An Afghan man comforts two men injured in an insurgent attack in Kabul, May 2011. Photo by Hossein Fatemi/Panos

Mental health

An Afghan man comforts two men injured in an insurgent attack in Kabul, May 2011. Photo by Hossein Fatemi/Panos

We heal one another

When a person is in distress, we can draw on deep, evolved mechanisms to calm the storm, through attention, touch and care

Brandon Kohrt

An Afghan man comforts two men injured in an insurgent attack in Kabul, May 2011. Photo by Hossein Fatemi/Panos

Brandon Kohrt

is associate professor of psychiatry and behavioural sciences at George Washington University. His work addresses improving mental health services for populations affected by conflict, disasters and other humanitarian emergencies. He has focused on strategies to reduce stigma against people with mental illness around the world. He has consulted with the Carter Center Mental Health Program in Liberia and has been advisor to Transcultural Psychosocial Organization in Nepal. He co-edited the book Global Mental Health: Anthropological Perspectives (2016).

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When I talk to my patients about emotion regulation, among the first things that come into their minds are usually deep breathing and meditation. Those who’ve gone through counselling might describe cognitive-behavioural approaches, where they follow set steps to challenge the assumptions underlying their emotional reactions. With all the added distress, anxiety and depression associated with the COVID-19 pandemic, many of my patients, friends and family members also talk about using the many relaxation and mindfulness apps now available.

As a psychiatrist, I appreciate that these techniques have the potential to be helpful. Many have been validated in well-designed research studies. But there’s another aspect of my identity that makes me doubt whether emotional regulation is something we’re really supposed to do alone. That side of me is the trained anthropologist. I’ve practised psychiatry for more than a decade, but I’ve been travelling around the world for much longer trying to understand how people face and respond to suffering.

Twenty-five years ago, I spent some months at a small concrete temple in southeastern Nepal. Families would bring their loved ones when they could no longer support them at home. The priests at the temple would listen as the families explained their problems. The person in distress would stay a few weeks, months or even longer. Every morning, the residents would worship together, chanting and rocking as they sat cross-legged or kneeling on the floor. While I was initially captivated by what was, to my eyes, this more unusual form of healing, I began to notice the people coming by, day by day, for a conversation with one of the priests. They’d describe the worries in their hearts and their minds, and the holy man would sit with them, never in a rush. Sometimes, he would teach them a mantra or wipe their backs and shoulders with a feather brush. Then they would leave with more light in their faces. Some came back often, others I only saw once.

I’ve seen that style of interaction again and again. In northern Uganda, a village health worker sat under a tree talking to a woman who had been shunned by her neighbours because she had a child with a rare neurological disorder. In Liberia, a police officer, whose daughter lived with a mental illness, sat listening to a colleague who was explaining how distressing it was to enforce quarantine during the Ebola outbreak. In Haiti, a houngan priest talked with a teacher about digging his way out of the rubble after buildings had crumbled around him in the 2010 earthquake. If you listen closely, these conversations aren’t limited to people in helping professions. There’s a taxi driver and a passenger talking about the stress of raising teenagers. Or a woman sharing with her spouse about anger at her coworkers after a day at the office.

Emotion regulation to reduce distress appears to be a fundamental human behaviour that doesn’t just happen within us, but between us. We’re constantly consoling others and being consoled, from instances of forgettable disappointment to life-changing traumas. Unfortunately, mainstream psychiatry and psychology, as well as the self-help movement, is burdened by the expectation that self-regulation skills must be mastered to achieve wellbeing.

In my clinical training, I’d originally thought of managing distress as a technical skill for professionals. To be effective, helping others regulate their emotions called for the training of psychologists, religious leaders or other specialists. However, observing the cross-cultural elements of emotion regulation between people makes me think that it’s actually a human universal taking on myriad manifestations. And as a ubiquitous human behaviour, arguably it should be understood from an evolutionary perspective.

With the anthropologists Catherine Panter-Brick of Yale University and Melvin Konner of Emory University, as well as with Vikram Patel, the world’s leading expert in global mental health at Harvard University, and my colleague Katherine Ottman at George Washington University, we endeavoured to identify what evolutionary theory could tell us about interpersonal healing and emotion regulation between people. Fields such as evolutionary medicine and evolutionary psychiatry had already worked to shed light on the origins of physical and mental illnesses, uncovering mismatches between the selection pressures that shaped who we are and the current environmental, dietary, social and other factors that affect us in daily life. However, the question of psychological healing hadn’t been explored in similar depth. Why do humans spend minutes every day, to hours and weeks of our lives, comforting others in distress, even when that’s not our profession? Why do we as humans support one another, and why does it look similar across cultures and throughout the history of our species?

If emotional processes are bound up with social rupture, it follows that they’ll play a role in social repair

These questions seem superficially like those about altruism: that is, why do we do anything nice for others at all, from an evolutionary perspective? Survival of the fittest, in popular culture, has typically been simplified to an ethos of absolute individualism. However, beginning in the 1960s and ’70s, evolutionary biologists developed models for altruism that moved beyond helping others just because of shared DNA. Tit-for-tat dynamics and quid-pro-quo social exchanges remained prominent as explanations, but contemporary evolutionary theory also recognises how shared social behaviours are important for survival because of competition between social groups. For one thing, cooperation is helpful in procuring and protecting resources. A group member who monopolises all the resources from others might get a short-term benefit, but she’s more vulnerable to threats overall because the group as whole has been weakened. At a certain point in our evolutionary history, other humans became a much bigger threat than other predatory animals. This intragroup competition can be seen in other social mammals too, especially nonhuman primates. Jane Goodall’s writings on chimpanzees are rich with descriptions of group formations and fissures, forced exclusion and intragroup reconciliations.

Emotions, whether positive or distressing, are strongly linked to these social dynamics. Feelings such as anger, jealousy, shame, guilt, loneliness and grief are often triggered by changes to one’s position within a group or to important personal relationships. So, if emotional processes are bound up with social rupture, it follows that they’re likely to play a role in social repair. There must be a mechanism that tells us that other people are part of our social circles and so help us preserve the social fabric. Emotions work a bit like a social immune system: social relationships provoke an emotional inflammatory reaction when something threatens them. But there are also ways to dampen that response and avoid a state of social sepsis, bringing people back into the fold when relationships have been ruptured.

A striking example of this comes from my work with former child soldiers. In many cases, the experience of returning home after being a child combatant is even more distressing than the war itself. Guilt, shame and lasting anger are common. Families, teachers and members of the community might fear the returnees, or feel a sense of guilt and shame about failing to prevent their children from joining the conflict. In Uganda, Mozambique and Sierra Leone, traditional healing rituals were used to symbolically separate children from the actions they’d committed, with gestures representing the guilt, shame, anger and distress leaving the body. In Nepal, traditional healers would symbolically wrap the hearts and minds of child soldiers to calm the distress. Here, though, we saw that the emotional regulation of parents, teachers and others was sometimes even more important. We trained community members to help teachers who were scared of having child soldiers in the classroom to discuss their fears. Similarly, they sat with family members who were overwhelmed with the ambivalence of joy and dread about their child returning. By spending time with these people, community health workers helped them to feel less alone; their emotions made more sense to them, and they could begin reforming relationships with their children.

Just as there are similarities in how language works across cultures, there seems to be a grammar of how humans support one another in the face of psychological distress. From an evolutionary perspective, it makes sense that the human social immune system evolved in a way that resembles language. Language is a social behaviour that supports how groups function, and it requires a listener and a speaker to function. Emotional regulation is a similarly dynamic interpersonal process.

Many anthropologists have written about common elements of shamanic healing, comparing these with psychotherapy and other forms of counselling. In the 1960s, Jerome Frank, a psychiatrist, and Claude Lévi-Strauss, an anthropologist, separately described universal elements of healing. Later, the anthropologist James Dow, who spent decades studying healing practices in the Caribbean and Mexico, built upon deep structure in linguistic theory to identify certain common steps: there’s a body of symbols shared between the healer and the suffering person; the healer persuades the sufferer that the problem can be explained; the healer attaches the suffering to a transactional symbol through emotion; the healer manipulates the symbols to create emotional change and alleviate suffering.

What’s striking is how this description of symbolic healing resonates with what we understand about empathy in nonhuman primates and other mammals. According to the primatologist Frans de Waal and the psychologist Stephanie Preston, emotion is transferred from the animal in distress to another member of its group. That happens through contagion, which can be conveyed by distress sounds, facial expressions or other body language, and is then received via mirror neurons and other neurological processes. As a consequence, the distressed animal and the consoling one share the same affect, or state of feeling. The consoling animal is able to regulate its distress and channel this sense of balance into consolation, in order to help the distressed creature by its physical presence, grooming behaviours or other soothing interactions. De Waal and Preston also add another important step: as the distressed animal is calmed, emotional transfer allows the consoler to experience relief – a form of self-reward that perpetuates such helping behaviours.

We can reframe the suffering of others even when we feel it ourselves. We organise it, make sense of it, alleviate it

These displays of emotional consoling probably evolved because of increased complexity in how animals communicate distress. If a vervet monkey sees a snake and reacts with fear, other monkeys in the group will do better if they can react quickly by internalising that fear, rather than waiting to see the snake for themselves. However, as emotional relationships became more intricate, there are times when an extreme behavioural response won’t be needed – even if it feels that way. Group members need to manage those reactions within a social immune system. In neuroscience terms, we often think of the later-evolving frontal lobe as the part of the brain responsible for emotional regulation: it tamps down or modifies activity in the more ‘primitive’ areas of the brain, such as the amygdala, associated with fear and distress. But our social relationships also play this role of reducing states of distress. Friends, family and social groups are kinds of ‘extended frontal lobes’, as the psychiatrist James Griffith likes to say. They help us to calm down and cope with loss, trauma and violation.

We can map these processes in our everyday lives. Seeing others in a state of despair can bring us to tears. When we see someone who’s afraid, we’re put on alert to the possibility of danger nearby. This emotional contagion would put all of us in total disarray if grief, panic or anger just passed unabated from one group member to the next. When that does happen, we get mob violence. However, that’s not the typical response, because we can reframe the suffering of others even when we feel it for ourselves. We organise it, make sense of it, and alleviate it.

We’re then able to respond to the other person in distress. We implicitly and explicitly communicate how the distress can be calmed. This might be through physical presence, such as sitting together or giving a hug. Physical contact can have profound biochemical reactions that reduce stress. We lean on cognitive processes too, as people talk through the situation and identify reasons for reassurance or hope, or solve the problem collaboratively. At the heart of all of these interactions is being together. Certain psychotherapy techniques or religious or shamanic manipulations can even symbolically transform the stress. One of my collaborators in Uganda is Byamah Mutamba: his parents named him ‘Mutamba’, which is a shortened form of the Runyakitara phrase ‘one who heals loneliness’ – never has there been a more apt name for a gifted psychiatrist. When we boil down psychological therapy, its core message is: ‘You are not alone.’

Unfortunately, we don’t live in a world where it’s easy to alleviate suffering through interactions with other people. The documented rise in distress during the pandemic was likely due to the disruption of many of these processes. After all, physical presence and being together evolved as the most basic form of interpersonal emotion regulation – a chimpanzee grooming another chimpanzee in distress. That contact and its neurophysiological impact on our brains and bodies has been lost or greatly constricted for many of us. Even just mundane human connections can be emotionally soothing: think of the average day for students from preschool to college who are connecting with scores of others in brief encounters. Being thrown together like this offers numerous opportunities to share the small or large distressing bits of the day, leaning on someone to understand and process it – without needing to intentionally reach out in order to connect over a Zoom call. When it comes to professional mental health services, in many ways remote care has been incredibly helpful, and should be continued. But there are also situations when being in the same room is important to observe the body and to allow for emotions to flow freely.

It’s not like we had all of this figured out before COVID-19, anyway. There was plenty of unabated distress going around. Understanding why interpersonal emotional regulation fails is another reason why an evolutionary framework can be useful. While emotional contagion is important within groups, it can be counterproductive for competition between groups. Feeling sadness when you see the suffering face of a rival might not help your kin or collective to thrive. Unfortunately, our biology seems to play out this way. Whereas the neurotransmitter oxytocin has an important role in bonding and empathy for ‘in-group’ members, it contributes to feelings of pleasure at the suffering of ‘out-group’ members. It’s a biological pathway for Schadenfreude. Neuropsychological and neuroimaging studies suggest that we don’t have the same emotional contagion lever for most out-group members. To raise the stakes against empathy even further, when a person is feeling anxious, threatened or distressed, they shrink their circle of who counts as an ‘in-group’. In times when we’re feeling joyful, magnanimity prevails. But when we feel threatened, we retreat to emotional connectedness with a small circle of intimates, and even those individuals might not be seen, proverbially, as being in the same boat.

The question of in-group vs out-group is especially complex for humans because of cultural evolution. In many other species, biological phenotypes – physical features, smells, threat calls, fixed behavioural patterns – tend to determine group status. But thanks to cultural evolution, humans use a whole host of features to fix ‘in-group’ vs ‘out-group’ status. Language is a large part, but also dress, behaviour and symbols that signify belonging and shared life experiences. There’s a mammoth-sized catalogue of studies showing that health professionals, including mental health professionals, often don’t demonstrate empathy for their patients; in particular, most studies have demonstrated notable lack of empathy among white doctors working with Black patients.

If health workers feel this shared humanity, then they’re better able to soothe their patients’ distress

So, what’s an evolutionarily informed response? One part of the story is to expand the diversity of the mental health workforce. If empathy is fostered by shared group identity, then our healers need to look more like the communities they serve. In the United States in 2016, only 16 per cent of active psychologists were from minority populations despite comprising 40 per cent of the US population. It’s worse with practising psychiatrists: only 10 per cent are from underrepresented minorities. Given the disproportionate burden of stressors in minority communities, including racism, economic barriers, police violence and other factors, the gap is especially worrisome. There are similar disparities on a global level. Mental health specialists are concentrated in high-income countries, where one in five people have access to appropriate care for depression. But in the low- and middle-income countries of Africa, East Asia and South America, only one in 27 people have access to comparable care.

One global strategy is to train people who aren’t mental health specialists to take on some of the roles that a psychiatrist or psychologist would play. These programmes are grounded in the idea that we all have the potential to support one another. Whereas clinical training for psychiatrists and psychologists typically focuses on mastering techniques for a specific class of treatment, educating lay persons is about channelling many of these foundational helping skills. Training helps to reclaim abilities that lie inside all of us and aren’t exclusive to those with years of professional training.

Panter-Brick has worked with a programme in Jordan where Syrian refugees are supported to reduce distress and promote resilience among fellow refugees. Patel has led the global movement for these initiatives with community health workers and non-specialists in low- and middle-income countries, and is now expanding these efforts within the US. We’re learning that these programmes, initially designed out of necessity, have the advantage of promoting empathic care because the consolers and consoled come from the same communities and shared life experiences.

That said, my colleagues and I are also aware that identity matching isn’t the only, or even the preferred solution. You might have more in common with someone halfway around the world than with your neighbour, at least in terms of the features bound up with your personal distress. Entire healing systems based on the notion that consoler and consoled should look the same will be problematic – not least because those in power, designing these systems, might not have a clear idea of who’ll feel emotionally connected to whom. Therefore, another strategy is to consider how to foster empathy and connection broadly among health professionals, non-specialists working in communities, and the general public.

This is where social psychology and evolutionary theory can come together. Evolutionary theory suggests why certain group behaviours emerge, while social psychology offers a way to use that information to change social dynamics. The psychologist Gordon Allport established the foundation for this in the 1950s, with work that coincided with the civil rights movement and racial integration in schools. Allport and colleagues suggested that intergroup contact could break down prejudice and barriers when the groups had a common goal (some echoes of evolutionary theory right there), and designed activities for white and Black students to do together to build this cooperation and cement aspects of shared identity. (They placed less effort on integrating teachers, however, as has been widely criticised.)

Since Allport, researchers have paid much more attention to how to build empathy when groups come together. I’ve spent the past decade trying to understand how to foster the empathy that doctors, nurses and community health workers feel towards patients living with mental illness in places ranging from Nepal to Ethiopia to Liberia. We train those living with mental illness to tell their stories, combined with photographs they take of their lives. These narratives follow an arc that brings health workers on an emotional journey, encouraging the flow of empathy and hopefully changing how they connect with patients. They show how much doctors and health workers have in common with those they treat, and how they care about the same things: looking after children and family members, economic security, participating in collective activities, and seeing the beauty in everyday life. If health workers feel this shared humanity – that they share some in-group qualities – then they’re better able to soothe their patients’ distress. The empathy and emotional contagion flow more swiftly, followed by consolation and resolution, and with the health workers getting the psychological reward from helping another person.

Each one of us could benefit from thinking in evolutionary terms about collective emotional regulation. One important step is to recall that being helped by others is not a sign of weakness: it is fundamental to what we do and who we are. We should be willing to seek help when we need it, and to connect with others who are in distress. In hospitals and other workplaces around the world, we expect staff to be able to handle everything they’re going through with COVID-19, at work and at home. And if you’re struggling, then it’s your responsibility to do some form of ‘self-care’. The medical practice where I work paid for all employees to have a subscription to a popular mindfulness app. But it’s equally important to make time to connect with others. A colleague might be the person most likely to be able to sustain that flow of empathy because of a shared context and culture. We all need more confidence that we can be helpful simply by being there, listening, and sharing another’s emotion. It makes us stronger as a group.

Collective empathy is also something that we need to promote in our children, in their schools, and in our parenting, to build on these natural instincts and sustain them. One day, when my wife and I were arguing – as happens when a family is locked up together for a year – our four-year-old daughter came over with a colourful pinwheel. In her remote Zoom preschool classes, she’d been taught to use it when she was feeling angry or upset. Once she experienced the emotional contagion of distress from my wife and me, she brought the pinwheel to us, on her own initiative, as something both symbolic and physiological to do together. She was our little shaman, doing what humans have done to support one another for hundreds of thousands of years. She knew that we heal together.

To read more about emotion regulation, visit Psyche, a digital magazine from Aeon that illuminates the human condition through psychology, philosophical understanding and the arts.

Brandon Kohrt

is associate professor of psychiatry and behavioural sciences at George Washington University. His work addresses improving mental health services for populations affected by conflict, disasters and other humanitarian emergencies. He has focused on strategies to reduce stigma against people with mental illness around the world. He has consulted with the Carter Center Mental Health Program in Liberia and has been advisor to Transcultural Psychosocial Organization in Nepal. He co-edited the book Global Mental Health: Anthropological Perspectives (2016).
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