The Age of Permanent Anxiety

Dr Sarb Johal faces the screen, his warm brown eyes framed by stylish silver glasses. In the background is his spare room-slash-home office, the kind familiar to anyone now well-versed in video calls. He’s explaining to me that these days a lot of us have anxiety about our anxiety.

“One of the things that we are dealing with here is almost like a meta-anxiety,” he says in a voice that instantly calms me, right down to my last parasympathetic nerve. His soothing tone wouldn’t be out of place on a British home renovation show: talking you off the metaphorical ledge as your budget blows out, gently prodding you to explore your foolish endeavours on your own. We are one of the first generational cohorts spending a long time thinking about the feelings that we’re having, he explains. “We have a very acute awareness of the anxiety that we’re experiencing right now. Not only are we reflecting upon it a lot, but it’s being reflected at us from multiple channels. It’s coming at you from all angles. You can’t escape.”

I am flooded with a sense of relief when he says this. We’re talking during the lockdown that started in mid-August after the first reported community case of the Delta variant of Covid-19 was discovered in Auckland, where I live, and looks as if it may now stretch on until at least late November. Time has become slippery, not helped by the unfriendly hours my brain has decided are best for writing this article. I’ve been waking most days about 3.45am and usually begin my mornings by checking the New York Times’ Coronavirus World Map, hoping for a miraculous drop in global case numbers overnight. Instead, I invariably find something new to feel anxious about. As Alert Level 4 became Alert Level 3, and unexplained cases of Covid-19 kept appearing in the daily tallies, I started taking very hot baths at 4pm in an attempt to calm down. The government’s three step plan for moving out of Level 3, announced in early October, created as many new worries as it did assurances.

Johal is in many ways a good person to talk to, then. An expert on psychosocial recovery and disaster communication, he has advised the United Kingdom and New Zealand governments and the World Health Organization through major national and international crises, including the Christchurch earthquakes and the Covid-19 pandemic. (When government documents started circulating shortly after the quakes indicating that Christchurch’s recovery phase might take just two years, Johal was of the then-lone view that it was more likely to have a 10-to-20-year timeline.)

On Twitter, Johal recently sought to reassure his nearly 4000 followers with a thread comparing the uncertainty of the latest Covid outbreak to a plane unable to land in bumpy weather and being instructed to circle around the airport. “Looking out of the window, you can’t see. You don’t have complete information,” he wote. “The pilot doesn’t have complete information either . . . After a long flight, or a long lockdown, where expectations have been set for a smooth landing and being able to move on with our lives, it can be very difficult to change the plan.” But while we may have to take a more uncomfortable route to safety than we might have wanted, he notes, we will get there in the end. The thread was shared more than 100 times, including by microbiologist Siouxsie Wiles, who noted that it was “just the thing everyone in New Zealand needs to read right now”.

In the 2018 essay collection Headlands: New Stories of Anxiety, the writer Michelle Langstone describes her anxiety as a “fever you catch”, recalling an incident where she once took off all her clothes in a Mt Eden restaurant’s bathroom to “try to put out the fire”. An experience like this is not the same as getting a bit stressed out or worried sometimes. There is a difference between what many might see as reasonable responses to existential threat, and anxiety as a clinically diagnosed and treated mental illness. There are genetic predispositions to anxiety, the same way there is for many cancers, but there are also a range of experiences and social determinants that may tip people from “worrying” or “overthinking” towards an anxiety disorder as it might present to a clinician.

It’s difficult to completely separate the two categories, and in this story we’re talking about both, necessarily sliding between medical diagnoses and the increasing feelings of dread and fear that prompted 63 per cent of New Zealanders to say in a recent UMR poll that they think the worst of the pandemic is yet to come. In a 2021 Deloitte survey, 40 per cent of millennials said they felt stressed “all the time”. For Gen Z, it was 45 per cent.

Anxiety is a physical experience — both in its immediate onset and its effects — and a sustained response to a threat that may not yet be present. Our brains usually manage responses to threat and fear in a way that doesn’t allow these feelings to interfere with our daily lives. If you see a shark in the shallows at the beach, for example, your brain rightly recognises this as a possible threat and prompts a “flight” mechanism which causes you to jump out of the water. When you are anxious, though, a flood of stress hormones is released, making these parts of the brain hyperactive. It becomes harder to respond rationally. An anxious brain will begin constantly anticipating that a shark might be in the water, and conclude that the ocean is a place to be permanently avoided.

Anxiety also impacts a person’s retention of memories, and the kinds of memories that are retained (for example, you might keep only the bad memories of the shark, and forget the many good times you spent swimming safely). You might have trouble breathing, experience headaches, tension or an upset stomach. Experienced regularly over a long period of time, anxiety can manifest physiological problems including irritable bowel syndrome, constant headaches, breathing problems, loss of sensation in the body, vision problems, a permanent feeling of fogginess and a loss of libido. High levels of stress hormones like cortisol, epinephrine and norepinephrine can also raise our blood pressure, increasing the risk of stroke or heart attack.

Anxiety is a family of disorders, of which the most common is generalised anxiety disorder (GAD), defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as “excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events”. A person experiencing GAD “finds it difficult to control the worry”. Clinicians will look for symptoms like restlessness, fatigue, difficulty concentrating, irritability, muscle tension and sleep disturbance. Anxiety among young people in particular has been rising for at least the last seven years according to New Zealand Ministry of Health data — and it’s this change which has those working in the field particularly worried.

In 2019, Auckland-based clinical psychologist Gwendoline Smith wrote The Book of Knowing to help young people understand their brain and how it affects the way they feel. After it was published, her Ponsonby practice suddenly exploded with enquiries from 16-to- 21-year-olds.

Many of them claimed they didn’t worry, exactly — that’s something Mum does, they said — but when Smith asked them whether they thought they were overthinking, the answer was a resounding yes. Overthinking about how they’re going at school, overthinking about being on social media or off it, and overthinking the overthinking their parents are doing. Social anxiety, previously known as social phobia, is the next most common form of anxiety after GAD and its onset often occurs at a young age.

Smith, a psychologist for 40 years, defines social anxiety as “the fear of being negatively evaluated, the fear of judgement”. The young people she sees often struggle with deciding what to wear. “They don’t want to go out, they don’t want to go shopping because the phobia is actually other people’s eyes.” Simple things like eating in front of people can lead to feelings of shame, embarrassment and dread. Worrisome overthinking switches on their fight-or-flight mechanism, making them feel awkward and causing them to blush — they hate that, Smith says, because they fear they will be judged or mocked for blushing. It’s something of a vicious cycle as kids then withdraw to avoid that experience, further lowering their tolerance for discomfort.

In a seminar Smith conducted for correspondence school teachers a couple of years ago, she learned that 75 per cent of their students were at home because of anxiety — a startlingly high number. “It used to be that you’d only have a correspondence school teacher if you lived on a boat in the middle of the Hokianga Harbour,” she says.

Smith is in her 60s, with a sharp haircut and an extraordinarily good collection of large and colourful earrings. She is funny, bold and blunt, with no qualms about cutting through the bullshit. She’s exactly the kind of person you’d want to sit down with to solve the problems of the world.

In my own case, Smith catches me making assumptions that oversimplify the complex roots of anxiety. She does think the increase in social anxiety is a contemporary phenomenon, inextricably linked to social media, where people can “curate their lives”, count the “likes” on posts, and watch other kids, popular kids, at parties they weren’t invited to. Social media becomes a sort of dashboard of comparative judgement as they evaluate themselves against their peers. But she cautions against reducing things to a single cause, or seeing the rise in anxiety as a generational fault or weakness. While the pressures of social media are certainly a factor, Smith also suggests that a period of prosperity over the past few decades for those with means in the Western world has left people without the skills to teach their kids about setbacks, failure and the normality of negative experiences and emotions.

A Life Education Trust survey taken this year of teachers, principals and deputy principals at 2500 primary and intermediate schools found anxiety was the biggest issue in New Zealand schools, with 90 per cent saying it was a concern. A counsellor at one large North Island high school told me that over the last year they have dealt with 839 cases of anxiety and 104 cases of depression, in kids from a range of different backgrounds and social classes.

Covid-19 has led to anxiety among kids who are worried about bringing the virus home when they know their parents can’t afford to take time off work, this counsellor says. This is worse for kids whose part-time jobs are now considered essential to the household income. Feelings of futility about the future are compounded by seeing their parents unable to afford a house, and miserable in the rentals they can afford. My heart breaks a little as the counsellor tells me that some of the young men he talks to question what they might be able to offer a potential partner. “I hear it from a lot of my young guys,” he says. “‘I don’t feel like I’m much of a catch. Who would want me?’”

Teenagers have always been nocturnal, but this counsellor is seeing disruption to sleep cycles beyond the usual predilection for late nights. The kids he works with talk about being too scared to get off messaging apps for fear of missing out or being excluded — or worse, because they’re attempting to monitor a mate who might be at risk of self-harming. As one kid explained, “I have to stay awake. I have to talk to them and listen to them for hours and hours.”

Kids from more deprived families and those from wealthy families have different reasons for worrying about the future. Kids who are well-off may feel as if nothing they do is good enough for their parents; that they must strive for perfection as success takes on increasingly ostentatious forms. Being satisfied with an okay life and “normal job” is no longer enough. The counsellor says some kids are opting out of school events and activities to get away from what they think their parents see as an opportunity to compare notes about their kids’ achievements.

Lockdowns have also left some children spending more time in unsafe homes with nowhere to escape, no friends to see or supportive adults outside their homes to turn to, says Shae Ronald, the CEO of Youthline, an organisation that supports youth mental health. During lockdowns, Youthline has noticed children as young as eight calling the helpline in distress.

Ronald speaks gently, but she does not mince her words. “We are in a youth mental health crisis and that has been exacerbated by Covid-19,” she says. “We’re seeing younger young people contacting our helpline.” When a child under 10 calls Youthline, counsellors will usually seek to involve their parents, whanau or caregivers where possible, whereas teenagers, who have more agency, are simply encouraged to do so. Counsellors ask simple questions using concrete language around risk like “What is home like?” or what makes them sad, to be sure the children understand them. With older children, they use more metaphorical language, like “What’s sitting on top of you?”, or phrases like “safety plan”.

During the Level 4 lockdown last year, Youthline dealt with a 90 per cent increase in care and protection matters, where children are at risk of serious harm from others or have parents who can’t look after them. It also recorded a 23 per cent increase in suicide risk — which was the most common issue raised in messages to Youthline’s text helpline in the year following the first lockdown in March–April 2020.

The world young people are entering is precarious, their future volatile. Even resilient people can struggle. Josh Robertson is a 21-year-old multimedia journalist working at TVNZ’s Re: News, an online, youth-focused current affairs platform. It’s his first job since finishing a Bachelor of Communications last year. He feels optimistic about his career choice as people are “consuming more content than ever”, but describes the future as frustrating and hazy. “I can’t imagine myself a year from now,” he says. Robertson has almost forgotten what it’s like to not be in a pandemic. He often feels pessimistic about climate change, although he points out his generation has been brought up with the knowledge that the planet is headed for catastrophe, so he is in some sense “used to it”. He describes parties where the chat will turn to the grim state of it all: everyone kind of slumps, and then someone switches the topic. He’s also worried about how easy it is for information to spread on the internet with no way of verifying whether it’s true. “You learn not to trust anything,” he says.

One of the defining forces of the age we live in is access to information. In your pocket at all times, often unfiltered, unmitigated and unmoderated. Rapidly distributed, democratised information zinging straight into your brain from all over the world. The democratisation of mental health information and the corresponding rise in ‘therapy speak’ among young people can be attributed in part to this incredible access. We are connected in ways we never thought possible and while we might marvel at what this information has enabled, it also creates what Sarb Johal describes as a kind of contagion of negative emotions.

We are often saturated in the details of the crises of the day, whether we want to be or not. Excruciating footage of the 2019 Christchurch mosque shootings emerged almost immediately after the incident unfolded; social media platforms were left playing whack-a-mole trying to remove it as their own users kept sharing it. A video from September’s LynnMall stabbing in Auckland also emerged within hours of the incident. You can hear police gunshots and the panic in people’s voices; just outside the entrance to the Countdown supermarket a trail of blood is visible on the floor.

In the early days of the pandemic, aerial shots of mass graves dug on Hart Island in New York by workers in hazmat suits floated across my social media feed. Images of plywood coffins — crude markings scratched into them with ballpoint pen by gloved hands — filled me with feelings of fear and intense sadness. Hart Island is where many who died of HIV/AIDS in the 1980s and 90s were buried, unloved and abandoned. Now it was a burial ground for the unclaimed bodies of those who died of Covid-19.

It might be easier to exist during a time of crisis if we weren’t also being exposed to every single bad thing happening on the planet. In an essay from her collection Trick Mirror, the American writer Jia Tolentino observes that the internet “was dramatically increasing our ability to know about things, while our ability to change things stayed the same, or possibly shrank right in front of us”.

A 2020 survey by the American Psychological Association found that three-quarters of Americans are stressed out over the future of their country, and the constant consumption of news was a major contributor. Dr Steven Stosny coined the term “headline stress disorder” in the wake of the US election in 2016 that saw Donald Trump become president. I remember watching the election results that year in an Auckland pub which was packed to the rafters, all of us tuning in from half a world away to a domestic election that months of non-stop news transformed into a full-on global clash of cultures.

What happens to an entire generation of people growing up without a clear view of their future, with a sense of pessimism about the fate of the planet and feelings of futility about what they might be able to achieve and experience? What will it do to our society if diagnosed uncertainty continues to increase, compounded by unchecked socioeconomic inequality?

Psychologists around the world are already predicting that the mental health impacts of the pandemic will far outlast the physical health effects. Yuko Nippoda, a psychotherapist and spokesperson for the United Kingdom Council for Psychotherapy, says that there are many people who suffer from anxiety already, but “because of this deadly disease, people who tend to feel anxious more easily will continue to feel this and the condition might worsen”.

It’s a common misconception that anxiety leads to aggressive behaviour. Though that can happen as people enter fight-or-flight mode (for example, US researchers have found that anxiety about being infected by Covid-19 can cause people to become angry when others don’t follow health guidelines like masking or washing their hands), it’s more likely that over time people will just withdraw from situations that make them anxious. They will pass up opportunities, try to get out of going to school, or skip work. In 2020, the Australian Productivity Commission found that mental illness was costing Australia about $220 billion per year in lost productivity, participation and life expectancy. In New Zealand, the estimate is at least $12 billion.

Anxiety can also change our political behaviour — the authors of the prescient 2015 book Anxious Politics: Democratic Citizenship in a Threatening World found that anxiety during a public health crisis can have two seemingly contradictory effects. In some cases, it increases people’s willingness to trust expert opinion and pay attention to what’s going on in the news.

But it can also drive people in the opposite direction. Research conducted during the pandemic in eight countries — including New Zealand — found there is a correlation between conspiratorial belief and higher levels of consumption of digital media.

During times of uncertainty we seek ways to make sense of what’s happening. Psychologists refer to these as schema or cognitive frameworks. Exposure to large amounts of conflicting information and ambiguity online — advice on mask-wearing for example — results in higher levels of stress or anxiety. In order to make sense of the conflicting information, people construct alternative explanations for the ambiguity. The study exploring these effects, published in April 2021 in the journal Frontiers in Psychology, was a collaboration by researchers from Belgium, the Netherlands, Switzerland, Germany and Canada. They concluded that these anxious responses might “set in motion a never-ending chain reaction in which people seek for more information to reduce uncertainty and stress, but in contrast stumble upon stress-evoking discourses”.

It’s not clear that our mental health system could cope with a significant further rise in anxiety. If you have severe anxiety you may fall within what mental health advocates call the “missing middle”, the 20 per cent of New Zealanders who are dealing with a level of mental illness that affects their daily lives. This group doesn’t meet the criteria for in-patient care, but they need more help than can be provided by an occasional check-in with their GP. There is a real gap in the provision of holistic care, and to bridge it there needs to be more investment in the mental health workforce, as well as more coordination across agencies to ensure that people don’t just bounce around the system with a fragmented list of “problems” that are treated in isolation. If, for example, an unstable housing situation is the main exacerbator of a person’s anxiety, but they are only referred into the healthcare system, they might be prescribed medication but offered no help to deal with their anxiety’s root causes. Currently, a lack of funding for mental health services means that people are often put on year-long waiting lists to see psychologists or psychiatrists. When they seek help from different government agencies, they are in effect starting from scratch each time; there is no mechanism which allows each agency a full view of their situation.

There are also concerns medication is being used as a default treatment for anxiety because it’s cost-effective. Between 2012 and 2020, there has been a 26 per cent rise in the number of antipsychotics dispensed and a 20 per cent rise in antidepressants — both used to treat anxiety. The Ministry of Health describes this as a “positive” sign, that more people are seeking help when they need it.

Others aren’t so sure. Both Sarb Johal and Dougal Sutherland, a clinical psychologist at Wellington’s Victoria University, see a problem with a continued reliance on medication to treat anxiety in the absence of therapy and support to deal with traumatic events and help people develop the skills to cope with life transitions and loss. While they emphasise that medication can be a necessary stabiliser, there is a risk of suppressing emotions people can be taught to regulate. “The great thing about psychological therapies is that you understand what’s happening for you, and know what to do about it,” says Sutherland. “And you don’t really get that with medication. All you learn is how to take a pill.”

Sutherland also points out that an unchecked epidemic of anxiety among young people will put more pressure on already stretched adult mental health services in future. It’s estimated that district health boards need an additional 268 psychologists to meet demand. The results of a recently released survey of psychologists in private practice showed half of them had closed their waiting lists.

While a “larger platoon” would be helpful, an army of psychologists is not the answer, Sutherland says. “We’re never going to train enough psychologists [to meet demand]. Even if we triple the number, we’re still not going to train enough to be able to get a psychologist to see everybody.”

In some ways, we are lucky, in that the work to address these shortcomings has already started. A major government inquiry into mental health in 2018 and subsequent report, He Ara Oranga, has set in motion a shift in how we approach mental health in New Zealand. This isn’t just a question of funding. A 2017 article in the Australian and New Zealand Journal of Psychiatry found that even though investment in mental health in New Zealand increased by some $3 billion between 2008 and 2016 — including a doubling of the psychiatric and psychologist workforce and an increase in people accessing mental health and medication — mental health and wellbeing statistics in the same period showed no improvement. In fact, they got worse.

He Ara Oranga suggests we should move from our current reliance on an already overloaded health system towards a “biopsychosocial” model of mental wellbeing, which recognises that people’s mental wellbeing is an interaction between biological factors like genetics and brain chemistry, social factors like upbringing, significant and difficult life experiences, poverty or discrimination, and psychological or behavioural factors including beliefs and coping skills.

Shaun Robinson, chief executive of the Mental Health Foundation, says the aim should be a society where most people are able to bounce back from life’s setbacks, even in the face of difficult times, because they’re able to see their mental wellbeing as something that doesn’t just randomly deteriorate but as something which can, with the right support, be actively looked after. He is not anti-medication — he takes daily medication for bipolar disorder, one part of a holistic approach that allows him to live “a really good life”.

In late September, Minister of Health Andrew Little announced a plan to deliver on He Ara Oranga’s 40 recommendations. Called Kia Manawanui, the 10-year plan involves increased funding and moves to address the social, cultural, environmental and economic factors that can affect mental wellbeing. As the inquiry team put it, it’s a “‘once in a generation’ opportunity for change”.

Hasn’t life always been hard? War, famine, disease, slavery — all surely no less threatening and anxiety-inducing as what we face now? Perhaps. Psychologists like Johal are reluctant to rule on whether these times are truly as unprecedented as we think they are. But we’re not in competition with the past. While it can be useful to consider in a morning gratitude meditation the various ways in which you are more fortunate than those who lived through the Black Death, it does little to fix real problems in the here and now. To ignore what we know about why we feel the way we feel and to avoid figuring out how we might adapt is to live with our heads buried in the sand.

A key finding of He Ara Oranga was that New Zealand’s mental health problems are not solely up to the health system or even the government to fix — some solutions lie in our own hands. There is growing evidence that becoming involved in climate activism can help alleviate climate anxiety. Even just talking about it with like-minded people can help — climate cafes have started popping up in cities across the world where people can meet and chat about their climate-related fears. In the United States, an organisation called the Good Grief Network runs a 10-step programme which runs not unlike an Alcoholics Anonymous meeting, with small groups of people coming together to first “accept the severity of the predicament” and then “reinvest in meaningful efforts” to make change.

Here in New Zealand, the rural community initiative Farmstrong teaches farmers to proactively look after their own mental wellbeing and share their experiences with each other, essentially teaching peerto- peer support. The Mental Health Foundation also endorses the Māori mental health model developed by Dr Mason Durie in 1984, Te Whare Tapa Whā, one of the foundational frameworks for He Ara Oranga. The name alludes to four cornerstones of wellbeing: taha tinana (physical health), taha wairua (spiritual health), taha whānau (family health) and taha hinengaro (mental health). Without suggesting we appropriate Te Whare Tapa Whā for everyone in New Zealand before addressing the numerous inequities that exist for Māori, moving towards models like this one sound like where we should be heading, because it’s an effort we can all play a part in.

In a recent interview, Green MP Chlöe Swarbrick questioned why the “colossal disruption” of the pandemic couldn’t be used as a reset to come up with a more equitable way of running things. There are many reasons to assume the world is on a trajectory to a future worse than the present — but it doesn’t have to be. The political writer and novelist Arundhati Roy wrote in her 2003 essay collection, War Talk, that “another world is not only possible, she is on her way. On a quiet day, I can hear her breathing.” The line feels more resonant now than ever. When the only certainty about the future is that it’s uncertain, a radical embrace of change might be the only hope we have to avoid being crushed under the weight of our collective anxiety.

Anna Rawhiti-Connell is a writer and columnist, and currently feeling a bit anxious herself really.

This story appeared in the December 2021 issue of North & South.