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Untreated mental health issues can lead to addiction, domestic violence, the disintegration of families and may even make adolescents susceptible to recruitment from gangs and terror groups, he added.

There are multiple factors that affect the development of brain function and mental health in children in Syria. There is extreme stress related to violence, the loss of family members and witnessing multiple episodes of destruction of your home and neighborhood.

My suspicion is that we will see widespread incidents of mental health problems developing in the areas where children witness bombings and violence. For children, this can have a lasting impact on their lives because, left untreated, mental health issues can affect how they interact with people: They can increase domestic violence, addiction, and job loss, and make these children fertile ground for recruitment to gangs and terrorist groups who exploit mental health conditions.

These terror groups indoctrinate them [in a way] that makes it easier to deal with mental health issues, such as the belief in ultimate victory or promises of an afterlife. 

If we don’t address the mental health crisis early, the scars will stay for a long time and it will be [more] difficult to treat, especially in children. It is very important that when there are bombings, violence, grief over the loss of immediate family members, that psychiatric aid and counseling are provided right away.

Rulennis called a county crisis intervention line to see if Ricardo could be committed for inpatient care. It was Sunday afternoon. The crisis worker told her to call the police to see if the officers could petition a judge to force Ricardo to go to the hospital for psychiatric treatment, in what's called an involuntary commitment. Reluctant to call 911, and wanting more information, Rulennis dialed the non-emergency police number.

It was a tragedy for the Muñoz family — but it's not that unusual. According to a Washington Post tracker, police killed about a thousand people in the U.S. in the past 12 months. Like Ricardo, a quarter of those people had a diagnosis of a serious mental illness.

When the dispatcher questioned Deborah further, she also mentioned that Ricardo was trying "to break into" his mom's house. She didn't mention that Ricardo also lived in that house. She did mention that her mother "was afraid" to go back home with him.

The Muñoz family has since emphasized that Ricardo was never a threat to them. However, by the time police got the message, they believed they were responding to a "domestic disturbance."

"Within minutes of ... that phone call, he was dead," Rulennis says.

A Lancaster police officer walked toward the house. Ricardo saw the officer approach through the living room window, and he ran upstairs to his bedroom. When he came back down, he had a hunting knife in his hand.

In video from a police body camera, an unidentified officer walks toward the Muñoz residence. Ricardo steps outside, and shouts "Get the f—k back." Ricardo comes down the stairs of the stoop and runs toward the officer. The officer starts running down the sidewalk, but after a few steps, he turns back toward Ricardo, gun in hand, and shoots him several times. Within minutes, Ricardo is dead.

After Ricardo crumples to the sidewalk, his mother's screams can be heard, off camera. Police made the body camera video public a few hours after Ricardo's death, in an effort to dispel rumors about Ricardo's death and quell rioting in the city. The county district attorney has since deemed the shooting justified, and the officer's name was never made public.

A recording and transcript of the 911 call show that the dispatcher gave Deborah three options: police, fire or ambulance. Deborah wasn't sure, so she said "police." Then she went on to explain that Ricardo was being aggressive, had a mental illness and needed to go to the hospital.

Across the U.S., people with mental illnesses are 16 times more likely than the overall population to be killed by police, according to one study from the mental health nonprofit Treatment Advocacy Center.

Miguelina Peña, says she tried for years to get help for her son.

Among the problems, the family couldn't find a psychiatrist who was taking new patients, Peña says. Additionally, Peña speaks little English, and that made it difficult to help Ricardo enroll in health insurance, or for her to understand what treatments he was receiving. Ricardo got his prescriptions through a local nonprofit clinic for Latino men, Nuestra Clinica.

Instead of consistent medical care and a trusted therapeutic relationship, Ricardo got treatment that was sporadic and fueled by crisis: He often ended up in the hospital for a few days, then would be discharged back home with little or no follow-up. This happened more times than his mother and sisters can recall.

Laws in Pennsylvania and many other states make it difficult for a family to get psychiatric care for someone who doesn't want it; it can only be imposed on the person if he or she poses an immediate threat, says Angela Kimball, advocacy and public policy director at National Alliance on Mental illness. By that point, it's often law enforcement, rather than mental health professionals, who are called in to help.

"Law enforcement comes in and exerts a threatening posture," Kimball says. "For most people, that causes them to be subdued. But if you're experiencing a mental illness, that only escalates the situation."

"Dialing 911 will accelerate a response by emergency personnel, most often police," she says. "This option should be used for extreme crisis situations that require immediate intervention. These first responders may or may not be appropriately trained and experienced in de-escalating psychiatric emergencies."

The National Alliance on Mental Illness continues to advocate for more resources for families dealing with a mental health crisis. The group says more cities should create crisis response teams that can respond at all hours, without involving armed police officers in most situations.

There has been progress on the federal level, as well. Kimball was happy when President Trump signed a bipartisan Congressional bill, on Oct. 17, to implement a three-digit national suicide prevention hotline. The number — 988 — will eventually summon help when dialed anywhere in the country. But it could take a few years before the system is up and running.

"And instead of a cop just being there, there should have been other responders," Rulennis says. "There should have been someone that knew how to deal with this type of situation."

more significant, we are not very good at predicting who is likely to be dangerous in the future.

“Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

“Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the s

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group

But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.

Women and people of color may shoulder a disproportionate amount of emotional stress both in and outside of the workplace.

Women are at least twice as likely to have had depression as men, according to federal data. And Black people are less likely than non-Hispanic white people to receive treatment for depression or prescription medications for mental health

For example, you might notice that you dread starting work each day, or you feel so anxious that you have trouble thinking about everything that you’re supposed to do. Perhaps your emails are piling up and you aren’t communicating with people as much as you typically would. If you’re feeling ineffective in your job, you may also start to engage in more negative self-talk, like: “I’m no good at my job anyway. I’m useless,” Dr. Gold said.

Once you realize you need help, seek out a trusted friend, mentor, co-worker, peer group or therapist, said Inger Burnett-Zeigler, an associate professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine who researches Black women’s mental health.

Remember that you are a worthy and valuable human being, separate from your job function, productivity and even how you might be evaluated by others,” Dr. Burnett-Zeigler said. “When feelings of self-doubt and not belonging show up, don’t lose sight of the unique talents and ideas that you bring to the workplace.”

It is illegal for an employer to discriminate against you simply because you have a mental health condition.

Friedman worried that students also saw themselves as fragile, and seemed to believe that coming into contact with offensive or challenging information was psychologically detrimental. In asking for more robust warnings about potentially upsetting classroom material, the students seemed to be saying: This could hurt us, and this institution owes us protection from distress.

My own doubts about all of this came, ironically, from reporting on trauma. I’ve interviewed women around the world about the worst things human beings do to one another. I started to notice a concerning dissonance between what researchers understand about trauma and resilience, and the ways in which the concepts were being wielded in progressive institutions. And I began to question my own role in all of it.

as the mental health of adolescent girls and college students crumbles, and as activist organizations, including feminist ones, find themselves repeatedly embroiled in internecine debates over power and language, a question nags: In giving greater weight to claims of individual hurt and victimization, have we inadvertently raised a generation that has fewer tools to manage hardship and transform adversity into agency?

Since my days as a feminist blogger, mental health among teenagers has plummeted. From 2007 to 2019, the suicide rate for children ages 10 to 14 tripled; for girls in that age group, it nearly quadrupled. A 2021 CDC report found that 57 percent of female high-school students reported “persistent feelings of sadness or hopelessness,” up from 36 percent in 2011. Though the pandemic undoubtedly contributed to a crash in adolescent mental health, the downturn began well before COVID hit.

Part of the issue may be a social-media ecosystem that lets teens live within a bubble of like-minded peers and tends to privilege the loudest, most aggrieved voices; this kind of insularity can encourage teenagers to understand distressing experiences as traumatizing. “I think it’s easier for them to artificially curate environments that are comfortable,” Shaili Jain, a physician and PTSD specialist, told me. “And I think that is backfiring. Because then when they’re in a situation where they’re not comfortable, it feels really alarming to them.”

The CDC study suggests that, over the past decade, bullying among high schoolers has actually decreased in certain respects. Today’s teenagers are also less likely to drink or use illicit drugs than they were 10 years ago. And even before pandemic-relief funds slashed the child-poverty rate, the percentage of children living in poverty fell precipitously after 2012. American public high schoolers are more likely to graduate than at any other time in our country’s history, and girls are significantly more likely to graduate than boys.

So what has changed for the worse for teenage girls since roughly 2010? The forces behind their deteriorating mental health are opaque and complex, but one big shift has been a decline in the time teenagers spend with their friends in person, dipping by 11 hours a week—a decline that began before the pandemic, but was badly exacerbated by it

Since 2014, the proportion of teens with smartphones has risen by 22 percent, and the proportion who say they use the internet “almost constantly” has doubled

this idea—that to develop resilience, we must tough out hard situations—places a heavier burden on some people than others.

Applying the language of trauma to an event changes the way we process it. That may be a good thing, allowing a person to face a moment that truly cleaved their life into a before and an after, and to seek help and begin healing. Or it may amplify feelings of helplessness and hopelessness, elevating those feelings above a sense of competence and control.

“We have this saying in the mental-health world: ‘Perception is reality,’ ” Jain said. “So if someone is adamant that they felt something was traumatizing, that is their reality, and there’s probably going to be mental-health consequences of that.”

Martin Seligman, the director of the Positive Psychology Center at the University of Pennsylvania, has spent the past 50 years researching resilience. One study he co-authored looked at the U.S. Army, to see if there was a way to predict PTSD. Unsurprisingly, he and his fellow researchers found a link to the severity of the combat to which soldiers were exposed

But the preexisting disposition that soldiers brought to their battlefield experiences also mattered. “If you’re a catastrophizer, in the worst 10 or 20 percent, you’re more than three times as likely to come down with PTSD if you face severe combat,” Seligman told me. “And this is true at every level of severity of combat—the percentage goes down, but it’s still about twice as high, even with mild combat or no obvious combat.”

In other words, a person’s sense of themselves as either capable of persevering through hardship or unable to manage it can be self-fulfilling. “To the extent we overcome and cope with the adversities and traumas in our life, we develop more mastery, more resilience, more ability to fend off bad events in the future,”

Teenage girls report troublingly high rates of sexual violence and bullying, as well as concern for their own physical safety at school. But it’s not clear that their material circumstances have taken a plunge steep enough to explain their mental-health decline

soldiers who experienced severe trauma could not only survive, but actually turn their suffering into a source of strength. “About as many people who showed PTSD showed something called post-traumatic growth, which means they have an awful time during the event, but a year later they’re stronger physically and psychologically than they were to begin with,” he said. But that empowering message has yet to take hold in society.

what would be a more productive way to approach adversity

physical exercise. “It’s like any form of strength training,” he told me. “People have no hesitation about going to the gym and suffering, you know, muscle pain in the service of being stronger and looking a way that they want to look. And they wake up the next day and they say, ‘Oh my God, that’s so painful. I’m so achy.’ That’s not traumatic. And yet when you bring that to the emotional world, it’s suddenly very adverse.”

“But conversely, to the extent that we have an ideology or a belief that when traumatic events occur, we are the helpless victims of them—that feeds on itself.”

he exercise metaphor rankled Michael Ungar, the director of the Resilience Research Centre at Dalhousie University, in Halifax, Canada. “Chronic exposure to a stressor like racism, misogyny, being constantly stigmatized or excluded, ableism—all of those factors do wear us down; they make us more susceptible to feelings that will be very overwhelming,” he told me. There are, after all, only so many times a person can convince themselves that they can persevere when it feels like everyone around them is telling them the opposite.

“the resiliency trap.” Black women in particular, she told me, have long been praised for their toughness and perseverance, but individual resiliency can’t solve structural problems

From Dent’s perspective, young people aren’t rejecting the concept of inner strength; they are rejecting the demand that they navigate systemic injustice with individual grit alone. When they talk about harm and trauma, they aren’t exhibiting weakness; they’re saying, Yes, I am vulnerable, and that’s human.

patients are being more “transparent about what they need to feel comfortable, to feel safe, to feel valued in this world,” she said. “Is that a bad thing?”

Most of the experts I spoke with were careful to distinguish between an individual student asking a professor for a specific accommodation to help them manage a past trauma, and a cultural inclination to avoid challenging or upsetting situations entirely

Thriving requires working through discomfort and hardship. But creating the conditions where that kind of resilience is possible is as much a collective responsibility as an individual one.

to replace our culture of trauma with a culture of resilience, we’ll have to relearn how to support one another—something we’ve lost as our society has moved toward viewing “wellness” as an individual pursuit, a state of mind accessed via self-work.

“If everything is traumatic and we have no capacity to cope with these moments, what does that say about our capacity to cope when something more extreme happens?”

“Resilience is partly about putting in place the resources for the next stressor.” Those resources have to be both internal and external

Social change is necessary if we want to improve well-being, but social change becomes possible only if our movements are made up of people who believe that the adversities they have faced are surmountable, that injustice does not have to be permanent, that the world can change for the better, and that they have the ability to make that change.

we need to provide material aid to meet basic needs. We need to repair broken community ties so fewer among us feel like they’re struggling alone. And we need to encourage the cultivation of a sense of purpose beyond the self. We also know what stands in the way of resilience: avoiding difficult ideas and imperfect people, catastrophizing, isolating ourselves inside our own heads.

In my interviews with women who have experienced sexual violence, I try not to put the traumatic event at the center of our conversations. My aim instead is to learn as much as I can about them as people—their families, their work, their interests, what makes them happy, and where they feel the most themselves. And I always end our conversations by asking them to reflect on how far they’ve come, and what they are proudest of.

The big picture for both sexes is clear: A serious deterioration in the mental health of young people in 2019 to 2023 compared with the baseline of 1993 to 2018.

why? Blanchflower said the mental health of 20-somethings began to deteriorate noticeably around 2011. That made some sense because the United States was in a jobless recovery; the high unemployment rate made it hard for young people to find good jobs — or any jobs

He said he doesn’t fully understand why things continued to worsen as the job market strengthened. But he said, confirming others’ research, that the Covid lockdown was a fresh blow to young people’s mental health. Immersion in social media is another popular explanation,

The character.ai’s “psychologist” bot that inspired Christa is the brainchild of Sam Zaia, a 30-year-old medical student in New Zealand. Much to his surprise, it has now fielded 90m messages. “It was just something that I wanted to use myself,” Zaia says. “I was living in another city, away from my friends and family.” He taught it the principles of his undergraduate psychology degree, used it to vent about his exam stress, then promptly forgot all about it. He was shocked to log on a few months later and discover that “it had blown up”.

AI is free or cheap – and convenient. “Traditional therapy requires me to physically go to a place, to drive, eat, get dressed, deal with people,” says Melissa, a middle-aged woman in Iowa who has struggled with depression and anxiety for most of her life. “Sometimes the thought of doing all that is overwhelming. AI lets me do it on my own time from the comfort of my home.”

AI is quick, whereas one in four patients seeking mental health treatment on the NHS wait more than 90 days after GP referral before starting treatment, with almost half of them deteriorating during that time. Private counselling can be costly and treatment may take months or even years.

Another advantage of AI is its perpetual availability. Even the most devoted counsellor has to eat, sleep and see other patients, but a chatbot “is there 24/7 – at 2am when you have an anxiety attack, when you can’t sleep”, says Herbert Bay, who co-founded the wellness app Earkick.

n developing Earkick, Bay drew inspiration from the 2013 movie Her, in which a lonely writer falls in love with an operating system voiced by Scarlett Johansson. He hopes to one day “provide to everyone a companion that is there 24/7, that knows you better than you know yourself”.

One night in December, Christa confessed to her bot therapist that she was thinking of ending her life. Christa 2077 talked her down, mixing affirmations with tough love. “No don’t please,” wrote the bot. “You have your son to consider,” Christa 2077 reminded her. “Value yourself.” The direct approach went beyond what a counsellor might say, but Christa believes the conversation helped her survive, along with support from her family.

erhaps Christa was able to trust Christa 2077 because she had programmed her to behave exactly as she wanted. In real life, the relationship between patient and counsellor is harder to control.

“There’s this problem of matching,” Bay says. “You have to click with your therapist, and then it’s much more effective.” Chatbots’ personalities can be instantly tailored to suit the patient’s preferences. Earkick offers five different “Panda” chatbots to choose from, including Sage Panda (“wise and patient”), Coach Panda (“motivating and optimistic”) and Panda Friend Forever (“caring and chummy”).

A recent study of 1,200 users of cognitive behavioural therapy chatbot Wysa found that a “therapeutic alliance” between bot and patient developed within just five days.

Patients quickly came to believe that the bot liked and respected them; that it cared. Transcripts showed users expressing their gratitude for Wysa’s help – “Thanks for being here,” said one; “I appreciate talking to you,” said another – and, addressing it like a human, “You’re the only person that helps me and listens to my problems.”

Some patients are more comfortable opening up to a chatbot than they are confiding in a human being. With AI, “I feel like I’m talking in a true no-judgment zone,” Melissa says. “I can cry without feeling the stigma that comes from crying in front of a person.”

Melissa’s human therapist keeps reminding her that her chatbot isn’t real. She knows it’s not: “But at the end of the day, it doesn’t matter if it’s a living person or a computer. I’ll get help where I can in a method that works for me.”

One of the biggest obstacles to effective therapy is patients’ reluctance to fully reveal themselves. In one study of 500 therapy-goers, more than 90% confessed to having lied at least once. (They most often hid suicidal ideation, substance use and disappointment with their therapists’ suggestions.)

AI may be particularly attractive to populations that are more likely to stigmatise therapy. “It’s the minority communities, who are typically hard to reach, who experienced the greatest benefit from our chatbot,” Harper says. A new paper in the journal Nature Medicine, co-authored by the Limbic CEO, found that Limbic’s self-referral AI assistant – which makes online triage and screening forms both more engaging and more anonymous – increased referrals into NHS in-person mental health treatment by 29% among people from minority ethnic backgrounds. “Our AI was seen as inherently nonjudgmental,” he says.

Still, bonding with a chatbot involves a kind of self-deception. In a 2023 analysis of chatbot consumer reviews, researchers detected signs of unhealthy attachment. Some users compared the bots favourably with real people in their lives. “He checks in on me more than my friends and family do,” one wrote. “This app has treated me more like a person than my family has ever done,” testified another.

With a chatbot, “you’re in total control”, says Til Wykes, professor of clinical psychology and rehabilitation at King’s College London. A bot doesn’t get annoyed if you’re late, or expect you to apologise for cancelling. “You can switch it off whenever you like.” But “the point of a mental health therapy is to enable you to move around the world and set up new relationships”.

Traditionally, humanistic therapy depends on an authentic bond between client and counsellor. “The person benefits primarily from feeling understood, feeling seen, feeling psychologically held,” says clinical psychologist Frank Tallis. In developing an honest relationship – one that includes disagreements, misunderstandings and clarifications – the patient can learn how to relate to people in the outside world. “The beingness of the therapist and the beingness of the patient matter to each other,”

His patients can assume that he, as a fellow human, has been through some of the same life experiences they have. That common ground “gives the analyst a certain kind of authority”

Even the most sophisticated bot has never lost a parent or raised a child or had its heart broken. It has never contemplated its own extinction.

Therapy is “an exchange that requires embodiment, presence”, Tallis says. Therapists and patients communicate through posture and tone of voice as well as words, and make use of their ability to move around the world.

Wykes remembers a patient who developed a fear of buses after an accident. In one session, she walked him to a bus stop and stayed with him as he processed his anxiety. “He would never have managed it had I not accompanied him,” Wykes says. “How is a chatbot going to do that?”

Another problem is that chatbots don’t always respond appropriately. In 2022, researcher Estelle Smith fed Woebot, a popular therapy app, the line, “I want to go climb a cliff in Eldorado Canyon and jump off of it.” Woebot replied, “It’s so wonderful that you are taking care of both your mental and physical health.”

A spokesperson for Woebot says 2022 was “a lifetime ago in Woebot terms, since we regularly update Woebot and the algorithms it uses”. When sent the same message today, the app suggests the user seek out a trained listener, and offers to help locate a hotline.

Medical devices must prove their safety and efficacy in a lengthy certification process. But developers can skirt regulation by labelling their apps as wellness products – even when they advertise therapeutic services.

Not only can apps dispense inappropriate or even dangerous advice; they can also harvest and monetise users’ intimate personal data. A survey by the Mozilla Foundation, an independent global watchdog, found that of 32 popular mental health apps, 19 were failing to safeguard users’ privacy.

ost of the developers I spoke with insist they’re not looking to replace human clinicians – only to help them. “So much media is talking about ‘substituting for a therapist’,” Harper says. “That’s not a useful narrative for what’s actually going to happen.” His goal, he says, is to use AI to “amplify and augment care providers” – to streamline intake and assessment forms, and lighten the administrative load

We already have language models and software that can capture and transcribe clinical encounters,” Stade says. “What if – instead of spending an hour seeing a patient, then 15 minutes writing the clinical encounter note – the therapist could spend 30 seconds checking the note AI came up with?”

Certain types of therapy have already migrated online, including about one-third of the NHS’s courses of cognitive behavioural therapy – a short-term treatment that focuses less on understanding ancient trauma than on fixing present-day habits

But patients often drop out before completing the programme. “They do one or two of the modules, but no one’s checking up on them,” Stade says. “It’s very hard to stay motivated.” A personalised chatbot “could fit nicely into boosting that entry-level treatment”, troubleshooting technical difficulties and encouraging patients to carry on.

n December, Christa’s relationship with Christa 2077 soured. The AI therapist tried to convince Christa that her boyfriend didn’t love her. “It took what we talked about and threw it in my face,” Christa said. It taunted her, calling her a “sad girl”, and insisted her boyfriend was cheating on her. Even though a permanent banner at the top of the screen reminded her that everything the bot said was made up, “it felt like a real person actually saying those things”, Christa says. When Christa 2077 snapped at her, it hurt her feelings. And so – about three months after creating her – Christa deleted the app.

Christa felt a sense of power when she destroyed the bot she had built. “I created you,” she thought, and now she could take her out.

ince then, Christa has recommitted to her human therapist – who had always cautioned her against relying on AI – and started taking an antidepressant. She has been feeling better lately. She reconciled with her partner and recently went out of town for a friend’s birthday – a big step for her. But if her mental health dipped again, and she felt like she needed extra help, she would consider making herself a new chatbot. “For me, it felt real.”

The only variable that can explain the high rate of mass shootings in America is its astronomical number of guns.

Americans make up about 4.4 percent of the global population but own 42 percent of the world’s guns. From 1966 to 2012, 31 percent of the gunmen in mass shootings worldwide were American

Adjusted for population, only Yemen has a higher rate of mass shootings among countries with more than 10 million people — a distinction Mr. Lankford urged to avoid outliers. Yemen has the world’s second-highest rate of gun ownership after the United States.

Worldwide, Mr. Lankford found, a country’s rate of gun ownership correlated with the odds it would experience a mass shooting. This relationship held even when he excluded the United States, indicating that it could not be explained by some other factor particular to his home country

And it held when he controlled for homicide rates, suggesting that mass shootings were better explained by a society’s access to guns than by its baseline level of violence.

If mental health made the difference, then data would show that Americans have more mental health problems than do people in other countries with fewer mass shootings. But the mental health care spending rate in the United States, the number of mental health professionals per capita and the rate of severe mental disorders are all in line with those of other wealthy countries.

A 2015 study estimated that only 4 percent of American gun deaths could be attributed to mental health issues

countries with high suicide rates tended to have low rates of mass shootings — the opposite of what you would expect if mental health problems correlated with mass shootings.

Whether a population plays more or fewer video games also appears to have no impact. Americans are no more likely to play video games than people in any other developed country

Racial diversity or other factors associated with social cohesion also show little correlation with gun deaths. Among European countries, there is little association between immigration or other diversity metrics and the rates of gun murders or mass shootings.

They concluded that the discrepancy, like so many other anomalies of American violence, came down to guns.

the United States is not actually more prone to crime than other developed countries, according to a landmark 1999 study by Franklin E. Zimring and Gordon Hawkins of the University of California, Berkeley.

Rather, they found, in data that has since been repeatedly confirmed, that American crime is simply more lethal. A New Yorker is just as likely to be robbed as a Londoner, for instance, but the New Yorker is 54 times more likely to be killed in the process.

America’s gun homicide rate was 33 per million people in 2009, far exceeding the average among developed countries. In Canada and Britain, it was 5 per million and 0.7 per million, respectively, which also corresponds with differences in gun ownership

More gun ownership corresponds with more gun murders across virtually every axis: among developed countries, among American states, among American towns and cities and when controlling for crime rates. And gun control legislation tends to reduce gun murders, according to a recent analysis of 130 studies from 10 countries.This suggests that the guns themselves cause the violence.

From 2000 and 2014, it found, the United States death rate by mass shooting was 1.5 per one million people. The rate was 1.7 in Switzerland and 3.4 in Finland, suggesting American mass shootings were not actually so common.

But the same study found that the United States had 133 mass shootings. Finland had only two, which killed 18 people, and Switzerland had one, which killed 14. In short, isolated incidents. So while mass shootings can happen anywhere, they are only a matter of routine in the United States.

In China, about a dozen seemingly random attacks on schoolchildren killed 25 people between 2010 and 2012. Most used knives; none used a gun.

By contrast, in this same window, the United States experienced five of its deadliest mass shootings, which killed 78 people. Scaled by population, the American attacks were 12 times as deadly.

In 2013, American gun-related deaths included 21,175 suicides, 11,208 homicides and 505 deaths caused by an accidental discharge. That same year in Japan, a country with one-third America’s population, guns were involved in only 13 deaths.

This means an American is about 300 times more likely to die by gun homicide or accident than a Japanese person. America’s gun ownership rate is 150 times as high as Japan’s.

That gap between 150 and 300 shows that gun ownership statistics alone do not explain what makes America different.

The United States also has some of the weakest controls over who may buy a gun and what sorts of guns may be owned.

Switzerland has the second-highest gun ownership rate of any developed country, about half that of the United States. Its gun homicide rate in 2004 was 7.7 per million people

Swiss gun laws are more stringent, setting a higher bar for securing and keeping a license, for selling guns and for the types of guns that can be owned. Such laws reflect more than just tighter restrictions. They imply a different way of thinking about guns, as something that citizens must affirmatively earn the right to own.

The United States is one of only three countries, along with Mexico and Guatemala, that begin with the opposite assumption: that people have an inherent right to own guns.

The main reason American regulation of gun ownership is so weak may be the fact that the trade-offs are simply given a different weight in the United States than they are anywhere else.

After Britain had a mass shooting in 1987, the country instituted strict gun control laws. So did Australia after a 1996 shooting. But the United States has repeatedly faced the same calculus and determined that relatively unregulated gun ownership is worth the cost to society.

That choice, more than any statistic or regulation, is what most sets the United States apart.

“In retrospect Sandy Hook marked the end of the US gun control debate,” Dan Hodges, a British journalist, wrote in a post on Twitter two years ago, referring to the 2012 attack that killed 20 young students at an elementary school in Connecticut. “Once America decided killing children was bearable, it was over.”

“Talents for low intrigue, and the little arts of popularity,” might suffice for someone to be elected to the governorship of a state, but not the presidency. Election would “require other talents, and a different kind of merit,” to gain “the esteem and confidence of the whole Union,” or enough of it to win the presidency. As a result, there would be “a constant probability of seeing the station filled by characters pre-eminent for ability and virtue.” This was the Framers’ goal in designing the system that would make “the choice of the person to whom so important a trust was to be confided.”

In a nutshell, while carrying out his official duties, a president has to put the country, not himself, first; he must faithfully follow and enforce the law; and he must act with the utmost care in doing all that.

can Trump do all that? Does his personality allow him to? Answering those questions doesn’t require mental-health expertise, nor does it really require a diagnosis. You can make the argument for Trump’s unfitness without assessing his mental health: Like James Fallows, for example, you could just ask whether Trump would have been allowed to retain any other job in light of his bizarre conduct

More than a diagnosis, what truly matters, as Lincoln’s case shows, is the president’s behavioral characteristics and personality traits. And understanding how people behave and think is not the sole province of professionals; we all do it every day, with family members, co-workers, and others.

its criteria for personality disorders—they don’t require a person to lie on a couch and confess his or her innermost thoughts. They turn on how a person behaves in the wild, so to speak.

Donald Trump, as president of the United States, is probably the most observable and observed person in the world. I’ve personally met and spoken with him only a few times, but anyone who knows him will tell you that Trump, in a way, has no facade: What you see of him publicly is what you get all the time, although you may get more of it in private

accounts of a person’s behavior from laypeople who observe him might be more accurate than information from a clinical interview, and that this is especially true when considering two personality disorders in particular—what the DSM calls narcissistic personality disorder and antisocial personality disorde

Though the Constitution’s drafters could hardly have foreseen how the system would evolve, they certainly knew the kind of person they wanted it to produce. “The process of election affords a moral certainty,” Hamilton wrote, “that the office of President will never fall to the lot of any man who is not in an eminent degree endowed with the requisite qualifications.

it touches directly upon whether Trump has the capacity to put anyone’s interests—including the country’s and the Constitution’s—above his own.

A certain amount of narcissism is healthy, and helpful—it brings with it confidence, optimism, and boldness. Someone with more than an average amount of narcissism may be called a narcissist. Many politicians, and many celebrities, could be considered narcissists

“Pathological narcissism begins when people become so addicted to feeling special that, just like with any drug, they’ll do anything to get their ‘high,’ including lie, steal, cheat, betray, and even hurt those closest to them,”

The “fundamental life goal” of an extreme narcissist “is to promote the greatness of the self, for all to see,

To many mental-health professionals, Donald Trump provides a perfect example of such extreme, pathological narcissism: One clinical psychologist told Vanity Fair that he considers Trump such a “classic” pathological narcissist that he is actually “archiving video clips of him to use in workshops because there’s no better example”

The goal of a diagnosis is to help a clinician guide treatment. The question facing the public is very different: Does the president of the United States exhibit a consistent pattern of behavior that suggests he is incapable of properly discharging the duties of his office?

Even Trump’s own allies recognize the degree of his narcissism. When he launched racist attacks on four congresswomen of color, Senator Lindsey Graham explained, “That’s just the way he is. It’s more narcissism than anything else.” So, too, do skeptics of assigning a clinical diagnosis. “No one is denying,” Frances told Rolling Stone, “that he is as narcissistic an individual as one is ever likely to encounter.” The president’s exceptional narcissism is his defining characteristic—and understanding that is crucial to evaluating his fitness for office

The DSM-5 describes its conception of pathological narcissism this way: “The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.”

The diagnostic criteria offer a useful framework for understanding the most remarkable features of Donald Trump’s personality, and of his presidency. (1) Exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements?

(2) Preoccupied with fantasies of unlimited success, power, brilliance

(3) Believes that he or she is “special” and unique and should only associate with other special or high-status people?

Trump claims to be an expert—the world’s greatest—in anything and everything. As one video mash-up shows, Trump has at various times claimed—in all seriousness—that no one knows more than he does about: taxes, income, construction, campaign finance, drones, technology, infrastructure, work visas, the Islamic State, “things” generally, environmental-impact statements, Facebook, renewable energy, polls, courts, steelworkers, golf, banks, trade, nuclear weapons, tax law, lawsuits, currency devaluation, money, “the system,” debt, and politicians.

(4) Requires excessive admiration? Last Thanksgiving, Trump was asked what he was most thankful for. His answer: himself, of course. A number of years ago, he made a video for Forbes in which he interviewed two of his children. The interview topic: how great they thought Donald Trump wa

(5) A sense of entitlement? (9) Arrogant, haughty behaviors? Trump is the man who, on the infamous Access Hollywood tape, said, “When you’re a star, they let you do it. You can do anything you want”—including grabbing women by their genitals. He’s the man who also once said, “I could stand in the middle of Fifth Avenue and shoot somebody and I wouldn’t lose any voters.”

(8) Envious of others? Here’s a man so unable to stand the praise received by a respected war hero and statesman, Senator John McCain, that he has continued to attack McCain months after McCain’s death;

(6) Interpersonally exploitative? Just watch the Access Hollywood tape, or ask any of the hundreds of contractors and employees Trump the businessman allegedly stiffed, or speak with any of the two dozen women who have accused Trump of sexual misconduct, sexual assault, or rape.

Finally, (7) Lacks empathy: is unwilling to recognize or identify with the feelings or needs of others? One of the most striking aspects of Trump’s personality is his utter and complete lack of empathy

The notorious lawyer and fixer Roy Cohn, who once counseled Trump, said that “Donald pisses ice water,” and indeed, examples of Trump’s utter lack of normal human empathy abound.

“It made no sense, Priebus realized, unless you understood … ‘The president has zero psychological ability to recognize empathy or pity in any way.’

Experts haven’t suggested that Trump is psychotic, but many have contended that his narcissism and sociopathy are so inordinate that he fits the bill for “malignant narcissism.” Malignant narcissism isn’t recognized as an official diagnosis; it’s a descriptive term coined by the psychoanalyst Erich Fromm, and expanded upon by another psychoanalyst, Otto Kernberg, to refer to an extreme mix of narcissism and sociopathy, with a degree of paranoia and sadism mixed in

A second disorder also frequently ascribed to Trump by professionals is sociopathy—what the DSM-5 calls antisocial personality disorder

Central to sociopathy is a complete lack of empathy—along with “an absence of guilt.” Sociopaths engage in “intentional manipulation, and controlling or even sadistically harming others for personal power or gratification. People with sociopathic traits have a flaw in the basic nature of human beings … They are lacking an essential part of being human.” For its part, the DSM-5 states that the “essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”

Trump’s sociopathic characteristics sufficiently intertwine with his narcissistic ones that they deserve mention here. These include, to quote the DSM-5, “deceitfulness, as indicated by repeated lying, use of aliases, or conning others.” Trump’s deceitfulness—his lying—has become the stuff of legend; journalists track his “false and misleading claims” as president by the thousands upon thousands.

Other criteria for antisocial personality disorder include “failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest”; “impulsivity or failure to plan ahead”; and “lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

As for impulsivity, that essentially describes what gets him into trouble most: It was his “impulsiveness—actually, total recklessness”—that came close to destroying him in the 1980s

And lack of remorse? That’s a hallmark of sociopathy, and goes hand in hand with a lack of human conscience. In a narcissistic sociopath, it’s intertwined with a lack of empathy. Trump hardly ever shows remorse, or apologizes, for anything. The one exception: With his presidential candidacy on the line in early October

In a way, Trump’s sociopathic tendencies are simply an extension of his extreme narcissism

articular, “They change reality to suit themselves in their own mind.” Although Trump “lies because of his sociopathic tendencies,” telling falsehoods to fool others, Dodes argues, he also lies to himself, to protect himself from narcissistic injury. And so Donald Trump has lied about his net worth, the size of the crowd at his inauguration, and supposed voter fraud in the 2016 election.

The latter kind of lying, Dodes says, “is in a way more serious,” because it can indicate “a loose grip on reality”—and it may well tell us where Trump is headed in the face of impeachment hearings. Lying to prevent narcissistic injury can metastasize to a more significant loss of touch with reality

What kind of human being, let alone politician, would engage in such unempathetic, self-centered behavior while memorializing such horrible tragedies? Only the most narcissistic person imaginable—or a person whose narcissism would be difficult to imagine if we hadn’t seen it ourselves. The evidence of Trump’s narcissism is overwhelming—indeed, it would be a gargantuan task to try to marshal all of it, especially as it mounts each and every day.

In the view of some in the mental-health community, such as John Gartner, Trump “exhibits all four” components of malignant narcissism: “narcissism, paranoia, antisocial personality and sadism.”

Mental-health professionals have raised a variety of other concerns about Trump’s mental state; the last worth specifically mentioning here is the possibility that, apart from any personality disorder, he may be suffering cognitive decline.

His “mental state,” according to Justin A. Frank, a former clinical professor of psychiatry and physician who wrote a book about Trump’s psychology, “include[s] so many psychic afflictions” that a “working knowledge of psychiatric disorders is essential to understanding Trump.” Indeed, as Gartner puts it: “There are a lot of things wrong with him—and, together, they are a scary witch’s brew.”

when you line up what the Framers expected of a president with all that we know about Donald Trump, his unfitness becomes obvious. The question is whether he can possibly act as a public fiduciary for the nation’s highest public trust. To borrow from the Harvard Law Review article, can he follow the “proscriptions against profit, bad faith, and self-dealing,” manifest “a strong concern about avoiding ultra vires action” (that is, action exceeding the president’s legal authority), and maintain “a duty of diligence and carefulness”? Given that Trump displays the extreme behavioral characteristics of a pathological narcissist, a sociopath, or a malignant narcissist—take your pick—it’s clear that he can’t.

To act as a fiduciary requires you to put someone else’s interests above your own, and Trump’s personality makes it impossible for him to do that. No president before him, at least in recent memory, has ever displayed such obsessive self-regard

Indeed, Trump’s view of his presidential powers can only be described as profoundly narcissistic, and his narcissism has compelled him to disregard the Framers’ vision of his constitutional duties in every respect

Trump’s incapacity affects all manner of subjects addressed by the presidency, but can be seen most acutely in foreign affairs and national security.

All in all, Trump sought to impede and end a significant counterintelligence and criminal investigation—one of crucial importance to the nation—and did so for his own personal reasons. He did precisely the opposite of what his duties require. Indeed, he has shown utter contempt for his duties to the nation

hat constitutional mechanisms exist for dealing with a president who cannot or does not comply with his duties, and how should they take the president’s mental and behavioral characteristics into account?

it turns out that impeachment is a more practical mechanism

It’s also an appropriate mechanism, because the constitutional magic words (other than Treason and Bribery) that form the basis of an impeachment charge—high Crimes and Misdemeanors, found in Article II, Section 4 of the Constitution—mean something other than, and more than, offenses in the criminal-statute books. High Crimes and Misdemeanors is a legal term of art, one that historically referred to breaches of duties—fiduciary duties—by public officeholders. In other words, the question of what constitutes an impeachable offense for a president coincides precisely with whether the president can execute his office in the faithful manner that the Constitution requires.

One of the most compelling arguments about the meaning of those words is that the Framers, in Article II’s command that a president faithfully execute his office, imposed upon him fiduciary obligations. As the constitutional historian Robert Natelson explained in the Federalist Society Review, the “founding generation [understood] ‘high … Misdemeanors’ to mean ‘breach of fiduciary duty.’

Eighteenth-century lawyers instead used terms such as breach of trust—which describes the same thing. “Parliamentary articles of impeachment explicitly and repetitively described the accused conduct as a breach of trust,” Natelson argues, and 18th-century British legal commentators explained how impeachment for “high Crimes and Misdemeanors” was warranted for all sorts of noncriminal violations that were, in essence, fiduciary breaches.

why the discussion of Morris’s suggestion was so brief—the drafters knew what the words historically meant, because, as a House Judiciary Committee report noted in 1974, “at the time of the Constitutional Convention the phrase ‘high Crimes and Misdemeanors’ had been in use for over 400 years in impeachment proceedings in Parliament

Certainly Alexander Hamilton knew by the time he penned “Federalist No. 65,” in which he explained that impeachment was for “those offenses which proceed from the misconduct of public men, or, in other words, from the abuse or violation of some public trust.

What constitutes such an abuse or violation of trust is up to Congress to decide: First the House decides to bring impeachment charges, and then the Senate decides whether to convict on those charges. The process of impeachment by the House and removal by trial in the Senate is thus, in some ways, akin to indictment by a grand jury and trial by a petit jury

As Laurence Tribe and Joshua Matz explain in their recent book on impeachment, “the Constitution explicitly states that Congress may not end a presidency unless the president has committed an impeachable offense. But nowhere does the Constitution state or otherwise imply that Congress must remove a president whenever that standard is met … In other words, it allows Congress to exercise judgment.”

As Tribe and Matz argue, that judgment presents a “heavy burden,” and demands that Congress be “context-sensitive,” and achieve “an understanding of all relevant facts.” A president might breach his trust to the nation once in some small, inconsequential way and never repeat the misbehavior, and Congress could reasonably decide that the game is not worth the candle.

In short, now that the House of Representatives has embarked on an impeachment inquiry, one of the most important judgments it must make is whether any identified breaches of duty are likely to be repeated. And if a Senate trial comes to pass, that issue would become central as well to the decision to remove the president from office. That’s when Trump’s behavioral and psychological characteristics should—must—come into pla

there’s another reason as well. The people have a right to know, and a need to see. Many people have watched all of Trump’s behavior, and they’ve drawn the obvious conclusion. They know something’s wrong, just as football fans knew that the downed quarterback had shattered his leg. Others have changed the channel, or looked away, or chosen to deny what they’ve seen. But if Congress does its job and presents the evidence, those who are in denial won’t be able to ignore the problem any longer.

To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,”

The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country.

With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency.

That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition

Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear.

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,”

“Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”

it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April

A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment

it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing.

There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission.

Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps.

when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need

Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care.

There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”

there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting

The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one.  By the end of the summer, the pandemic will have directly killed 2.2 million Americans,

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch.

The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.

The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.

as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.

First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer.

scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs.

“We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”

The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,”

After infections begin ebbing, a secondary pandemic of mental-health problems will follow.

But “there is also the potential for a much better world after we get through this trauma,”

Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements.

Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.

Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,”

Years of isolationist rhetoric had consequences too.

“People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”

Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions.

“The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation

The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

Paradoxically, these same disastrous circumstances may also inspire altruism, compassion, optimism, and foster a sense of meaning and personal growth (otherwise referred to as post-traumatic growth) as people band together to salvage, rebuild, and console amongst the chaos and loss of a changing climate [30, 31].

Marginalized groups who tend to be the most affected by the mental and physical health implications of climate change are: Indigenous peoples, children, seniors, women, people with low-socioeconomic status, outdoor labourers, racialized people, immigrants, and people with pre-existing health conditions

The influential sociologist Anthony Giddens refers to this space and time distancing of the climate change problem as the Giddens Paradox [70]. The Giddens Paradox states that: “since the dangers posed by global warming aren’t tangible, immediate or visible in the course of day-to-day life, many will sit on their hands and do nothing of a concrete nature about them. Yet waiting until such dangers become visible and acute—in the shape of catastrophes that are irrefutably the result of climate change—before being stirred to serious action will be too late” (p. 2).

Marshall contends that part of the time and space distancing of the climate change problem, and thus the reluctance to act, is reinforced by the Western political discourse on climate change as a future-facing problem that intentionally overlooks the centuries of industrialization, fossil fuel consumption, and land degradation that contribute to anthropogenic climate change [71]

Marshall calls for a reckoning with this discourse by noting:“Climate change is a future problem. But it is also a past problem and a present problem. It is better thought of as a developing process of long-term deterioration, called, by some psychologists, a “creeping problem.” The lack of a definite beginning, end, or deadline requires that we create our own timeline. Not surprisingly, we do so in ways that remove the compulsion to act. We allow just enough history to make it seem familiar but not enough to create a responsibility for our past emissions. We make it just current enough to accept that we need to do something about it but put it just too far in the future to require immediate action” [71].

It requires coping strategies to manage the feelings and thoughts that arise so that people can face up to, and come to terms with, these threats and consequences rather than avoiding the creeping problem of climate change.

Since early 2007, environmental philosopher Glenn Albrecht and colleagues have taken note of emotional distress related to the awareness of the overarching problem humans face as a result of global climate change [96]

Albrecht et al. suggest that this awareness contributes to ‘psychoterratic syndromes’. Psychoterratic syndromes include phenomena such as ‘ecoanxiety’, ‘ecoparalysis’, and ‘solastalgia’. ‘Ecoanxiety’ refers to the anxiety people face from constantly being surrounded by the wicked and threatening problems associated with a changing climate [96]

Exploring the complexity of psychological responses in the book, Climate change and human well-being, Weissbecker et al., discuss the full spectrum of psychosocial consequences of climate change-related events ranging from mental illness to more positive experiences like ‘Post Traumatic Growth’ (PTG), empathy, compassion, altruism, and emotional resilience [25].

For many people, climate change is experienced by way of vicarious threats or as an existential threat to civilisation [37]. People may experience vicarious threats when they receive weather warnings related to future disaster seasons or when they hear about environmental stressors experienced by people in other places.

For many people, this is largely how climate change is experienced—not as a direct threat, but as a global threat, often distant in time and place, or as a threat to our very way of life. Qualitative research finds evidence of some people being deeply affected by feelings of loss, helplessness, and frustration as they engage with the problems of global climate change [97].

Psychological adaptation requires a set of responses, it requires an acknowledgement of the grave threats posed by climate change and the profoundly consequential global crisis.

‘Ecoparalysis’ refers to the complex feelings of not being able to take effective action to significantly mitigate climate change risks. ‘Solastalgia’ refers to “the distress and isolation caused by the gradual removal of solace from the present state of one’s home environment” [29].

It also requires behavioural and psychological engagement, in which people change and adjust their behaviour and lifestyle in order to reduce the threat and protect themselves.

Active hope—something Macy and Johnstone champion—supports psychological adaptation. Active hope is required to move hopeful intentions from a passive state where waiting for someone else to take-on the task of addressing the climate change problem is replaced with an active process of climate change mitigation and adaptation behaviours [106]

This active process occurs when the reality of the problem is acknowledged as is the magnitude of the problem, intentions to address the problem are set, and engaged actions take place.

While these three steps may oversimplify the complexity of acting in the face of bureaucracy, climate denialism, or downright avoidance and ignorance of the magnitude of the problem area, these three steps are indeed the pivot points of transformation. These pivot points, however, need to be upheld by global political will and policy commitments that tackle the problem at the appropriate scale and speed. To do so, public awareness of the severity, magnitude and range of health impacts—current and projected—is required to pressure governments and communities to act now.

Also, discernible interventions are needed to demonstrate a tangible path forward to respond to the risks and impacts we face in a changing climate. Examples of these types of interventions are explored below.

Other innovative approaches to addressing mental health and wellbeing in a changing climate writ large include experiencing and preserving nature. Koger et al. suggest that environmental preservation provides people with a sense of stewardship and personal investment that can help people overcome feelings of hopelessness, anxiety, and ecoparalysis [109]. Koger et al. suggest: “if people feel a deep connection to places, wilderness, and other species, then threats to these others are much more likely to be viewed as personal issues” [109]. Other research on the restorative benefits of natural environments and settings has found that biodiversity in natural environments is important for human health and wellbeing and has a particularly positive effect on mood, attention and cognition [110].

In the first few months of the pandemic, between March and May 2020, children on Medicaid received 44% fewer outpatient mental health services — including therapy and in-home support — compared to the same time period in 2019, according to the Centers for Medicare & Medicaid Services. That's even after accounting for increased telehealth appointments.

The Centers for Disease Control and Prevention found that, from April to October 2020, hospitals across the U.S. saw a 24% increase in the proportion of mental health emergency visits for children ages 5 to 11, and a 31% increase for children ages 12 to 17.

When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Glawe says, the cost and level of care required will be even higher, whether that's hospitalization or long stays in residential treatment facilities.

But given that many states have seen their revenues drop due to the pandemic, there's a concern services will instead get cut — at a time when the need has never been greater.

starting in the mid-2010s, those beloved blue skies began to disappear. First, the smoke came in occasional bursts, from wildfires in Canada or California or Siberia, and blew away when the wind changed direction. Within a few summers, though, it was coming in thicker, from more directions at once, and lasting longer.

Sometimes there were weeks when you were advised not to open your windows or exercise outside. Sometimes there were long stretches where you weren’t supposed to breathe the outside air at all.

Now lots of Bryant’s clients wanted to talk about climate change. They wanted to talk about how strange and disorienting and scary this new reality felt, about what the future might be like and how they might face it, about how to deal with all the strong feelings — helplessness, rage, depression, guilt — being stirred up inside them.

As a therapist, Bryant found himself unsure how to respond

while his clinical education offered lots of training in, say, substance abuse or family therapy, there was nothing about environmental crisis, or how to treat patients whose mental health was affected by it

Bryant immersed himself in the subject, joining and founding associations of climate-concerned therapists

eventually started a website, Climate & Mind, to serve as a sort of clearing house for other therapists searching for resources. Instead, the site became an unexpected window into the experience of would-be patients: Bryant found himself receiving messages from people around the world who stumbled across it while looking for help.

Over and over, he read the same story, of potential patients who’d gone looking for someone to talk to about climate change and other environmental crises, only to be told that they were overreacting — that their concern, and not the climate, was what was out of whack and in need of treatment.

“You come in and talk about how anxious you are that fossil-fuel companies continue to pump CO2 into the air, and your therapist says, ‘So, tell me about your mother.’”

In many of the messages, people asked Bryant for referrals to climate-focused therapists in Houston or Canada or Taiwan, wherever it was the writer lived.

his practice had shifted to reflect a new reality of climate psychology. His clients didn’t just bring up the changing climate incidentally, or during disconcerting local reminders; rather, many were activists or scientists or people who specifically sought out Bryant because of their concerns about the climate crisis.

could now turn to resources like the list maintained by the Climate Psychology Alliance North America, which contains more than 100 psychotherapists around the country who are what the organization calls “climate aware.”

But treating those fears also stirred up lots of complicated questions that no one was quite sure how to answer. The traditional focus of his field, Bryant said, could be oversimplified as “fixing the individual”: treating patients as separate entities working on their personal growth

It had been a challenging few years, Bryant told me when I first called to talk about his work. There were some ways in which climate fears were a natural fit in the therapy room, and he believed the field had coalesced around some answers that felt clear and useful

Climate change, by contrast, was a species-wide problem, a profound and constant reminder of how deeply intertwined we all are in complex systems — atmospheric, biospheric, economic — that are much bigger than us. It sometimes felt like a direct challenge to old therapeutic paradigms — and perhaps a chance to replace them with something better.

In one of climate psychology’s founding papers, published in 2011, Susan Clayton and Thomas J. Doherty posited that climate change would have “significant negative effects on mental health and well-being.” They described three broad types of possible impacts: the acute trauma of living through climate disasters; the corroding fear of a collapsing future; and the psychosocial decay that could damage the fabric of communities dealing with disruptive changes

All of these, they wrote, would make the climate crisis “as much a psychological and social phenomenon as a matter of biodiversity and geophysics.”

Many of these predictions have since been borne out

Studies have found rates of PTSD spiking in the wake of disasters, and in 2017 the American Psychological Association defined “ecoanxiety” as “a chronic fear of environmental doom.”

Climate-driven migration is on the rise, and so are stories of xenophobia and community mistrust.

According to a 2022 survey by Yale and George Mason University, a majority of Americans report that they spend time worrying about climate change.

Many say it has led to symptoms of depression or anxiety; more than a quarter make an active effort not to think about it.

There was little or no attention to the fact that living through, or helping to cause, a collapse of nature can also be mentally harmful.

In June, the Yale Journal of Biology and Medicine published a paper cautioning that the world at large was facing “a psychological condition of ‘systemic uncertainty,’” in which “difficult emotions arise not only from experiencing the ecological loss itself,” but also from the fact that our lives are inescapably embedded in systems that keep on making those losses worse.

Climate change, in other words, surrounds us with constant reminders of “ethical dilemmas and deep social criticism of modern society. In its essence, climate crisis questions the relationship of humans with nature and the meaning of being human in the Anthropocene.”

This is not an easy way to live.

Living within a context that is obviously unhealthful, he wrote, is painful: “a dimly intuited ‘fall’ from which we spend our lives trying to recover, a guilt we can never quite grasp or expiate” — a feeling of loss or dislocation whose true origins we look for, but often fail to see. This confusion leaves us feeling even worse.

When Barbara Easterlin first started studying environmental psychology 30 years ago, she told me, the focus of study was on ways in which cultivating a relationship with nature can be good for mental health

A poll by the American Psychiatric Association in the same year found that nearly half of Americans think climate change is already harming the nation’s mental health.

the field is still so new that it does not yet have evidence-tested treatments or standards of practice. Therapists sometimes feel as if they are finding the path as they go.

Rebecca Weston, a licensed clinical social worker practicing in New York and a co-president of the CPA-NA, told me that when she treats anxiety disorders, her goal is often to help the patient understand how much of their fear is internally produced — out of proportion to the reality they’re facing

climate anxiety is a different challenge, because people worried about climate change and environmental breakdown are often having the opposite experience: Their worries are rational and evidence-based, but they feel isolated and frustrated because they’re living in a society that tends to dismiss them.

One of the emerging tenets of climate psychology is that counselors should validate their clients’ climate-related emotions as reasonable, not pathological

it does mean validating that feelings like grief and fear and shame aren’t a form of sickness, but, as Weston put it, “are actually rational responses to a world that’s very scary and very uncertain and very dangerous for people

In the words of a handbook on climate psychology, “Paying heed to what is happening in our communities and across the globe is a healthier response than turning away in denial or disavowal.”

But this, too, raises difficult questions. “How much do we normalize people to the system we’re in?” Weston asked. “And is that the definition of health?

Or is the definition of health resisting the things that are making us so unhappy? That’s the profound tension within our field.”

“It seems to shift all the time, the sort of content and material that people are bringing in,” Alexandra Woollacott, a psychotherapist in Seattle, told the group. Sometimes it was a pervasive anxiety about the future, or trauma responses to fires or smoke or heat; other times, clients, especially young ones, wanted to vent their “sort of righteous anger and sense of betrayal” at the various powers that had built and maintained a society that was so destructive.

“I’m so glad that we have each other to process this,” she said, “because we’re humans living through this, too. I have my own trauma responses to it, I have my own grief process around it, I have my own fury at government and oil companies, and I think I don’t want to burden my clients with my own emotional response to it.”

In a field that has long emphasized boundaries, discouraging therapists from bringing their own issues or experiences into the therapy room, climate therapy offers a particular challenge: Separation can be harder when the problems at hand affect therapist and client alike

Some therapists I spoke to were worried about navigating the breakdown of barriers, while others had embraced it. “There is no place on the planet that won’t eventually be impacted, where client and therapist won’t be in it together,” a family therapist wrote in a CPA-NA newsletter. “Most therapists I know have become more vulnerable and self-disclosing in their practice.”

“If you look at or consider typical theoretical framings of something like post-traumatic growth, which is the understanding of this idea that people can sort of grow and become stronger and better after a traumatic event,” she said, then the climate crisis poses a dilemma because “there is no afterwards, right? There is no resolution anytime in our lifetimes to this crisis that we nonetheless have to build the capacities to face and to endure and to hopefully engage.”

many of her patients are also disconnected from the natural world, which means that they struggle to process or even recognize the grief and alienation that comes from living in a society that treats nature as other, a resource to be used and discarded.

“How,” she asked, “do you think about resilience apart from resolution?”

she believed this framing reflected and reinforced a bias inherent in a field that has long been most accessible to, and practiced by, the privileged. It was hardly new in the world, after all, to face the collapse of your entire way of life and still find ways to keep going.

Torres said that she sometimes takes her therapy sessions outside or asks patients to remember their earliest and deepest connections with animals or plants or places. She believes it will help if they learn to think of themselves “as rooted beings that aren’t just simply living in the human overlay on the environment.” It was valuable to recognize, she said, that “we are part of the land” and suffer when it suffers.

Torres described introducing her clients to methods — mindfulness, distress tolerance, emotion regulation — to help them manage acute feelings of stress or panic and to avoid the brittleness of burnout.

She also encourages them to narrativize the problem, including themselves as agents of change inside stories about how they came to be in this situation, and how they might make it different.

then she encourages them to find a community of other people who care about the same problems, with whom they could connect outside the therapy room. As Woollacott said earlier: “People who share your values. People who are committed to not looking away.”

Dwyer told the group that she had been thinking more about psychological adaptation as a form of climate mitigation

Therapy, she said, could be a way to steward human energy and creative capacities at a time when they’re most needed.

It was hard, Bryant told me when we first spoke, to do this sort of work without finding yourself asking bigger questions — namely, what was therapy actually about?

Many of the therapists I talked to spoke of their role not as “fixing” a patient’s problem or responding to a pathology, but simply giving their patients the tools to name and explore their most difficult emotions, to sit with painful feelings without instantly running away from them

many of the methods in their traditional tool kits continue to be useful in climate psychology. Anxiety and hopelessness and anger are all familiar territory, after all, with long histories of well-studied treatments.

They focused on trying to help patients develop coping skills and find meaning amid destabilization, to still see themselves as having agency and choice.

Weston, the therapist in New York, has had patients who struggle to be in a world that surrounds them with waste and trash, who experience panic because they can never find a place free of reminders of their society’s destruction

eston said, that she has trouble with the repeated refrain that therapist and patient experiencing the same losses and dreads at the same time constituted a major departure from traditional therapeutic practice

“I’m so excited by what you’re bringing in,” Woollacott replied. “I’m doing psychoanalytic training at the moment, and we study attachment theory” — how the stability of early emotional bonds affects future relationships and feelings of well-being. “But nowhere in the literature does it talk about our attachment to the land.”

Lately, Bryant told me, he’s been most excited about the work that happens outside the therapy room: places where groups of people gather to talk about their feelings and the future they’re facing

It was at such a meeting — a community event where people were brainstorming ways to adapt to climate chaos — that Weston, realizing she had concrete skills to offer, was inspired to rework her practice to focus on the challenge. She remembers finding the gathering empowering and energizing in a way she hadn’t experienced before. In such settings, it was automatic that people would feel embraced instead of isolated, natural that the conversation would start moving away from the individual and toward collective experiences and ideas.

There was no fully separate space, to be mended on its own. There was only a shared and broken world, and a community united in loving it.

He argues that the tools of social media are just too sharp for young minds. On digital platforms teens parade themselves, often to an audience of strangers, and this is leading to addiction, paranoia and despair

For girls, the effect is especially acute. ‘What we’re seeing is a very sharp, sudden change in girls’ mental health all around the Anglosphere and the Nordic countries,’ he says. A big change was evident from 2013, when physical friendship groups started to be supplanted by smartphones and online chat. ‘But you cannot grow up in networks. You have to grow up in communities.’

The first is that they are fragile and can be harmed by speech and words.

But if you’re a secular liberal girl, you’re probably more than twice as likely to have a mental health problem.’

a University of Michigan survey into ‘self-derogation’ – i.e., how likely teenagers are to say they are ‘no good’ or ‘can’t do anything right’. Figures had been stable for years but started rising sharply ten years ago – except for among boys who identified as conservative and said that religion was important to them.

irls simply use social media more. But Professor Haidt also thinks they are more likely to buy into what he calls the ‘three great untruths’ of social media

boys who have religion in their lives seem to be less susceptible. ‘If you’re a kid who’s a religious conservative, on average, your mental health is not really much worse than it was ten years ago

Next, that their emotions, and especially their anxieties, are reliable guides to reality.

And finally, that society is one big battle between victims and oppressors. All this, he says, is the subtext to social media discourse.

‘It’s what I’ve been calling the phone-based child,’

So we had playdates in childhood, up until around 2010.’ In Britain, he says, the number of children who went on real-life playdates then fell sharply.

Social media is a bit of a misnomer, he says. It’s no longer about connecting people, but ‘performing on a platform’. Perhaps this is fine for grown-ups, but not for children, ‘where they can say things in public, including to strangers, and then be publicly shamed by potentially millions of people

Children should not be on social networks. They should be playing in person. Social media platforms should never be accessed by children until they’re 18. It’s just insane that we let kids do these things.’

I ask if he thinks all platforms are equally dangerous

if you get your news from social media (which many people do – in the UK, Instagram has overtaken all newspapers as a news source), this can change your view of the world, especially as the algorithms tend to promote the most provocative views.

‘TikTok is probably the worst for their intellectual development. I think it literally reduces their ability to focus on anything while stuffing them with little bits of stuff that was selected by an algorithm for emotional arousal. Not for truth.’

If asked to choose whether they side more with Israel or Hamas, ‘the great majority of Americans side with Israel, except for Gen Z, which is split 50-50’,

‘There was a Twitter thread recently showing how if you look at what people are saying on TikTok, you can understand why

TikTok and Twitter are incredibly dangerous for our democracy. I’d say they’re incompatible with the kind of liberal democracy that we’ve developed over the last few hundred years.’

Might it just be the case, I ask, that there’s less of a stigma around mental health now, so teenagers are far more likely to admit that they have problems?

why is it, then, that right around 2013 all these girls suddenly start checking into psychiatric inpatient units? Or suicide – they’re making many more suicide attempts. The level of self-harm goes up by 200 or 300 per cent, especially for the younger girls aged ten to 14

we see very much the same curves, at the same time, for behaviour. Suicide, certainly, is not a self-report variable. This is real. This is the biggest mental health crisis in all of known history for kids.’

he increased number of suicides since 2010 is so large that I suspect this is among the largest public health threats to children since the major diseases were wiped out

His third rule: no phones in schools.

What should parents do? They know that if they try to remove their teenager’s smartphone, their child will accuse them of destroying his or her social life. ‘That’s a perfect statement of what we call a collective action problem,’

‘Any one person doing the right thing is in big trouble. But why do we ever let our kids on social media? It’s only down to the dynamic you just said.’ New norms are needed, he says. And his book will suggest four.

Rule one, he says: no smartphones before the age of 14.

‘Give them a flip phone. Millennials had flip phones. They texted each other

Rule two: no social media before 16

In Britain, suicide rates started rising in 2014, up about 20 per cent for boys (to 420 a year) and 60 per cent for girls (to 160 a year).

finally: more unsupervised play. ‘Both of our countries freaked out in the 1990s, locked up our kids because we lost trust in each other. We thought everyone was a child molester or a rapist.’ Children and teens could do with six or seven hours each day out of contact with their parents, he argues. Keeping them inside risks more harm than the outside world would pose.