King's College London

With the Prime Minister set to announce changes to the UK's lockdown measures this evening, Professor Sir Simon Wessely and Dr Jo Daniels look at how the messaging is shifting.

So far, the rationale for most of the decisions taken on our behalf in the coronavirus crisis has been simple – to save lives. But recent comments from political leaders and officials have introduced a new dimension – that of reassurance.

 

Last week, the Prime Minister correctly identified that research on the effectiveness of face covering is equivocal, except for NHS workers, before adding that “people might still find this reassuring”. The Deputy Chief Medical Officer similarly observed that temperature taking in restaurants might offer some “public reassurance” but there was negligible evidence of effectiveness in case identification,

 

Recent work from my own university, King’s College London, has shown that 44 per cent of the UK population is “suffering” under the lockdown, with the vast majority of this group feeling very anxious and depressed and a significant proportion sleeping badly. The case for new measures and messaging to reassure this half of the country that their safety will not be compromised once the all-clear is sounded therefore seems logical on the surface. But look deeper, and the case seems a lot less wise.

 

There is considerable evidence about the impact of reassuring anxious individuals and anxious populations. It shows that this approach generally doesn’t work, particularly once the quantifiable danger has passed. Reassurance offers transient false comfort that rapidly fades; when unwarranted, it promotes distress – particularly in relation to health-related anxiety.

 

It serves as a warning: there is something to be reassured about. When the dentist says “This won’t hurt”, our anxiety spikes and we expect pain, which in turn increases the likelihood of feeling pain, due to heightened attention and hypervigilance.

 

When it is accompanied by or presented with facts from a credible source, reassurance can be effective. But this is not what is being offered at the moment. In the absence of this, reassurance will rarely change behaviour or ameliorates distress, but might do the opposite.

 

Instead it is better to mobilise the public to tolerate the uncertainty of the current situation and encourage them to gradually return to the workplace, use public transport, or send their children back to school.

 

In the initial aftermath of the 2005 London bombings, there was a substantial decrease in the number of people using the Underground. However, over time, most had little alternative but to use the Tube to get back to work. For many, the initial return to the tube would have made them more nervous than normal, but with each journey without incident the anxiety diminished and eventually disappeared.

 

One of the many unpleasant ironies of the current situation is that social life has been turned on its head. Social contact – which before Covid-19 gave most people their biggest source of happiness, not to mention their ability to tolerate adversity – has now become the greatest threat to our health.

 

And a large number of people are currently very anxious about their health. Emerging research suggesting it may be as high as 17 per cent of the population – a three-fold increase on normal levels. But it is naïve to believe this anxiety will simply dissipate once the situation improves. For some, reassurance that it is now “safe”, whatever that means, will not prove sufficient. Nothing is ever completely safe. Instead we must tolerate the uncertainty of life.

 

Those with health-related anxiety often focus on a particular health concern, such as cancer or multiple sclerosis. The therapeutic approach here is not to offer certainty and reassurance that there is no malignancy, or that MS won’t appear later down the track (as we can never disprove this); it is to reduce health-related distress, and to some degree, increase tolerance of uncertainty. We are only able to the offer best evidence we have at the time, in a clear and transparent manner.

 

In the current crisis, unless measures such as compulsory face coverings are to be in place in perpetuity, like wearing seat belts or not drink driving, then consideration must be given to how they will be withdrawn. When the risk assessment changes so that they can be, we can anticipate that many people will remain anxious about catching SARS-CoV-2. Which means they will get anxious not only when they remove their covering, but even more when someone else does. The sight of an uncovered face will trigger elevated anxiety in those with health concerns, by serving as a reminder that what was a very real, life-threatening threat could still be present. How can one ever be sure that it isn’t?

 

Anxiety would only reduce once it became clear that being in the vicinity of someone not wearing a face mask is unlikely to cause either party to become infected, or at least no more likely than before the pandemic (the average person pre-Covid-19 experienced about four symptomatic viral infections a year).

 

So perhaps people will start to take off those masks and not feel uncomfortable when someone else does the same, as the acute crisis draws to a conclusion. Perhaps. But that didn’t happen in Japan after the swine flu pandemic – instead, people just kept wearing them. In 2018, 5.5 billion disposable face masks were manufactured in Japan.  

 

Likewise how will we know when we should end the “socially distanced” office, which if the reports of the current plans are anything to go by, sound particularly soulless, unattractive and isolating? For many, the current circumstances are more comfortable because, despite the anxiety, they feel “safe” at home. Lifting of restrictions may elicit fear that they would be exposed to danger again. It is one thing to say that as a matter of environmental policy we now wish a greater proportion of the population to work at home, it is quite another to do that by making the workplace “safe” but so austere that no one would want to work there anyway.

 

The problem with a policy that is designed to make people “feel safe”, as opposed to actually being safe, is that there is no end point and no exit strategy. Achieving that “feeling” of safety is a subjective experience and a common feature that complicates anxiety – for example, how many times should we wash our hands before we feel safe? It is likely to be many more times if anxious.

 

This is the problem with what we call affective (ie emotion-based) rather cognitive reasoning. Some people will feel safe in the exactly the same environment that another feels in danger. It was for similar reasons that society started to move away from the so called “precautionary principle” that guided many policies a decade or so ago. You could never say the risk of something happening was zero, and not doing something “just in case” meant many desirable things were never done, or alternatively, undesirable things done.

We see examples of this in relation to environmental matters such as the prohibition on nuclear power plants at the expense of continued fossil fuel use, or genetically modified crops. Not surprisingly, these arguments have surfaced again in the context of facemasks.

 

Policies designed solely to simply reassure may never end. There will be many vulnerable people who refuse to stay in a room if someone is not masked, or will refuse to enter a bar or restaurant unless everyone is socially distanced (in which case it wouldn’t be a bar or restaurant that most of us would understand anyway). We should remember that this does not arise from being bloody-minded or belligerent, but out of fear and anxiety. So if we are to embrace policies whose main role is to make people feel safe, they must have a clear end point. Not when everyone “feels” safe, because that is unattainable – but when we have, for example, achieved a specific prevalence of the agent, or a specified number of days without a specified number of cases.

 

So a government that does want to get us back to work and school and even fun should be cautious about continuing or imposing new restrictions solely for the purpose of reassurance. Imposing restrictions was correctly justified as “following the science”. They should follow the science just as closely when it comes to removing them.

Professor Sir Simon Wessely is Regius Chair of Psychiatry at King’s College London, and Director of the NIHR PHE Health Protection Research Unit in Emergency Preparedness and Response.

Dr Jo Daniels is an Associate Professor in Clinical Psychology at the University of Bath.