’re really lucky to live in the time that we do live in, where there are these modes of communication and modes of staying connected that can allow us to get through this stuff.”
Likewise, Santos predicts what she calls a “surge” in happiness will occur once things do return to normal. “We’re going to realize all the things we took for granted,” she says, such as getting your favorite latte at your go-to cafe or giving your mom a hug.
We did that every day without an enormous burst of happiness from that, and now we’re kind of like, ‘How was I not incredibly grateful every time I did that?’ I think we’re all going to have so much more to savor when we get out of this. And recognizing that–that we are going to get out of this. Most of us are going to be fine. We’re going to get to enjoy things that make us happy in a way we’ve never experienced before."

Psychiatrist and trauma specialist Bessel Van Der Kolk speaks on the collective trauma of the COVID Pandemic and how we can manage depression, anger, and our relationships.

Brain scans could help personalize treatment for people who are depressed or suicidal

By Emily Underwood
Aug. 20, 2019 , 12:45 PM

By his late 20s, Moe had attained the young adult dream. A technology job paid for his studio apartment just blocks from the beach in Santa Barbara, California. Leisure time was crowded with close friends and hobbies, such as playing the guitar. He had even earned his pilot's license. "There was nothing I could have complained about," he says.

Yet Moe soon began a slide he couldn't control. Insomnia struck, along with panic attacks. As the mild depression he'd experienced since childhood deepened, Moe's life collapsed. He lost his job, abandoned his interests, and withdrew from his friends. "I lost the emotions that made me feel human," Moe says. (He asked that this story not use his full name.)

Although many people with depression respond well to treatment, Moe wasn't one of them. Now 37, he has tried antidepressant drugs and cycled through years of therapy. Moe has never attempted suicide, but he falls into a high-risk group: Though most people with depression don't die by suicide, about 30% of those who don't respond to multiple antidepressant drugs or therapy make at least one attempt. Moe was desperate for relief and fearful for his future. So when he heard about a clinical trial testing a new approach to treating depression at Stanford University in Palo Alto, California, near his home, he signed up.

People like Moe present a conundrum to doctors but an opportunity for researchers: a group whose health could be transformed by precision psychiatry. Depression is often treated as a single disease, but many researchers agree that it is actually multiple, distinct ailments. Some of those conditions may heighten suicide risk more than others. How many depression subtypes exist—and how they differ—is hotly debated. One way researchers are trying to settle the question is by peering into the brain. They're studying the neural circuits that light up during specific tasks and then correlating those patterns of activation with symptoms.

Those efforts are part of a broader campaign to explore the brain biology of mental illness, including depression, bipolar disorder, and active suicidality. The goal is not just to find biological markers of risk, but to tailor care accordingly—sometimes by reaching beyond psychiatry's usual armamentarium—and improve the prognosis of Moe and others like him.

The study Moe is part of, Research on Anxiety and Depression-Anhedonia Treatment (RAD-AT), sits on the leading edge of such efforts. It enrolls volunteers with a subtype of depression who are at higher risk of suicide than other types, and the study is among the first to offer treatments based partly on brain circuitry.

Whether such a targeted approach to depression can prevent suicide isn't clear. But researchers hope that linking symptoms to brain biology could help people who have languished despite treatment. Moe also longs for something else: insight into his own condition. "Therapists always [say], ‘Tell me the reason you feel this way,’" he says. "I want an answer."

The RAD-AT study is led by Leanne Williams, a Stanford clinical neuroscientist who has spent more than 20 years probing how depression manifests in the brain. She has orchestrated international collaborations to collect thousands of brain scans from depressed people. Like many in her field, Williams is driven to prevent depression's worst outcome: She lost a patient early in her career and, more recently, a loved one.

Thanks to her own and others' data, Williams believes at least six subtypes of depression exist. Each is generated by abnormal activity in a distinct set of brain circuits that regulate mood and cognition. One subtype affects a circuit called the default mode network, a constellation of brain regions that generates aimless mental chatter when the brain is "in idle" and can lead to unrelenting negative thoughts. Another type dampens reward networks, robbing a person of the ability to feel pleasure, a depression symptom called anhedonia. Those two subtypes, along with a third called cognitive control—which orchestrates attention, planning, and impulse control—often respond poorly to depression treatments, Williams says. She and others worry most about the anhedonia and cognitive control groups, partly because of their elevated suicide risk.

Scientists have already found several brain features that align with suicide risk. The best studied comes from neuroscientist John Mann of Columbia University. In the early 1980s, he examined the brains of people who had died by suicide, donated by their families. The organs had markedly lower levels of the neurotransmitter serotonin than those of depressed people who had died in other ways.

More recent work by him and his colleague Maria Oquendo, a psychiatrist at the University of Pennsylvania, suggests low serotonin levels may be more common in depressed people who attempt or die by suicide after struggling with persistent suicidal thoughts. That hypothesis is based on studies in which the pair used positron emission tomography (PET) imaging, which uses radioactive labels to track neurotransmitters, to capture serotonin levels in the brain. The team's data, which included a 2016 study of 100 depressed and suicidal people, suggest the low-serotonin group is biologically distinct from people who experience "spiky" bursts of suicidal thoughts during acute stress, such as a financial catastrophe or a breakup.

A June study in the Proceedings of the National Academy of Sciences, led by neuroscientist Irina Esterlis at Yale University, marked another step forward. It focused on post-traumatic stress disorder (PTSD), which can also raise the risk of suicide. Esterlis's group also used PET imaging. Among people with PTSD, those who had experienced suicidal thoughts had 30% more receptors for the signaling molecule glutamate, suggesting they were making less glutamate and the brain was struggling to compensate. The work pointed to a biomarker of suicide risk in people with PTSD. Her finding also engendered hope that ketamine, a drug that targets glutamate, might help people in that group. Recently approved as a rapid-acting antidepressant, ketamine is now being tested to see whether it can reduce suicidality.

Categorizing patients into neat buckets on the basis of neurotransmitter levels and other brain scan features is challenging. No matter what any scan measures and what struggles a patient faces, a scan is a snapshot in time. It can't reliably capture symptoms that wax and wane. "How does one pull up a brain readout of an emotional fluctuation like a surge of elation or anxiety or suicidal thoughts?" asks Helen Mayberg, a neurologist at Mount Sinai Hospital in New York City.

Depression subtypes can be parsed in many ways, and scientists don't agree on the best approach. Some researchers sort people based on how they respond to treatment, others according to symptoms. Volunteers are typically asked to engage in mental tasks, but those tasks can vary. Other researchers use biological markers as diverse as genetics, hormones, and gut bacteria to distinguish dozens of depression categories. In a 2016 study, on which Mayberg was an author, researchers analyzing 1000 functional magnetic resonance imaging (fMRI) scans of depressed people found four depression subtypes, not the six Williams has identified. Unlike PET scans, fMRIs measure brain activity by detecting changes in blood oxygen levels. But a separate group could not replicate the finding, Mayberg notes.

Because depression is so varied and complex, nailing down definitive categories could take many thousands of brain scans, says Elizabeth Ballard, a clinical psychologist at the National Institute of Mental Health in Bethesda, Maryland. But, "Everybody acknowledges that is what's needed," she says.

If the goal is to prevent suicides, some researchers also question whether probing depression is a good starting point, because most of those patients aren't at risk. Some scientists even argue that the biology of suicidal behavior is so different from that of depression—and can include symptoms of anxiety, agitation, and impulsivity—that "suicidal behavior" should be a stand-alone diagnosis. "We can't simply rely on the treatment of depression" to prevent suicide, Oquendo says, because suicidal behavior has different biological roots.

Williams agrees that suicidality and depression don't neatly align, but she rejects the notion that they must be studied separately. In some people, the two are undoubtedly intertwined, she says. Her partner, an emergency room doctor, had long struggled with depression but feared that seeking treatment could mar his professional reputation. Four years ago, he killed himself. The loss steeled her resolve to crack the biology of depression and improve its treatment. "Regardless of the labels," Williams says, "we need to look at where the crisis is."

For Williams, characterizing depression begins with the fMRI scanner, where her study volunteers lie, heads immobilized, while performing a battery of mental tasks. Each task exercises a different assembly of circuits that correspond to the six depression subtypes Williams has hypothesized are key to guiding treatment. The subtypes marked by repetitious negative thoughts and anhedonia are rooted in the default mode and reward circuits, whereas others involve circuits that respond to threat or help the brain maintain focus. When those circuits are dysfunctional, people may interpret events in a more negative light or feel trapped inside a mental "fog," Williams says.

The scan detects neuronal activity by measuring changes in blood oxygen levels, revealing how different regions of the brain fire and coordinate brainwide neuronal chatter. To account for individual variation in brain structure and activity, researchers must digitally "strip" the brain from the skull and align it to a standard model, says neuroimaging research engineer Brooke Staveland, who works with Williams at Stanford.

Sophisticated computer algorithms extract relevant patterns from the fMRI results and compare them with the healthy baseline. The result is a six-item chart that scores activity in each circuit, helping the researchers flag abnormalities.

Although Williams and her team have scanned patients with depression for years, the 8-week RAD-AT study goes a step further. It examines how 160 people with the anhedonia depression subtype, who often aren't helped by antidepressant drugs, respond to two treatments: transcranial magnetic stimulation, a noninvasive therapy that uses magnetic fields to stimulate nerve cells and is approved for treatment-resistant depression, and pramipexole, a drug for Parkinson's disease. Pramipexole mimics dopamine, the signaling molecule for the reward circuit that seems sluggish in those patients. In other studies, Williams is targeting additional subtypes, such as the tough-to-treat variants involving the default mode and cognitive control networks.

To qualify for RAD-AT, volunteers must score higher than normal on a standard questionnaire of anhedonia. Those who do are offered one of the two treatments. (Because pramipexole can increase impulsivity, actively suicidal people are excluded from the study for safety reasons.) Participants get their brains scanned beforehand to gauge activity in the reward and other depression-related circuits. After 8 weeks, they'll get scanned again to see whether treatment altered the circuits' activity and whether that change is associated with a change in symptoms.

Moe's brain scans are among those now being analyzed and considered alongside his clinical history. So far, the two appear to match up: He maxed out at an anhedonia score of 50, the highest possible, and had abnormally low activity on a task that activates the reward circuit: looking at photos of happy faces. If Moe's inability to experience pleasure is driven by too little dopamine, pramipexole could help, Williams says. In July, Moe agreed to take it.

What ultimately matters to Williams is not the number of depression or suicide subtypes, but how that knowledge helps patients. One barrier to widespread application is the time and expense of brain scanning. Williams is working to shorten the time to analyze a scan from a few hours to 5 minutes, and she and colleagues are weighing whether more easily tracked measures, such as heart rate, can serve as proxies for certain neuroimaging data. If so, the researchers hope to create wearable devices to help monitor depression, anxiety, and suicidal behaviors in real time. But first Williams needs more data, from her own lab and others, to determine whether differences in brain biology can translate to better treatment decisions.

RAD-AT is slated to end next year. Meanwhile, Williams and colleagues are running other neuroimaging studies, including one of 250 young people with depression that will explore how suicidal thoughts and prior attempts manifest in the brain. One young woman, who was actively suicidal, had refused medication because it failed her in the past. Brain scans suggested an abnormality in one of the three brain circuit types that don't respond well to antidepressants. She was then offered—and accepted—transcranial magnetic stimulation because previous studies showed its ability to correct abnormal activity in that network.

Her symptom scores and level of suicidality dropped into the healthy range. "I remember when she said to her mom, ‘I feel like myself,’" Williams says. Recasting depression as a disease of misfiring circuits can be a huge relief for people, she believes. Depression's stigma stopped her partner from seeking treatment. By lifting it, she hopes to make it easier for others to get help.
Moe is providing another, still provisional, data point. After 2 weeks on pramipexole, he felt better than he had in years. While driving to Stanford for an appointment, Moe switched on his car radio and heard the indie rock he'd loved in college. To his amazement, the music moved him. "I teared up for the first time in a long time, not because I was sad but because I was connecting with something again," he says.

Moe knows it's too early to tell whether what he describes as his reawakening will endure. If he continues to benefit, he'll keep taking pramipexole under a psychiatrist's supervision. But right now, he feels hope. "It's so weird," he says, "that you can take a medication and then wake up and say, ‘I think there's a future now.’"

A Therapist’s Guide to Staying Sane During a Pandemic
You can let anxiety consume you, or you can feel the fear and also find joy in ordinary life, even now.

This article appeared in "The Atlantic"
by Lori Gottlieb
March 17, 2020

“IF I CAN'T TOUCH MY FACE SOON, I MAY NEED TO GO TO THERAPY!” I tweeted last week when coronavirus panic seemed to reach a new high.
I’m a psychotherapist—I write the “Dear Therapist” column for this publication—and underneath the quip was the hope that others might feel less alone in this very strange and anxiety-provoking time. Yes, we have bigger concerns than suppressing the urge to touch our face all day long (though who knew we touched it so much?). Yes, people are dying, others are critically ill, and more confirmed cases are announced daily.

But also, there’s this: Our hands are chapped from sanitizers and soap, our kids are home from school, our workplaces are shutting down, our in-person gatherings have been canceled, and our grocery-store shelves are nearly empty. In other words, our lives are affected in ways big and small, but at least we’re in this seemingly surreal situation together.
That was what I was getting at, anyway. Then someone tweeted back at me: “Not funny.”

It’s true; a global pandemic isn’t funny. But as we all take measures to protect our physical health, we also need to protect our emotional health. So what I responded with was this: “Everyone copes with horrible situations differently. For some, humor is a balm. It’s BOTH/AND: It’s horrible AND we can allow our souls to breathe.”

Both/and is a concept I often share with my therapy patients, but it’s especially relevant now if we’re going to bolster our psychological immune systems along with our physical ones. Both/and is how I can say to my son “I’m so glad I get to spend this extra time with you” when I walk past his remote classroom (i.e., the den). He’ll be going to college in the not-too-distant future, and although the reason he’s home with me is horrible, I’m still glad to see him. It’s both/and.

Of course, it’s normal to feel anxiety right now, and while we need to allow ourselves the space to feel these feelings, we also need to give ourselves the space to let them go. Some anxiety is productive—it’s what motivates us to wash our hands often and distance ourselves from others when there’s an important reason to do so. If we weren’t reasonably worried, none of us would be taking these measures, and the virus would spread even more. But unproductive anxiety— unchecked rumination—can make our mind spin in all kinds of frightening directions. Instead of helping us to stay grounded in the present--I’m safe and making dinner; I’m snuggled up with my family as we watch this movie; I’m writing this column—our anxiety spins stories about the future that go something like I or someone I love will get deathly ill from the coronavirus.
This kind of anxiety causes us to futurize and catastrophize, both of which take up a lot of emotional real estate. It’s a vicious cycle: The more we worry, the more we try to control our worry with something tangible, such as information. But clinging to our screens for the latest update has the opposite effect because it serves as fodder for more futurizing and catastrophizing. A daily update makes sense. But bingeing on up-to-the-minute news is like stress eating—it’s bloating our minds with unhealthy food that will make us feel sick.

A few years ago, a patient of mine who was going through cancer treatment told me that she’d come to a realization: She could think about her cancer all day, about the uncertainty of what might happen, or she could feel her fear at times but also be present in her life right now. She could watch Netflix with her husband and have a dance party with her young children and belt out a song in the shower in between her moments of understandable fear.

Today, she’s cancer-free—for now. She’s aware that the cancer could come back. Is that cough just reflux or something else? Is this fatigue at the end of the weekend due to three birthday parties, a soccer match, and a child’s piano recital, or a possible recurrence? It’s on her mind daily, the way COVID-19, the disease caused by the novel coronavirus, is on most of our minds daily, but the anxiety no longer consumes her the way she imagined it would, because when she had cancer, she became a master at living in the mindset of both/and.

This same patient once observed that most people complain about the ordinary until they no longer have it. Then, when it’s disrupted, they desperately want it back—but don’t realize that what they took for granted is still right there in front of them. Her experience applies to many of us now. In being confined to our homes as much as possible, whether alone or together, we have an opportunity to embrace the ordinary—to play board games, cook meals, watch entire TV seasons, read books, take walks, do puzzles, get those art supplies out of the back of the closet, catch up with people we “meant to call” weeks or months ago and make one another laugh—precisely because our busy routines have been disrupted.

All of this ordinariness connects us at a time when we need connection the most. We’re calling people and talking voice-to-voice, giving them our full attention when we ask, “How are you?” because we’re particularly invested in the answer. We’re taking quiet walks with a friend or family member. We’re experiencing the intimacy of seeing inside our co-workers’ bedrooms with their hastily made beds in our Zoom meetings. We’re asking about their parents, siblings, spouses, and children in a way we don’t normally do at the office. We’re publicly reaching out on social media to recommend books, movies, podcasts, soothing playlists, and museums we can visit virtually while we’re separate but oh-so-together in our fear. In this world that has had trouble practicing civility lately, we are experiencing a much-needed resurgence of kindness.

And, yes, we’re laughing about the fact that we can’t touch our face. Or about how we’re channeling our anxiety into a massive spring cleaning (both Marie Kondo–style and disinfectant-style). Or about how we can’t get the “Happy Birthday” song out of our head at night after singing it while washing our hands all day.

For me, in the past couple of days, COVID-19 has gone from a tragic news story to a real threat to people I know. A friend’s close friend was hospitalized with the virus. I’m not minimizing the seriousness of this pandemic, and I don’t have my head in the sand, but I’m taking good psychological care, and I recommend that all of us pay as much attention to protecting our emotional health as we do to guarding our physical health. A virus can invade our bodies, but we get to decide whether we let it invade our minds.
So let’s all let out a big exhale (10 feet away from other people) and remind ourselves to practice both/and as many times a day as we need to. 

Lori Gottlieb is a contributing writer at The Atlantic and a psychotherapist based in Los Angeles. She is the author of Maybe You Should Talk to Someone.

Story by David Brooks
March 2020 Issue

The scene is one many of us have somewhere in our family history: Dozens of people celebrating Thanksgiving or some other holiday around a makeshift stretch of family tables—siblings, cousins, aunts, uncles, great-aunts. The grandparents are telling the old family stories for the 37th time. “It was the most beautiful place you’ve ever seen in your life,” says one, remembering his first day in America. “There were lights everywhere … It was a celebration of light! I thought they were for me.”
 
The oldsters start squabbling about whose memory is better. “It was cold that day,” one says about some faraway memory. “What are you talking about? It was May, late May,” says another. The young children sit wide-eyed, absorbing family lore and trying to piece together the plotline of the generations.

After the meal, there are piles of plates in the sink, squads of children conspiring mischievously in the basement. Groups of young parents huddle in a hallway, making plans. The old men nap on couches, waiting for dessert. It’s the extended family in all its tangled, loving, exhausting glory.
This particular family is the one depicted in Barry Levinson’s 1990 film, Avalon, based on his own childhood in Baltimore. Five brothers came to America from Eastern Europe around the time of World War I and built a wallpaper business. For a while they did everything together, like in the old country. But as the movie goes along, the extended family begins to split apart. Some members move to the suburbs for more privacy and space. One leaves for a job in a different state. The big blowup comes over something that seems trivial but isn’t: The eldest of the brothers arrives late to a Thanksgiving dinner to find that the family has begun the meal without him.

“You cut the turkey without me?” he cries. “Your own flesh and blood! … You cut the turkey?” The pace of life is speeding up. Convenience, privacy, and mobility are more important than family loyalty. “The idea that they would eat before the brother arrived was a sign of disrespect,” Levinson told me recently when I asked him about that scene. “That was the real crack in the family. When you violate the protocol, the whole family structure begins to collapse.”

As the years go by in the movie, the extended family plays a smaller and smaller role. By the 1960s, there’s no extended family at Thanksgiving. It’s just a young father and mother and their son and daughter, eating turkey off trays in front of the television. In the final scene, the main character is living alone in a nursing home, wondering what happened. “In the end, you spend everything you’ve ever saved, sell everything you’ve ever owned, just to exist in a place like this.”
“In my childhood,” Levinson told me, “you’d gather around the grandparents and they would tell the family stories … Now individuals sit around the TV, watching other families’ stories.” The main theme of Avalon, he said, is “the decentralization of the family. And that has continued even further today. Once, families at least gathered around the television. Now each person has their own screen.”

This is the story of our times—the story of the family, once a dense cluster of many siblings and extended kin, fragmenting into ever smaller and more fragile forms. The initial result of that fragmentation, the nuclear family, didn’t seem so bad. But then, because the nuclear family is so brittle, the fragmentation continued. In many sectors of society, nuclear families fragmented into single-parent families, single-parent families into chaotic families or no families.
If you want to summarize the changes in family structure over the past century, the truest thing to say is this: We’ve made life freer for individuals and more unstable for families. We’ve made life better for adults but worse for children. We’ve moved from big, interconnected, and extended families, which helped protect the most vulnerable people in society from the shocks of life, to smaller, detached nuclear families (a married couple and their children), which give the most privileged people in society room to maximize their talents and expand their options. The shift from bigger and interconnected extended families to smaller and detached nuclear families ultimately led to a familial system that liberates the rich and ravages the working-class and the poor.
This article is about that process, and the devastation it has wrought—and about how Americans are now groping to build new kinds of family and find better ways to live.

Part I
The Era of Extended Clans

Through the early parts of American history, most people lived in what, by today’s standards, were big, sprawling households. In 1800, three-quarters of American workers were farmers. Most of the other quarter worked in small family businesses, like dry-goods stores. People needed a lot of labor to run these enterprises. It was not uncommon for married couples to have seven or eight children. In addition, there might be stray aunts, uncles, and cousins, as well as unrelated servants, apprentices, and farmhands. (On some southern farms, of course, enslaved African Americans were also an integral part of production and work life.)

Steven Ruggles, a professor of history and population studies at the University of Minnesota, calls these “corporate families”—social units organized around a family business. According to Ruggles, in 1800, 90 percent of American families were corporate families. Until 1850, roughly three-quarters of Americans older than 65 lived with their kids and grandkids. Nuclear families existed, but they were surrounded by extended or corporate families.

Extended families have two great strengths. The first is resilience. An extended family is one or more families in a supporting web. Your spouse and children come first, but there are also cousins, in-laws, grandparents—a complex web of relationships among, say, seven, 10, or 20 people. If a mother dies, siblings, uncles, aunts, and grandparents are there to step in. If a relationship between a father and a child ruptures, others can fill the breach. Extended families have more people to share the unexpected burdens—when a kid gets sick in the middle of the day or when an adult unexpectedly loses a job.

A detached nuclear family, by contrast, is an intense set of relationships among, say, four people. If one relationship breaks, there are no shock absorbers. In a nuclear family, the end of the marriage means the end of the family as it was previously understood.

The second great strength of extended families is their socializing force. Multiple adults teach children right from wrong, how to behave toward others, how to be kind. Over the course of the 18th and 19th centuries, industrialization and cultural change began to threaten traditional ways of life. Many people in Britain and the United States doubled down on the extended family in order to create a moral haven in a heartless world. According to Ruggles, the prevalence of extended families living together roughly doubled from 1750 to 1900, and this way of life was more common than at any time before or since.

During the Victorian era, the idea of “hearth and home” became a cultural ideal. The home “is a sacred place, a vestal temple, a temple of the hearth watched over by Household Gods, before whose faces none may come but those whom they can receive with love,” the great Victorian social critic John Ruskin wrote. This shift was led by the upper-middle class, which was coming to see the family less as an economic unit and more as an emotional and moral unit, a rectory for the formation of hearts and souls.

But while extended families have strengths, they can also be exhausting and stifling. They allow little privacy; you are forced to be in daily intimate contact with people you didn’t choose. There’s more stability but less mobility. Family bonds are thicker, but individual choice is diminished. You have less space to make your own way in life. In the Victorian era, families were patriarchal, favoring men in general and first-born sons in particular.

As factories opened in the big U.S. cities, in the late 19th and early 20th centuries, young men and women left their extended families to chase the American dream. These young people married as soon as they could. A young man on a farm might wait until 26 to get married; in the lonely city, men married at 22 or 23. From 1890 to 1960, the average age of first marriage dropped by 3.6 years for men and 2.2 years for women.

The families they started were nuclear families. The decline of multigenerational cohabiting families exactly mirrors the decline in farm employment. Children were no longer raised to assume economic roles—they were raised so that at adolescence they could fly from the nest, become independent, and seek partners of their own. They were raised not for embeddedness but for autonomy. By the 1920s, the nuclear family with a male breadwinner had replaced the corporate family as the dominant family form. By 1960, 77.5 percent of all children were living with their two parents, who were married, and apart from their extended family.

The Short, Happy Life of the Nuclear Family

For a time, it all seemed to work. From 1950 to 1965, divorce rates dropped, fertility rates rose, and the American nuclear family seemed to be in wonderful shape. And most people seemed prosperous and happy. In these years, a kind of cult formed around this type of family—what McCall’s, the leading women’s magazine of the day, called “togetherness.” Healthy people lived in two-parent families. In a 1957 survey, more than half of the respondents said that unmarried people were “sick,” “immoral,” or “neurotic.”

During this period, a certain family ideal became engraved in our minds: a married couple with 2.5 kids. When we think of the American family, many of us still revert to this ideal. When we have debates about how to strengthen the family, we are thinking of the two-parent nuclear family, with one or two kids, probably living in some detached family home on some suburban street. We take it as the norm, even though this wasn’t the way most humans lived during the tens of thousands of years before 1950, and it isn’t the way most humans have lived during the 55 years since 1965.

Today, only a minority of American households are traditional two-parent nuclear families and only one-third of American individuals live in this kind of family. That 1950–65 window was not normal. It was a freakish historical moment when all of society conspired, wittingly and not, to obscure the essential fragility of the nuclear family.

For one thing, most women were relegated to the home. Many corporations, well into the mid-20th century, barred married women from employment: Companies would hire single women, but if those women got married, they would have to quit. Demeaning and disempowering treatment of women was rampant. Women spent enormous numbers of hours trapped inside the home under the headship of their husband, raising children.

For another thing, nuclear families in this era were much more connected to other nuclear families than they are today—constituting a “modified extended family,” as the sociologist Eugene Litwak calls it, “a coalition of nuclear families in a state of mutual dependence.” Even as late as the 1950s, before television and air-conditioning had fully caught on, people continued to live on one another’s front porches and were part of one another’s lives. Friends felt free to discipline one another’s children.

In his book The Lost City, the journalist Alan Ehrenhalt describes life in mid-century Chicago and its suburbs:
"To be a young homeowner in a suburb like Elmhurst in the 1950s was to participate in a communal enterprise that only the most determined loner could escape: barbecues, coffee klatches, volleyball games, baby-sitting co-ops and constant bartering of household goods, child rearing by the nearest parents who happened to be around, neighbors wandering through the door at any hour without knocking—all these were devices by which young adults who had been set down in a wilderness of tract homes made a community. It was a life lived in public.Finally, conditions in the wider society were ideal for family stability. The postwar period was a high-water mark of church attendance, unionization, social trust, and mass prosperity—all things that correlate with family cohesion. A man could relatively easily find a job that would allow him to be the breadwinner for a single-income family. By 1961, the median American man age 25 to 29 was earning nearly 400 percent more than his father had earned at about the same age."

In short, the period from 1950 to 1965 demonstrated that a stable society can be built around nuclear families—so long as women are relegated to the household, nuclear families are so intertwined that they are basically extended families by another name, and every economic and sociological condition in society is working together to support the institution.

Disintegration

But these conditions did not last. The constellation of forces that had briefly shored up the nuclear family began to fall away, and the sheltered family of the 1950s was supplanted by the stressed family of every decade since. Some of the strains were economic. Starting in the mid-’70s, young men’s wages declined, putting pressure on working-class families in particular. The major strains were cultural. Society became more individualistic and more self-oriented. People put greater value on privacy and autonomy. A rising feminist movement helped endow women with greater freedom to live and work as they chose.

A study of women’s magazines by the sociologists Francesca Cancian and Steven L. Gordon found that from 1900 to 1979, themes of putting family before self dominated in the 1950s: “Love means self-sacrifice and compromise.” In the 1960s and ’70s, putting self before family was prominent: “Love means self-expression and individuality.” Men absorbed these cultural themes, too. The master trend in Baby Boomer culture generally was liberation—“Free Bird,” “Born to Run,” “Ramblin’ Man.”

Eli Finkel, a psychologist and marriage scholar at Northwestern University, has argued that since the 1960s, the dominant family culture has been the “self-expressive marriage.” “Americans,” he has written, “now look to marriage increasingly for self-discovery, self-esteem and personal growth.” Marriage, according to the sociologists Kathryn Edin and Maria Kefalas, “is no longer primarily about childbearing and childrearing. Now marriage is primarily about adult fulfillment.”

This cultural shift was very good for some adults, but it was not so good for families generally. Fewer relatives are around in times of stress to help a couple work through them. If you married for love, staying together made less sense when the love died. This attenuation of marital ties may have begun during the late 1800s: The number of divorces increased about fifteenfold from 1870 to 1920, and then climbed more or less continuously through the first several decades of the nuclear-family era. As the intellectual historian Christopher Lasch noted in the late 1970s, the American family didn’t start coming apart in the 1960s; it had been “coming apart for more than 100 years.”

Americans today have less family than ever before. From 1970 to 2012, the share of households consisting of married couples with kids has been cut in half. In 1960, according to census data, just 13 percent of all households were single-person households. In 2018, that figure was 28 percent. In 1850, 75 percent of Americans older than 65 lived with relatives; by 1990, only 18 percent did.

Over the past two generations, people have spent less and less time in marriage—they are marrying later, if at all, and divorcing more. In 1950, 27 percent of marriages ended in divorce; today, about 45 percent do. In 1960, 72 percent of American adults were married. In 2017, nearly half of American adults were single. According to a 2014 report from the Urban Institute, roughly 90 percent of Baby Boomer women and 80 percent of Gen X women married by age 40, while only about 70 percent of late-Millennial women were expected to do so—the lowest rate in U.S. history. And while more than four-fifths of American adults in a 2019 Pew Research Center survey said that getting married is not essential to living a fulfilling life, it’s not just the institution of marriage they’re eschewing: In 2004, 33 percent of Americans ages 18 to 34 were living without a romantic partner, according to the General Social Survey; by 2018, that number was up to 51 percent.

Over the past two generations, families have also gotten a lot smaller. The general American birth rate is half of what it was in 1960. In 2012, most American family households had no children. There are more American homes with pets than with kids. In 1970, about 20 percent of households had five or more people. As of 2012, only 9.6 percent did.

We’re likely living through the most rapid change in family structure in human history. The causes are economic, cultural, and institutional all at once.Over the past two generations, the physical space separating nuclear families has widened. Before, sisters-in-law shouted greetings across the street at each other from their porches. Kids would dash from home to home and eat out of whoever’s fridge was closest by. But lawns have grown more expansive and porch life has declined, creating a buffer of space that separates the house and family from anyone else. As Mandy Len Catron recently noted in The Atlantic, married people are less likely to visit parents and siblings, and less inclined to help them do chores or offer emotional support. A code of family self-sufficiency prevails: Mom, Dad, and the kids are on their own, with a barrier around their island home.

Finally, over the past two generations, families have grown more unequal. America now has two entirely different family regimes. Among the highly educated, family patterns are almost as stable as they were in the 1950s; among the less fortunate, family life is often utter chaos. There’s a reason for that divide: Affluent people have the resources to effectively buy extended family, in order to shore themselves up. Think of all the child-rearing labor affluent parents now buy that used to be done by extended kin: babysitting, professional child care, tutoring, coaching, therapy, expensive after-school programs. (For that matter, think of how the affluent can hire therapists and life coaches for themselves, as replacement for kin or close friends.) These expensive tools and services not only support children’s development and help prepare them to compete in the meritocracy; by reducing stress and time commitments for parents, they preserve the amity of marriage. Affluent conservatives often pat themselves on the back for having stable nuclear families. They preach that everybody else should build stable families too. But then they ignore one of the main reasons their own families are stable: They can afford to purchase the support that extended family used to provide—and that the people they preach at, further down the income scale, cannot.

In 1970, the family structures of the rich and poor did not differ that greatly. Now there is a chasm between them. As of 2005, 85 percent of children born to upper-middle-class families were living with both biological parents when the mom was 40. Among working-class families, only 30 percent were. According to a 2012 report from the National Center for Health Statistics, college-educated women ages 22 to 44 have a 78 percent chance of having their first marriage last at least 20 years. Women in the same age range with a high-school degree or less have only about a 40 percent chance. Among Americans ages 18 to 55, only 26 percent of the poor and 39 percent of the working class are currently married. In her book Generation Unbound, Isabel Sawhill, an economist at the Brookings Institution, cited research indicating that differences in family structure have “increased income inequality by 25 percent.” If the U.S. returned to the marriage rates of 1970, child poverty would be 20 percent lower. As Andrew Cherlin, a sociologist at Johns Hopkins University, once put it, “It is the privileged Americans who are marrying, and marrying helps them stay privileged.”

When you put everything together, we’re likely living through the most rapid change in family structure in human history. The causes are economic, cultural, and institutional all at once. People who grow up in a nuclear family tend to have a more individualistic mind-set than people who grow up in a multigenerational extended clan. People with an individualistic mind-set tend to be less willing to sacrifice self for the sake of the family, and the result is more family disruption. People who grow up in disrupted families have more trouble getting the education they need to have prosperous careers. People who don’t have prosperous careers have trouble building stable families, because of financial challenges and other stressors. The children in those families become more isolated and more traumatized.

Many people growing up in this era have no secure base from which to launch themselves and no well-defined pathway to adulthood. For those who have the human capital to explore, fall down, and have their fall cushioned, that means great freedom and opportunity—and for those who lack those resources, it tends to mean great confusion, drift, and pain.

Over the past 50 years, federal and state governments have tried to mitigate the deleterious effects of these trends. They’ve tried to increase marriage rates, push down divorce rates, boost fertility, and all the rest. The focus has always been on strengthening the nuclear family, not the extended family. Occasionally, a discrete program will yield some positive results, but the widening of family inequality continues unabated.

The people who suffer the most from the decline in family support are the vulnerable—especially children. In 1960, roughly 5 percent of children were born to unmarried women. Now about 40 percent are. The Pew Research Center reported that 11 percent of children lived apart from their father in 1960. In 2010, 27 percent did. Now about half of American children will spend their childhood with both biological parents. Twenty percent of young adults have no contact at all with their father (though in some cases that’s because the father is deceased). American children are more likely to live in a single-parent household than children from any other country.

We all know stable and loving single-parent families. But on average, children of single parents or unmarried cohabiting parents tend to have worse health outcomes, worse mental-health outcomes, less academic success, more behavioral problems, and higher truancy rates than do children living with their two married biological parents. According to work by Richard V. Reeves, a co-director of the Center on Children and Families at the Brookings Institution, if you are born into poverty and raised by your married parents, you have an 80 percent chance of climbing out of it. If you are born into poverty and raised by an unmarried mother, you have a 50 percent chance of remaining stuck.

It’s not just the lack of relationships that hurts children; it’s the churn. According to a 2003 study that Andrew Cherlin cites, 12 percent of American kids had lived in at least three “parental partnerships” before they turned 15. The transition moments, when mom’s old partner moves out or her new partner moves in, are the hardest on kids, Cherlin shows.

While children are the vulnerable group most obviously affected by recent changes in family structure, they are not the only one.

Consider single men. Extended families provided men with the fortifying influences of male bonding and female companionship. Today many American males spend the first 20 years of their life without a father and the next 15 without a spouse. Kay Hymowitz of the Manhattan Institute has spent a good chunk of her career examining the wreckage caused by the decline of the American family, and cites evidence showing that, in the absence of the connection and meaning that family provides, unmarried men are less healthy—alcohol and drug abuse are common—earn less, and die sooner than married men.

The period when the nuclear family flourished was not normal. It was a freakish historical moment when all of society conspired to obscure its essential fragility.For women, the nuclear-family structure imposes different pressures. Though women have benefited greatly from the loosening of traditional family structures—they have more freedom to choose the lives they want—many mothers who decide to raise their young children without extended family nearby find that they have chosen a lifestyle that is brutally hard and isolating. The situation is exacerbated by the fact that women still spend significantly more time on housework and child care than men do, according to recent data. Thus, the reality we see around us: stressed, tired mothers trying to balance work and parenting, and having to reschedule work when family life gets messy.

Without extended families, older Americans have also suffered. According to the AARP, 35 percent of Americans over 45 say they are chronically lonely. Many older people are now “elder orphans,” with no close relatives or friends to take care of them. In 2015, The New York Times ran an article called “The Lonely Death of George Bell,” about a family-less 72-year-old man who died alone and rotted in his Queens apartment for so long that by the time police found him, his body was unrecognizable.

Finally, because groups that have endured greater levels of discrimination tend to have more fragile families, African Americans have suffered disproportionately in the era of the detached nuclear family. Nearly half of black families are led by an unmarried single woman, compared with less than one-sixth of white families. (The high rate of black incarceration guarantees a shortage of available men to be husbands or caretakers of children.) According to census data from 2010, 25 percent of black women over 35 have never been married, compared with 8 percent of white women. Two-thirds of African American children lived in single-parent families in 2018, compared with a quarter of white children. Black single-parent families are most concentrated in precisely those parts of the country in which slavery was most prevalent. Research by John Iceland, a professor of sociology and demography at Penn State, suggests that the differences between white and black family structure explain 30 percent of the affluence gap between the two groups.

In 2004, the journalist and urbanist Jane Jacobs published her final book, an assessment of North American society called Dark Age Ahead. At the core of her argument was the idea that families are “rigged to fail.” The structures that once supported the family no longer exist, she wrote. Jacobs was too pessimistic about many things, but for millions of people, the shift from big and/or extended families to detached nuclear families has indeed been a disaster.
As the social structures that support the family have decayed, the debate about it has taken on a mythical quality. Social conservatives insist that we can bring the nuclear family back. But the conditions that made for stable nuclear families in the 1950s are never returning. Conservatives have nothing to say to the kid whose dad has split, whose mom has had three other kids with different dads; “go live in a nuclear family” is really not relevant advice. If only a minority of households are traditional nuclear families, that means the majority are something else: single parents, never-married parents, blended families, grandparent-headed families, serial partnerships, and so on. Conservative ideas have not caught up with this reality.

Progressives, meanwhile, still talk like self-expressive individualists of the 1970s: People should have the freedom to pick whatever family form works for them. And, of course, they should. But many of the new family forms do not work well for most people—and while progressive elites say that all family structures are fine, their own behavior suggests that they believe otherwise. As the sociologist W. Bradford Wilcox has pointed out, highly educated progressives may talk a tolerant game on family structure when speaking about society at large, but they have extremely strict expectations for their own families. When Wilcox asked his University of Virginia students if they thought having a child out of wedlock was wrong, 62 percent said it was not wrong. When he asked the students how their own parents would feel if they themselves had a child out of wedlock, 97 percent said their parents would “freak out.” In a recent survey by the Institute for Family Studies, college-educated Californians ages 18 to 50 were less likely than those who hadn’t graduated from college to say that having a baby out of wedlock is wrong. But they were more likely to say that personally they did not approve of having a baby out of wedlock.

In other words, while social conservatives have a philosophy of family life they can’t operationalize, because it no longer is relevant, progressives have no philosophy of family life at all, because they don’t want to seem judgmental. The sexual revolution has come and gone, and it’s left us with no governing norms of family life, no guiding values, no articulated ideals. On this most central issue, our shared culture often has nothing relevant to say—and so for decades things have been falling apart.

The good news is that human beings adapt, even if politics are slow to do so. When one family form stops working, people cast about for something new—sometimes finding it in something very old.

Part II
Redefining Kinship

In the beginning was the band. For tens of thousands of years, people commonly lived in small bands of, say, 25 people, which linked up with perhaps 20 other bands to form a tribe. People in the band went out foraging for food and brought it back to share. They hunted together, fought wars together, made clothing for one another, looked after one another’s kids. In every realm of life, they relied on their extended family and wider kin.

Except they didn’t define kin the way we do today. We think of kin as those biologically related to us. But throughout most of human history, kinship was something you could create.

Anthropologists have been arguing for decades about what exactly kinship is. Studying traditional societies, they have found wide varieties of created kinship among different cultures. For the Ilongot people of the Philippines, people who migrated somewhere together are kin. For the New Guineans of the Nebilyer Valley, kinship is created by sharing grease—the life force found in mother’s milk or sweet potatoes. The Chuukese people in Micronesia have a saying: “My sibling from the same canoe”; if two people survive a dangerous trial at sea, then they become kin. On the Alaskan North Slope, the Inupiat name their children after dead people, and those children are considered members of their namesake’s family.

In other words, for vast stretches of human history people lived in extended families consisting of not just people they were related to but people they chose to cooperate with. An international research team recently did a genetic analysis of people who were buried together—and therefore presumably lived together—34,000 years ago in what is now Russia. They found that the people who were buried together were not closely related to one another. In a study of 32 present-day foraging societies, primary kin—parents, siblings, and children—usually made up less than 10 percent of a residential band. Extended families in traditional societies may or may not have been genetically close, but they were probably emotionally closer than most of us can imagine. In a beautiful essay on kinship, Marshall Sahlins, an anthropologist at the University of Chicago, says that kin in many such societies share a “mutuality of being.” The late religion scholar J. Prytz-Johansen wrote that kinship is experienced as an “inner solidarity” of souls. The late South African anthropologist Monica Wilson described kinsmen as “mystically dependent” on one another. Kinsmen belong to one another, Sahlins writes, because they see themselves as “members of one another.”

Back in the 17th and 18th centuries, when European Protestants came to North America, their relatively individualistic culture existed alongside Native Americans’ very communal culture. In his book Tribe, Sebastian Junger describes what happened next: While European settlers kept defecting to go live with Native American families, almost no Native Americans ever defected to go live with European families. Europeans occasionally captured Native Americans and forced them to come live with them. They taught them English and educated them in Western ways. But almost every time they were able, the indigenous Americans fled. European settlers were sometimes captured by Native Americans during wars and brought to live in Native communities. They rarely tried to run away. This bothered the Europeans. They had the superior civilization, so why were people voting with their feet to go live in another way?

When you read such accounts, you can’t help but wonder whether our civilization has somehow made a gigantic mistake.

We can’t go back, of course. Western individualists are no longer the kind of people who live in prehistoric bands. We may even no longer be the kind of people who were featured in the early scenes of Avalon. We value privacy and individual freedom too much.

Our culture is oddly stuck. We want stability and rootedness, but also mobility, dynamic capitalism, and the liberty to adopt the lifestyle we choose. We want close families, but not the legal, cultural, and sociological constraints that made them possible. We’ve seen the wreckage left behind by the collapse of the detached nuclear family. We’ve seen the rise of opioid addiction, of suicide, of depression, of inequality—all products, in part, of a family structure that is too fragile, and a society that is too detached, disconnected, and distrustful. And yet we can’t quite return to a more collective world. The words the historians Steven Mintz and Susan Kellogg wrote in 1988 are even truer today: “Many Americans are groping for a new paradigm of American family life, but in the meantime a profound sense of confusion and ambivalence reigns.”

From Nuclear Families to Forged Families

Yet recent signs suggest at least the possibility that a new family paradigm is emerging. Many of the statistics I’ve cited are dire. But they describe the past—what got us to where we are now. In reaction to family chaos, accumulating evidence suggests, the prioritization of family is beginning to make a comeback. Americans are experimenting with new forms of kinship and extended family in search of stability.

Usually behavior changes before we realize that a new cultural paradigm has emerged. Imagine hundreds of millions of tiny arrows. In times of social transformation, they shift direction—a few at first, and then a lot. Nobody notices for a while, but then eventually people begin to recognize that a new pattern, and a new set of values, has emerged.

That may be happening now—in part out of necessity but in part by choice. Since the 1970s, and especially since the 2008 recession, economic pressures have pushed Americans toward greater reliance on family. Starting around 2012, the share of children living with married parents began to inch up. And college students have more contact with their parents than they did a generation ago. We tend to deride this as helicopter parenting or a failure to launch, and it has its excesses. But the educational process is longer and more expensive these days, so it makes sense that young adults rely on their parents for longer than they used to.

In 1980, only 12 percent of Americans lived in multigenerational households. But the financial crisis of 2008 prompted a sharp rise in multigenerational homes. Today 20 percent of Americans--64 million people, an all-time high—live in multigenerational homes.

The revival of the extended family has largely been driven by young adults moving back home. In 2014, 35 percent of American men ages 18 to 34 lived with their parents. In time this shift might show itself to be mostly healthy, impelled not just by economic necessity but by beneficent social impulses; polling data suggest that many young people are already looking ahead to helping their parents in old age.

Another chunk of the revival is attributable to seniors moving in with their children. The percentage of seniors who live alone peaked around 1990. Now more than a fifth of Americans 65 and over live in multigenerational homes. This doesn’t count the large share of seniors who are moving to be close to their grandkids but not into the same household.

Immigrants and people of color—many of whom face greater economic and social stress—are more likely to live in extended-family households. More than 20 percent of Asians, black people, and Latinos live in multigenerational households, compared with 16 percent of white people. As America becomes more diverse, extended families are becoming more common.

African Americans have always relied on extended family more than white Americans do. “Despite the forces working to separate us—slavery, Jim Crow, forced migration, the prison system, gentrification—we have maintained an incredible commitment to each other,” Mia Birdsong, the author of the forthcoming book How We Show Up, told me recently. “The reality is, black families are expansive, fluid, and brilliantly rely on the support, knowledge, and capacity of ‘the village’ to take care of each other. Here’s an illustration: The white researcher/social worker/whatever sees a child moving between their mother’s house, their grandparents’ house, and their uncle’s house and sees that as ‘instability.’ But what’s actually happening is the family (extended and chosen) is leveraging all of its resources to raise that child.”

The black extended family survived even under slavery, and all the forced family separations that involved. Family was essential in the Jim Crow South and in the inner cities of the North, as a way to cope with the stresses of mass migration and limited opportunities, and with structural racism. But government policy sometimes made it more difficult for this family form to thrive. I began my career as a police reporter in Chicago, writing about public-housing projects like Cabrini-Green. Guided by social-science research, politicians tore down neighborhoods of rickety low-rise buildings—uprooting the complex webs of social connection those buildings supported, despite high rates of violence and crime—and put up big apartment buildings. The result was a horror: violent crime, gangs taking over the elevators, the erosion of family and neighborly life. Fortunately, those buildings have since been torn down themselves, replaced by mixed-income communities that are more amenable to the profusion of family forms.

I often ask African friends who have immigrated to America what most struck them when they arrived. Their answer is always a variation on a theme—the loneliness.The return of multigenerational living arrangements is already changing the built landscape. A 2016 survey by a real-estate consulting firm found that 44 percent of home buyers were looking for a home that would accommodate their elderly parents, and 42 percent wanted one that would accommodate their returning adult children. Home builders have responded by putting up houses that are what the construction firm Lennar calls “two homes under one roof.” These houses are carefully built so that family members can spend time together while also preserving their privacy. Many of these homes have a shared mudroom, laundry room, and common area. But the “in-law suite,” the place for aging parents, has its own entrance, kitchenette, and dining area. The “Millennial suite,” the place for boomeranging adult children, has its own driveway and entrance too. These developments, of course, cater to those who can afford houses in the first place—but they speak to a common realization: Family members of different generations need to do more to support one another.

The most interesting extended families are those that stretch across kinship lines. The past several years have seen the rise of new living arrangements that bring nonbiological kin into family or familylike relationships. On the website CoAbode, single mothers can find other single mothers interested in sharing a home. All across the country, you can find co-housing projects, in which groups of adults live as members of an extended family, with separate sleeping quarters and shared communal areas. Common, a real-estate-development company that launched in 2015, operates more than 25 co-housing communities, in six cities, where young singles can live this way. Common also recently teamed up with another developer, Tishman Speyer, to launch Kin, a co-housing community for young parents. Each young family has its own living quarters, but the facilities also have shared play spaces, child-care services, and family-oriented events and outings.

These experiments, and others like them, suggest that while people still want flexibility and some privacy, they are casting about for more communal ways of living, guided by a still-developing set of values. At a co-housing community in Oakland, California, called Temescal Commons, the 23 members, ranging in age from 1 to 83, live in a complex with nine housing units. This is not some rich Bay Area hipster commune. The apartments are small, and the residents are middle- and working-class. They have a shared courtyard and a shared industrial-size kitchen where residents prepare a communal dinner on Thursday and Sunday nights. Upkeep is a shared responsibility. The adults babysit one another’s children, and members borrow sugar and milk from one another. The older parents counsel the younger ones. When members of this extended family have suffered bouts of unemployment or major health crises, the whole clan has rallied together.

Courtney E. Martin, a writer who focuses on how people are redefining the American dream, is a Temescal Commons resident. “I really love that our kids grow up with different versions of adulthood all around, especially different versions of masculinity,” she told me. “We consider all of our kids all of our kids.” Martin has a 3-year-old daughter, Stella, who has a special bond with a young man in his 20s that never would have taken root outside this extended-family structure. “Stella makes him laugh, and David feels awesome that this 3-year-old adores him,” Martin said. This is the kind of magic, she concluded, that wealth can’t buy. You can only have it through time and commitment, by joining an extended family. This kind of community would fall apart if residents moved in and out. But at least in this case, they don’t.

As Martin was talking, I was struck by one crucial difference between the old extended families like those in Avalon and the new ones of today: the role of women. The extended family in Avalon thrived because all the women in the family were locked in the kitchen, feeding 25 people at a time. In 2008, a team of American and Japanese researchers found that women in multigenerational households in Japan were at greater risk of heart disease than women living with spouses only, likely because of stress. But today’s extended-family living arrangements have much more diverse gender roles.

And yet in at least one respect, the new families Americans are forming would look familiar to our hunter-gatherer ancestors from eons ago. That’s because they are chosen families—they transcend traditional kinship lines.

The modern chosen-family movement came to prominence in San Francisco in the 1980s among gay men and lesbians, many of whom had become estranged from their biological families and had only one another for support in coping with the trauma of the AIDS crisis. In her book, Families We Choose: Lesbians, Gays, Kinship, the anthropologist Kath Weston writes, “The families I saw gay men and lesbians creating in the Bay Area tended to have extremely fluid boundaries, not unlike kinship organization among sectors of the African-American, American Indian, and white working class.”

She continues:
Like their heterosexual counterparts, most gay men and lesbians insisted that family members are people who are “there for you,” people you can count on emotionally and materially. “They take care of me,” said one man, “I take care of them.”These groups are what Daniel Burns, a political scientist at the University of Dallas, calls “forged families.” Tragedy and suffering have pushed people together in a way that goes deeper than just a convenient living arrangement. They become, as the anthropologists say, “fictive kin.”

Over the past several decades, the decline of the nuclear family has created an epidemic of trauma—millions have been set adrift because what should have been the most loving and secure relationship in their life broke. Slowly, but with increasing frequency, these drifting individuals are coming together to create forged families. These forged families have a feeling of determined commitment. The members of your chosen family are the people who will show up for you no matter what. On Pinterest you can find placards to hang on the kitchen wall where forged families gather: “Family isn’t always blood. It’s the people in your life who want you in theirs; the ones who accept you for who you are. The ones who would do anything to see you smile & who love you no matter what.”

Two years ago, I started something called Weave: The Social Fabric Project. Weave exists to support and draw attention to people and organizations around the country who are building community. Over time, my colleagues and I have realized that one thing most of the Weavers have in common is this: They provide the kind of care to nonkin that many of us provide only to kin—the kind of support that used to be provided by the extended family.

Lisa Fitzpatrick, who was a health-care executive in New Orleans, is a Weaver. One day she was sitting in the passenger seat of a car when she noticed two young boys, 10 or 11, lifting something heavy. It was a gun. They used it to shoot her in the face. It was a gang-initiation ritual. When she recovered, she realized that she was just collateral damage. The real victims were the young boys who had to shoot somebody to get into a family, their gang.

She quit her job and began working with gang members. She opened her home to young kids who might otherwise join gangs. One Saturday afternoon, 35 kids were hanging around her house. She asked them why they were spending a lovely day at the home of a middle-aged woman. They replied, “You were the first person who ever opened the door.”

In Salt Lake City, an organization called the Other Side Academy provides serious felons with an extended family. Many of the men and women who are admitted into the program have been allowed to leave prison, where they were generally serving long sentences, but must live in a group home and work at shared businesses, a moving company and a thrift store. The goal is to transform the character of each family member. During the day they work as movers or cashiers. Then they dine together and gather several evenings a week for something called “Games”: They call one another out for any small moral failure—being sloppy with a move; not treating another family member with respect; being passive-aggressive, selfish, or avoidant.

Games is not polite. The residents scream at one another in order to break through the layers of armor that have built up in prison. Imagine two gigantic men covered in tattoos screaming “Fuck you! Fuck you! Fuck you!” At the session I attended, I thought they would come to blows. But after the anger, there’s a kind of closeness that didn’t exist before. Men and women who have never had a loving family suddenly have “relatives” who hold them accountable and demand a standard of moral excellence. Extreme integrity becomes a way of belonging to the clan. The Other Side Academy provides unwanted people with an opportunity to give care, and creates out of that care a ferocious forged family.

I could tell you hundreds of stories like this, about organizations that bring traumatized vets into extended-family settings, or nursing homes that house preschools so that senior citizens and young children can go through life together. In Baltimore, a nonprofit called Thread surrounds underperforming students with volunteers, some of whom are called “grandparents.” In Chicago, Becoming a Man helps disadvantaged youth form family-type bonds with one another. In Washington, D.C., I recently met a group of middle-aged female scientists—one a celebrated cellular biologist at the National Institutes of Health, another an astrophysicist—who live together in a Catholic lay community, pooling their resources and sharing their lives. The variety of forged families in America today is endless.

For many people, the era of the nuclear family has been a catastrophe. All forms of inequality are cruel, but family inequality may be the cruelest. It damages the heart.You may be part of a forged family yourself. I am. In 2015, I was invited to the house of a couple named Kathy and David, who had created an extended-family-like group in D.C. called All Our Kids, or AOK-DC. Some years earlier, Kathy and David had had a kid in D.C. Public Schools who had a friend named James, who often had nothing to eat and no place to stay, so they suggested that he stay with them. That kid had a friend in similar circumstances, and those friends had friends. By the time I joined them, roughly 25 kids were having dinner every Thursday night, and several of them were sleeping in the basement.

I joined the community and never left—they became my chosen family. We have dinner together on Thursday nights, celebrate holidays together, and vacation together. The kids call Kathy and David Mom and Dad. In the early days, the adults in our clan served as parental figures for the young people—replacing their broken cellphones, supporting them when depression struck, raising money for their college tuition. When a young woman in our group needed a new kidney, David gave her one of his.

We had our primary biological families, which came first, but we also had this family. Now the young people in this forged family are in their 20s and need us less. David and Kathy have left Washington, but they stay in constant contact. The dinners still happen. We still see one another and look after one another. The years of eating together and going through life together have created a bond. If a crisis hit anyone, we’d all show up. The experience has convinced me that everybody should have membership in a forged family with people completely unlike themselves.
Ever since I started working on this article, a chart has been haunting me. It plots the percentage of people living alone in a country against that nation’s GDP. There’s a strong correlation. Nations where a fifth of the people live alone, like Denmark and Finland, are a lot richer than nations where almost no one lives alone, like the ones in Latin America or Africa. Rich nations have smaller households than poor nations. The average German lives in a household with 2.7 people. The average Gambian lives in a household with 13.8 people.

That chart suggests two things, especially in the American context. First, the market wants us to live alone or with just a few people. That way we are mobile, unattached, and uncommitted, able to devote an enormous number of hours to our jobs. Second, when people who are raised in developed countries get money, they buy privacy.

For the privileged, this sort of works. The arrangement enables the affluent to dedicate more hours to work and email, unencumbered by family commitments. They can afford to hire people who will do the work that extended family used to do. But a lingering sadness lurks, an awareness that life is emotionally vacant when family and close friends aren’t physically present, when neighbors aren’t geographically or metaphorically close enough for you to lean on them, or for them to lean on you. Today’s crisis of connection flows from the impoverishment of family life.
I often ask African friends who have immigrated to America what most struck them when they arrived. Their answer is always a variation on a theme—the loneliness. It’s the empty suburban street in the middle of the day, maybe with a lone mother pushing a baby carriage on the sidewalk but nobody else around.

For those who are not privileged, the era of the isolated nuclear family has been a catastrophe. It’s led to broken families or no families; to merry-go-round families that leave children traumatized and isolated; to senior citizens dying alone in a room. All forms of inequality are cruel, but family inequality may be the cruelest. It damages the heart. Eventually family inequality even undermines the economy the nuclear family was meant to serve: Children who grow up in chaos have trouble becoming skilled, stable, and socially mobile employees later on.

When hyper-individualism kicked into gear in the 1960s, people experimented with new ways of living that embraced individualistic values. Today we are crawling out from the wreckage of that hyper-individualism—which left many families detached and unsupported—and people are experimenting with more connected ways of living, with new shapes and varieties of extended families. Government support can help nurture this experimentation, particularly for the working-class and the poor, with things like child tax credits, coaching programs to improve parenting skills in struggling families, subsidized early education, and expanded parental leave. While the most important shifts will be cultural, and driven by individual choices, family life is under so much social stress and economic pressure in the poorer reaches of American society that no recovery is likely without some government action.

The two-parent family, meanwhile, is not about to go extinct. For many people, especially those with financial and social resources, it is a great way to live and raise children. But a new and more communal ethos is emerging, one that is consistent with 21st-century reality and 21st-century values.

When we discuss the problems confronting the country, we don’t talk about family enough. It feels too judgmental. Too uncomfortable. Maybe even too religious. But the blunt fact is that the nuclear family has been crumbling in slow motion for decades, and many of our other problems—with education, mental health, addiction, the quality of the labor force—stem from that crumbling. We’ve left behind the nuclear-family paradigm of 1955. For most people it’s not coming back. Americans are hungering to live in extended and forged families, in ways that are new and ancient at the same time. This is a significant opportunity, a chance to thicken and broaden family relationships, a chance to allow more adults and children to live and grow under the loving gaze of a dozen pairs of eyes, and be caught, when they fall, by a dozen pairs of arms. For decades we have been eating at smaller and smaller tables, with fewer and fewer kin.
It’s time to find ways to bring back the big tables.

This article appears in the March 2020 print edition with the headline “The Nuclear Family Was a Mistake.”

David Brooks is a contributing writer at The Atlantic and a columnist for The New York Times. He is the author of The Road to Character and The Second Mountain: The Quest for a Moral Life.

DEAR SUGAR, The Rumpus Advice Column #71: The Ghost Ship That Didn’t Carry Us
By Sugar
April 21st, 2011

Dear Sugar,
For those of us who aren’t lucky enough to “just know,” how is a person to decide if he or she wants to have a child?
I’m a forty-one-year-old man and have been able thus far to postpone that decision while I got all the other pieces of my life in order. Generally speaking, I’ve enjoyed myself as a solo (or partnered) human. I’ve always had a hunch that as I continued on my path my feelings about parenthood would coalesce one way or the other and I would follow that where it took me. Well, my path has taken me here, to the point where all of my peers are having children and expounding on the wonders (and of course, trials) of their new lives, while I keep enjoying the same life.
I love my life. I love having the things that I know will be in shorter supply if I become a parent. Things like quiet, free time, spontaneous travel, pockets of non-obligation. I really value them. I’m sure that everyone does, but on the grand gradient of the human condition, I feel I sit farther to one end than most. To be blunt, I’m afraid to give that up. Afraid that if I become a parent, I will miss my “old” life.
As a male, I know that I have a little more leeway in terms of the biological clock, but my partner, who is now 40, does not. She is also on the fence about a child, and while the finer points of our specific concerns on the subject may differ, we are largely both grappling with the same questions. At this point, we’re trying to tease out the signal from the noise: do we want a child because we really want a child or are we thinking about having one because we’re afraid we will regret not having one later? We both now accept that the time for deferment is coming to a close and we need to step up and figure it out.
When I try to imagine myself as a father, I often think back to my two wonderful cats that I had from the age of twenty-two until I buried them in the back yard almost two years ago. They were born prematurely to a mother that was too sick to care for them. I bottle fed them, woke up in the middle of the night to wipe their bottoms, was there for every stage of their growth from kitten to cat and basically loved the be-jeezus out of them for their entire lives. I raised them to be trusting, loving creatures. And I did it consciously, even thinking at the time that it was great training for the day I had a child if that felt like the right thing. I really was their dad. And I loved it. Yet I also loved it that I could put an extra bowl of food and water on the floor and split town for a three-day weekend. I’m truly torn.
I was speaking yesterday to one of my closest friends who at forty just had his first child. While talking with him, I made the connection that I believe I am one of those people who could be perfectly happy without having children, and yet that doesn’t necessarily mean that I wouldn’t also be perfectly happy with children. He knows me well and as I said this, something clicked for us both.
So here I am now exploring this. Exploring it for real and deeply. Sugar, help me.
Signed,
Undecided


Dear Undecided,
There’s a poem I love by Tomas Tranströmer called “The Blue House.” I think of it every time I ponder questions such as yours about the irrevocable choices we make. The poem is narrated by a man who is standing in the woods near his house. When he looks at his house from this vantage point, he observes that it’s “as if I had just died and was seeing the house from a new angle.” It’s a wonderful image—that man among the trees—and it’s an instructive one too. There is a transformative power in seeing the familiar from a new, more distant perspective. It’s in this stance that Tranströmer’s narrator is capable of seeing his life for what it is while also acknowledging the lives he might have had. “The sketches,” Tranströmer writes, “all of them, want to become real.” The poem strikes a chord in me because it’s so very sadly and joyfully and devastatingly true. Every life, Tranströmer writes, “has a sister ship,” one that follows “quite another route” than the one we ended up taking. We want it to be otherwise, but it cannot be: the people we might have been live a different, phantom life than the people we are.

And so the question, sweet pea, is who do you intend to be. As you’ve stated in your letter, you believe you could be happy in either scenario—becoming a father or remaining childless. You wrote to me because you want clarity about which course to take, but perhaps you should let that go. Instead, take a figurative step into the forest like that man in the poem and simply gaze for a while at your blue house. I think if you did, you’d see what I see: that there will likely be no clarity, at least at the outset; there will only be the choice you make and the sure knowledge that either one will contain some loss.

We’re contemporaries. I’m forty-two. I have two children, whom I birthed in close succession in my mid-thirties. If a magic baby fairy had come to me when I was childless and 34 and promised to grant me another ten years of fertility and good knees so I could live a while longer in the serene, feline-focused, fabulously unfettered life I had, I’d have taken it in a flash. I, too, had spent my adult years assuming that someday, when it came to becoming a mother, I’d “just know.” I, too, placed myself on the leave-me-the-fuck-alone end on the “grand gradient of the human condition.” I decided to become pregnant when I did because I was nearing the final years of my fertility and because my desire to do this thing that everyone said was so profound was just barely stronger than my doubts about it were.

So I got knocked up. With a total lack of clarity. On this, Mr. Sugar and I were in complete accord. Though we were generally pleased to be having a baby, we were also deeply alarmed. We liked to have sex and ramble around foreign countries in decidedly un-baby-safe ways and spend hours reading in silence on two couches that faced each other across the living room. We liked to work for days without interruption on our respective art forms and take unscheduled naps with our cats and spend weeks backpacking in the wilderness. We did not, throughout my pregnancy, have many conversations about how awesome it was going to be once our baby was born and doing these things would become either indisputably or close to impossible. Mostly, we had ambivalent, mildly sickening talks about how we sure as shit hoped we hadn’t made a dreadful mistake. What if we love the baby but not as much as everyone says we will? I’d ask him every couple of weeks. What if the baby bores us or annoys us or grosses us out? What if we want to ride our bicycles across Iceland or hike around Mongolia? Fuck. We do want to ride our bicycles across Iceland or hike around Mongolia!
My point is not that you should have a baby, Undecided. It’s that possibly you expect to have a feeling about wanting to have a baby that will never come and so the clear desire for a baby isn’t an accurate gauge for you when you’re trying to decide whether or not you should have one. I know that sounds crazy, but it’s true.

So what then, is an accurate gauge?

You say that you and your partner don’t want to make the choice to become parents simply because you’re afraid you “will regret not having one later,” but I encourage you to reexamine that. Thinking deeply about your choices and actions from the stance of your future self can serve as both a motivational and a corrective force. It can help you stay true to who you really are as well as inspire you to leverage your desires against your fears.
Not regretting it later is the reason I’ve done at least three quarters of the best things in my life. It’s the reason I got pregnant with my first child, even though I’d have appreciated another decade from the magic baby fairy, and it’s also the reason I got pregnant with my second child, even though I was already overwhelmed by the first. Because you are content in your current childless life, attempting to determine what you might regret later strikes me as the best way for you to meaningfully explore if having a child is important to you. So much so, that I suspect that whether you’ll regret it later is the only question you must answer. It is the very one that will tell you what to do.

You already know the answers to everything else. You know you’re open to becoming a father and that you’re also open to remaining childless. You know you’ve gotten pleasure and satisfaction from nurturing the lives of others (in the form of your dear cats) and also that you get deep satisfaction from the freedom and independence a child-free life allows.

What don’t you know? Make a list. Write down everything you don’t know about your future life—which is everything, of course—but use your imagination. What are the thoughts and images that come to mind when you picture yourself at twice the age you are now? What springs forth if you imagine the 82 year-old self who opted to “keep enjoying the same life” and what when you picture the 82 year-old self with a thirty-nine year old son or daughter? Write down “same life” and “son or daughter” and underneath each make another list of the things you think those experiences would give to and take from you and then ponder which entries on your list might cancel each other out. Would the temporary loss of a considerable portion your personal freedom in middle age be significantly neutralized by the experience of loving someone more powerfully than you ever have? Would the achy uncertainty of never having been anyone’s father be defused by the glorious reality that you got to live your life relatively unconstrained by the needs of another? What is a good life? Write “good life” and list everything that you associate with a good life then rank them in order of importance. Have the most meaningful things in your life come to you as a result of ease or struggle? What scares you about sacrifice? What scares you about not sacrificing?

So there you are on the floor, your gigantic white piece of paper with things written all over it like a ship’s sail, and maybe you don’t have clarity still, maybe you don’t know what to do, but you feel something, don’t you? The sketches of your real life and your sister life are right there before you and you get to decide what to do. One is the life you’ll have, the other is the one you won’t. Switch them around in your head and see how it feels. Which affects you on a visceral level? Which won’t let you go? Which is ruled by fear? Which is ruled by desire? Which makes you want to close your eyes and jump and which makes you want to turn and run?

In spite of my fears, I didn’t regret having a baby. My son’s body against mine was the clarity I never had. The first few weeks of his life, I felt honestly rattled by the knowledge of how close I’d come to opting to live my life without him. It was a penetrating, relentless, unalterable thing, to be his mother, my life ending and beginning at once.

If I could go back in time I’d make the same choice in a snap. And yet, there remains my sister life. All the other things I could have done instead. I wouldn’t know what I couldn’t know until I became a mom, and so I’m certain there are things I don’t know because I can’t know because I did. Who would I have nurtured had I not been nurturing my two children over these past seven years? In what creative and practical forces would my love have been gathered up? What didn’t I write because I was catching my children at the bottoms of slides and spotting them as they balanced along the tops of low brick walls and pushing them endlessly in swings? What did I write because I did? Would I be happier and more intelligent and prettier if I had been free all this time to read in silence on a couch that sat opposite of Mr. Sugar’s? Would I complain less? Has sleep deprivation and the consumption of an exorbitant number of Annie’s Homegrown Organic Cheddar Bunnies taken years off of my life or added years onto it? Who would I have met if I had bicycled across Iceland and hiked around Mongolia and what would I have experienced and where would that have taken me?

I’ll never know and neither will you of the life you don’t choose. We’ll only know that whatever that sister life was, it was important and beautiful and not ours. It was the ghost ship that didn’t carry us. There’s nothing to do but salute it from the shore.
Yours,
Sugar

This article appeared in the online version of The Guardian:

How you attach to people may explain a lot about your inner life
Early interactions with caregivers can dramatically affect your beliefs about yourself, your expectations of others, and how you cope with stress and regulate your emotions as an adult

by Elitsa Dermendzhiyska

‘Anxious, avoidant and disorganised attachment styles develop as responses to inadequate caregiving.’ In 2006, a team of Norwegian researchers set out to study how experienced psychotherapists help people to change. Led by Michael Rønnestad, a professor of clinical psychology at the University of Oslo, the team followed 50 therapist-patient pairs, tracking, in minute detail, what the therapists did that made them so effective. Margrethe Halvorsen, a post-doc at the time, was given the job of interviewing the patients at the end of the treatment.
That’s how she met Cora – a woman in her late 40s, single, childless, easy to like. As a kid, Cora (a pseudonym) had suffered repeated sexual abuse at the hands of her mother and her mother’s friends. Before entering therapy, she habitually self-harmed. She’d tried to kill herself a number of times, too, her body still scarred by the remnants of suicides not carried through.
“Her story was in the room,” Halvorsen tells me, then grows quiet as she stumbles to convey the strong impression that Cora left on her. Seven years after they met, it’s still hard to articulate: “Maybe presence is the right word.”
It was the way that Cora spoke of the atrocities done to her – in a steady voice, with clear eyes – that made the researcher wonder how someone so scarred could seem so alive, and undiminished.
At one point during their interview, when Halvorsen asked Cora to describe her therapy in a picture or a word, she’d blurted out: “It saved my life.” Intrigued, she invited three fellow psychologists to help her delve deeper into Cora’s case and uncover what had happened in the therapy room.
Read more“We didn’t know what we were getting into,” Halvorsen told me. Following initial interviews with both Cora and her therapist, the researchers ploughed through a total of 242 summary notes that the two had written after each session over the course of the three-year study. From this data, the team selected and transcribed verbatim 25 sessions that seemed particularly important. The final material approached 500 pages of single-spaced text. Halvorsen and her colleagues puzzled over it for more than two years in a bid to understand what, exactly, had saved Cora’s life.
When you delve into it, the question of how people change through therapy can make your head swim. Here’s a psychological intervention that seems to work as well as drugs (and, studies suggest, possibly better over the long term), and yet what is it, precisely, that works? Two people sit in a room and talk, every week, for a set amount of time, and at some point one of them walks out the door a different person, no longer beleaguered by pain, crippled by fear or crushed by despair. Why? How?
Things get even more puzzling if you consider the sheer number of therapies on offer and the conflicting methods that they often employ. Some want you to feel more (eg, psychodynamic and emotion-focused approaches); others to feel less and think more (eg cognitive behavioural therapies, or CBT). The former see difficult emotions as something that needs to come out, be worked through and re-assimilated; the latter as something to be challenged and controlled through conscious modification of negative thoughts.
Some therapists don’t even talk much of the time, letting the silence wring uncomfortable truths out of their clients; others hardly pause between structured sequences of exercises and homework assignments. Across more than 400 psychotherapies available today, your shrink can take the form of a healer, a confidante, a clinical expert, a mental-fitness coach or any combination, shade and hue of these.
Over the past three years, I’ve talked to dozens of therapists from various schools, trying to understand how therapy works – and by this I mean heals: the darker entrapments of compulsive confession or the complex entanglements of unresolved transference are not my subjects here. Lately, I’ve broadened my quest to understand the basis of therapeutic efficacy to include researchers as well as practitioners, but most of these conversations left me feeling that neither the experts studying therapeutic change nor those effecting it could, when pressed, convincingly explain how people heal.
Begrudgingly, I kept going back to what Alan Kazdin, a professor of psychology and child psychiatry at Yale University, said in 2009 in a widely cited paper: “It is remarkable that after decades of psychotherapy research we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change."
To complicate matters, numerous studies over the past few decades have reached what seems a counterintuitive conclusion: that all psychotherapies have roughly equal effects. This is known as the “dodo bird verdict” – named after a character in Alice in Wonderland (1865) who declares after a running contest: “Everybody has won and all must have prizes.” That no single form of therapy has proved superior to others might come as a surprise to readers, but it’s mightily familiar to researchers in the field. “There is so much data for this conclusion that if it were not so threatening to specific theories it would long ago have been accepted as one of psychology’s major findings,” writes Arthur Bohart, professor emeritus at California State University, Dominguez Hills, and author of several books on psychotherapy.
Even so, this alleged equivalence among various therapies is a product of statistics. It says nothing about what works best for each specific individual, nor does it imply that you can pick any therapy and obtain the same benefit. Perhaps some people fare well with the structure and direction of a cognitive approach, while others respond better to the open-ended exploration and sense-making offered by psychodynamic or existential perspectives. When aggregated, these individual differences can cancel out, making all therapies appear equally effective.
A lot of researchers, however, believe that this is not the only explanation. For them, the deeper reason why no single psychotherapy seems to provide unique advantages over any other is that they all work because of shared elements. Chief among these is the therapeutic relationship, connected to positive outcomes by a wealth of evidence.
The emotional bond and the collaboration between client and therapist – called the alliance – have emerged as a strong predictor of improvement, even in therapies that don’t emphasise relational factors.
Until recently, most studies of this alliance could show only that it correlates with better mental health in clients, but advances in research methods now find evidence for a causal link, suggesting that the therapy relationship might indeed be healing. Similarly, research into the traits of effective therapists has revealed that their greater experience with or a stricter adherence to a specific approach do not lead to improved outcomes whereas empathy, warmth, hopefulness and emotional expressiveness do.
All of this suggests a tantalising alternative to both the medical professional’s and the layperson’s view of therapy: that what happens between client and therapist goes beyond mere talking, and goes deeper than clinical treatment. The relationship is both greater and more primal, and it compares with the developmental strides that play out between mother and baby, and that help to turn a diapered mess into a normal, healthy person. I am referring to attachment.
To push the analogy further, what if, attachment theory asks, therapy gives you the chance to reach back and repair your earliest emotional bonds, correcting, as you do, the noxious mechanics of your mental afflictions?
Attachment theory traces its roots to the British psychoanalyst John Bowlby, who in the 1950s combined evolutionary theory and psychoanalysis into a brave new paradigm. Aghast at his profession’s lack of academic rigour, Bowlby turned to the burgeoning science of animal behaviour. Experiments with infant monkeys (some so plainly cruel that no ethical board would permit them today) had challenged the then prevailing notion that infants see their mothers chiefly as a source of food.
Bowlby realised that “the mother-infant bond is not purely generated by the drive to latch onto the breast, but it’s also motivated by this idea of comfort”, says Jeremy Holmes, a British professor of psychological therapies (now part-retired) and co-author of the book Attachment in Therapeutic Practice (2018).
The search for comfort, or security, Bowlby argued, is an inborn need: we’ve evolved to seek attachment to “older, wiser” caregivers to protect us from danger during the long spell of helplessness known as childhood. The attachment figure, usually one or both parents, becomes a secure base from which to explore the world, and a safe haven to return to for comfort. According to Holmes, Bowlby saw in attachment theory “the beginning of a science of intimate relationships” and the promise that “if we could study parents and children, and the way they relate to each other, we can begin to understand what happens in the consulting room” between client and therapist.
Research on attachment theory suggests that early interactions with caregivers can dramatically affect your beliefs about yourself, your expectations of others, and the way you process information, cope with stress and regulate your emotions as an adult. For example, children of sensitive mothers – the cooing, soothing type – develop secure attachment, learn to accept and express negative feelings, lean on others for help, and trust their own ability to deal with stress.
By contrast, children of unresponsive or insensitive caregivers form insecure attachment. They become anxious and easily distressed by the smallest sign of separation from their attachment figure. Harsh or dismissive mothers produce avoidant infants, who suppress their emotions and deal with stress alone. Finally, children with abusive caregivers become disorganised: they switch between avoidant and anxious coping, engage in odd behaviours and, like Cora, often self-harm.
Anxious, avoidant and disorganised attachment styles develop as responses to inadequate caregiving: a case of “making the best of a bad situation”. But the repeated interactions with deficient early attachment figures can become neurally encoded and then subconsciously activated later in life, especially in stressful and intimate situations. That’s how your childhood attachment patterns can solidify into a corrosive part of your personality, distorting how you see and experience the world, and how you interact with other people.
The psychologist Mario Mikulincer of the Interdisciplinary Center Herzliya in Israel is one of the pioneers of modern attachment theory, studying precisely such cascading effects. In a number of experiments spanning two decades, he has found that, as adults, anxious people have low self-esteem and are easily overwhelmed by negative emotions. They also tend to exaggerate threats and doubt their ability to deal with them. Driven by a desperate need for safety, such people seek to “merge” with their partners and they can become suspicious, jealous or angry towards them, often without objective cause.
If the anxious among us crave connection, avoidant people strive for distance and control. They detach from strong emotions (both positive and negative), withdraw from conflicts and avoid intimacy. Their self-reliance means that they see themselves as strong and independent, but this positive image comes at the expense of maintaining a negative view of others. As a result, their close relationships remain superficial, cool and unsatisfying. And while being emotionally numb can help avoidant people weather ordinary challenges, research shows that, in the midst of a crisis, their defences can crumble and leave them extremely vulnerable.
It isn’t hard to see how such attachment patterns can undermine mental health. Both anxious and avoidant coping have been linked to a heightened risk of anxiety, depression, loneliness, eating and conduct disorders, alcohol dependence, substance abuse and hostility. The way to treat these problems, say attachment theorists, is in and through a new relationship. On this view, the good therapist becomes a temporary attachment figure, assuming the functions of a nurturing mother, repairing lost trust, restoring security, and instilling two of the key skills engendered by a normal childhood: the regulation of emotions and a healthy intimacy.
When Cora began therapy, it was clear that she would be a challenging patient. The letter from her GP asked for someone “courageous” to treat her, and you could see why: she insisted on retaining her right to self-harm and suicide. “I had the feeling that she could kill herself in the middle of the therapy, and I just had to take that risk,” her therapist told the researchers at the end of the study. So how did he manage to pull Cora back from the brink?
In teasing out some answers from the reams of data they’d collected, Halvorsen and her team found a curious call-and-response pattern emerging between Cora and the therapist, which has an analogue in mother-infant interactions. First, Cora would put herself down, then the therapist would acknowledge her negative emotions but also deflect them right away, recasting her destructive tendencies as survival mechanisms that she’d used as a kid to protect herself from the trauma but which hampered her as an adult. Gently but firmly, he challenged her self-loathing by reframing what she saw as damning and unacceptable about herself into something human and understandable.
Often, he asked her to think of “the child on the staircase”, referring to a memory that Cora had shared in an earlier session. “It is a really upsetting scene,” Halvorsen told me – one in which Cora’s mother gets angry at her. ‘I think she filled a suitcase with some of the child’s clothes and told the little girl to leave. And the girl was sitting outside on the staircase for many hours, and didn’t know what to do or where to go.” The therapist, Halvorsen noticed, would return to this scene over and over again, trying to evoke Cora’s self-compassion and counter her unrelenting self-criticism.
This pattern of empathising, then reframing and de-shaming looks uncannily like the mirroring-and-soothing exchanges between mother and infant in the first years of life. Spend any amount of time around a newborn and you’ll see that, when baby cries, mum swoops in, picks him up and then scrunches her face in an exaggerated imitation of his distress. According to Peter Fonagy, a psychopathology researcher at University College London, who has long studied children and young people, the mother’s amplified reflection forms a key part of the child’s developing a sense of self and emotional control. “Anxiety, for example, is for the infant a confusing mixture of physical changes, ideas and behaviours,” he told me. “When the mother reflects, or mirrors, the child’s anxiety, he now ‘knows’ what he’s feeling.”
This knowledge, says Fonagy, doesn’t come prewired into us. We don’t understand the meaning of our internal experiences until we see them externalised, or played out for us in the faces and reactions of our caregivers. “Paradoxically, even though I now know perfectly well when I feel anxious,” Fonagy explains in a video interview from 2016, “the anxiety that I recognise as my anxiety is actually not my own anxiety but is my picture of my mum looking back at me when I as a baby felt anxious.” The sensitive mother picks up on the infant’s mental and emotional state and mirrors it; the child learns to recognise his internal experience as “sadness” or “anxiety” or “joy”. Previously chaotic sensations now become coherent and integrated into the infant’s sense of who he is, allowing emotions to be processed, predicted and appropriately navigated.
But mum doesn’t just mirror baby’s emotional pain; she soothes it. Rocking the infant in her arms or cooing in that mellifluous voice that stops tears in their tracks, the responsive mother contains the baby’s negative feelings. Distress, writes Holmes in 2015, “is transmitted from baby to mother, ‘metabolised’ via mother’s musings” and so predigested. It is given back to the baby in an altered, less intense form.
Cora’s therapist likewise helped her to assimilate her most painful feelings. By learning to tolerate negative states, she could develop resilience in the face of her darker inner experiences. He encouraged her to let out her shame and anger, reflecting them back empathically in a way that made her feel seen and known. But he also contained and transformed those emotions for her by re-narrating them in terms of adaptation, protection and survival. Like a good mother, he predigested Cora’s distress by making sense of it and, by giving it a meaning and explanation, he transformed it into something that could be accepted and endured.
Eventually, the co-regulation of emotions between mother and infant, or therapist and client, paves the way to self-mastery and self-regulation. One way this happens in the early years, writes Mikulincer in 2003, is by internalising the caregiver: her voice and attitude become a part of you, and when you hit a rough patch, you pick yourself up using the same words your mother once used to soothe you. Another way to be weaned off emotional dependence in childhood is to grow your own inner resources by tackling and learning from challenges. In stretching herself, the young child confronts the inevitable risk of failure, as well as fighting the allure of myriad other activities, such as playing with toys or sticking her fingers into power sockets. “With the support, reassurance, guidance and encouragement of a caring and loving attachment figure, children can cope better with failure, persist in the task despite obstacles, and inhibit other impulses and distractions,” Mikulincer told me. In this way, kids increase their tolerance of negative emotions, and master valuable skills to deal with problems on their own.
A similar process occurs in therapy. After a while, clients internalise the warmth and understanding of their therapist, turning it into an internal resource to draw on for strength and support. A new, compassionate voice flickers into life, silencing that of the inner critic – itself an echo of insensitive earlier attachment figures. But this transformation doesn’t come easy. As the poet WH Auden wrote in The Age of Anxiety (1947): “We would rather be ruined than changed.” It is the therapist’s job, as a secure base and safe haven, to guide clients as they journey into unfamiliar waters, helping them stay hopeful and to persist through the pain, sadness, anger, fear, anxiety and despair they might need to face.
This happens not just through talking but wordlessly, too. In fact, according to the psychologist Allan Schore of the University of California, Los Angeles, who has studied attachment from the viewpoint of neurobiology over the past 20 years, change in therapy occurs not so much in the intellectual communication between client and therapist but in a more imperceptible way – through a conversation between two brains and two bodies. Perhaps this mode of attachment predominates in therapies where there is less talking, and more rule-following.
Once again, the process mirrors good caregiving early in life. Long before speech, mother and infant communicate with each other via nonverbal cues – facial expression, mutual gaze, vocal nuance, gesture and touch. In the squeeze of his fist, in the batting of an eyelash, the sensitive mother “reads” her child’s emotional states and responds appropriately through her own body. These wordless communications, writes Schore, get registered and processed by the baby’s right-brain hemisphere, shaping the nascent neural systems involved in emotion processing and automatic stress responses. Mum’s nonverbal signals become encoded as implicit, non-conscious strategies that the infant’s right brain will later activate unconsciously to regulate his emotions.
Again, something similar plays out in therapy. The good practitioner subconsciously tunes in to those emotions left unsaid, to the internal states the client might not even be aware of. Moment by moment, the therapist adjusts her own body language in response to her client’s internal rhythms, engaging them in a kind of dance in which both partners mutually influence and synchronise themselves to each other. According to Schore, over time the nonverbal attachment communications from the therapist can become imprinted into the client’s right brain, revising stored coping patterns, and giving rise to more flexible and adaptive ones.
To Fonagy, a factor that is just as fundamental to the restoration of wellbeing in therapy is social learning. From the vantage point of evolution, we might be hardwired to mistrust others because a negative bias serves survival. Yet, for an intensely social species such as ours, being constantly on guard doesn’t bode well. How, then, do we trust, cooperate and connect with other people while also protecting ourselves from the threat that they might pose?
The theory of natural pedagogy, proposed in 2011 by Gergely Csibra and György Gergely, professors of cognitive science at the Central European University in Budapest, suggests an answer. In this view, evolution has engineered a nifty mechanism to relax our natural vigilance so that we can learn from others. To recognise relevant and trustworthy sources of information, we rely on certain visual and verbal cues or signals. In childhood, writes Fonagy in 2014, these cues are the same ones that underlie secure attachment (the special vocalisations of “motherese”, for example). Babies, in other words, are primed to trust the sensitive caregiver, who, in turn, teaches them how to trust others and navigate their social world. A study from Harvard University in 2009 shows that securely attached children are discerning judges of credibility – they trust mum when she is being reasonable but go with their own judgments when her statements run against reality. Their security in themselves and others turns these kids into adults open to new information, comfortable with uncertainty and flexible with changing their views in light of new data.
The opposite holds for the insecurely attached. Anxious people tend to distort social cues and exaggerate threats, and this can mislead them into seeing their partners as unreliable, unsupportive or uninterested. Avoidant people focus on protecting themselves, which can make them cling to negative stereotypes of others in the face of ample evidence to the contrary. For example, Mikulincer’s study in 2003 had married couples rate their partner’s behaviour over the course of three weeks. While anxious people gave higher ratings when their spouses were objectively more supportive, avoidant people completely failed to register positive changes in their partners.
Therapy saved a refugee child. Fifty years on, he’s leading a mental health revolution
Insecure attachment, it appears, perpetuates our natural suspicion, keeping us closed off and unreceptive to socially relevant information. Fonagy calls this “epistemic mistrust”, and for him it might be the common denominator of many mental-health problems, explaining their severity and persistence. The chief value of psychotherapy, he says, lies in its potential to rekindle our epistemic trust and jumpstart our ability to learn from others in our social environment. By restoring attachment security, therapy lowers our social vigilance and opens us to trusting one person – the therapist – which eventually allows us to go out into the world and trust other people. The importance of this recognition is such that even in CBT sessions, when therapists are bombarded by clients’ upset feelings, they will temporarily shift their usual agenda or stance to empathise with the feeling state, and then shift back to emphasising cognitive themes and the rational control of emotional experience.
The restoration of secure attachment is what happened with Cora, too. In her last sessions, she realised that she wasn’t actually alone. She had a friend she could count on, and a sister who shared her childhood memories. It wasn’t that these people were absent before; she just wasn’t seeing them, or perhaps not trusting what was right in front of her. But her growing trust – first in the therapist, then in the goodwill of the world and her own ability to navigate it – allowed her to see others “more as opportunities for social contact, rather than threats”. Cora was by no means cured by her therapy: her trauma ran too deep. But she was saved. She was ready to live and to keep healing.
In their last session together, Cora left the therapist a parting gift – a carabiner. It is how, in the mountains, two climbers stay securely attached by rope, so that, if one stumbles, the link with the other will keep him from falling into the precipice.