Cities on the Couch: Mental Health in Post-Pandemic Urban Spaces
Relationships are vital – without human connection we simply cannot survive. You could be forgiven for thinking that living in cities and towns would insulate our mental wellbeing but, sadly, the opposite is true.
My organisation, representing nearly 10,500 psychotherapists and trainees, is especially concerned for the health of city dwellers in the midst of COVID-19. One of the most paradoxical issues created by the pandemic is the tension between society’s call for ‘social distancing’ and the critical need for connectedness with others.
The novel coronavirus has, at the time of writing, passed the six months mark in the UK and, sadly, shows no sign of ending soon. Lessons learnt from SARs and other pandemics suggest the mental health after-effects will be felt far longer than the virus itself.
We are working with more than 20 organisations to instigate sufficiently funded involvement of the psychotherapy and counselling workforce in responding to the many psychological impacts of the pandemic. At the time of writing, more than 10,000 people have signed our petition in support of our key asks.
Mental health issues already account for almost a quarter of the ill health burden in the UK, and yet a much smaller proportion of the NHS budget is spent on mental health services. For city dwellers, the picture looks worrying. While a study of 90,000 UK adults found, promisingly, general levels of anxiety and depression fell in early June as the lockdown measures were eased, the same was not true for city dwellers. It’s further compounded for those living in urban areas with lower income, children to care for, BAME community and those with pre-existing mental health conditions.
It is clear that our cities are at a watershed moment if we are to improve our wellbeing and create a healthier, more resilient future. The cities that boldly tackle this issue head-on without delay and put mental health and resilience at their heart are likely to pull ahead of the pack.
Remarkably, planners and designers are only starting to interrogate the emotional and mental implications of life in a city through the relatively new discipline of urban psychology, aided in no small part by the work of Chris Murray, Charles Landry and Mark Boyle, who held a groundbreaking Urban Psychology Summit in 2019, bringing together researchers, psychotherapy experts and planners.
Freud, the founder of modern psychotherapy, understood the intimate connection between our wellbeing and place. He pontificated on cities, writing in letters of his love-hate relationship to Vienna and, later, his home in exile in London’s Hampstead. He envisioned our minds as topography, a street map of our experiences and our desires, manifested through our conscious and unconscious utterances.
What implications might COVID-19 have for the design of our cities to better our health? Human connection is a vital factor in emotional wellbeing and societal stability. This is never more true than in the wake of a public health crisis, where individuals experience significant psychological stress due to physical illness, trauma or economic instability. Social connection has been described as “the variety of ways we can connect to others socially – whether that’s through physical, behavioural, social-cognitive, and emotional channels”.  There needs to be an urgent emphasis on building social support or connectedness among urban communities as a strategy to improve mental health.
For those of us living in cities during lockdown, our urban environments have served as a lifeline – whether that’s proximity to supportive neighbours in times of need or simply a good broadband, health provision and food deliveries. It’s the informal support, whether it’s shopping, childcare, or the visceral thrill of stepping out into our streets and onto balconies weekly to clap for carers. It has illuminated how much we thrive on our deep interconnectedness, which overrides the micro-irritations of incivility. What has shifted for so many of us is a heightened awareness of what we value about city life, and what needs to change if cities are to be the solution, not the problem.
Fortunately, city planners don’t have to look far for expertise. Psychotherapists hold a priceless repository of human experience and emotions connected to people’s habitats, and this remarkably untapped yet excellent resource should be integral to any discussions on the design and planning of cities. They possess a rich seam of knowledge about the connection between place and mental health, and are based on the data gathered from clients and service users from every echelon of society, comprising individuals, couples, families and groups.
Psychologists know the best conditions in which children learn and thrive, as well as how to mitigate the Adverse Childhood Experiences that may underlie 75% of adult mental health issues. There are currently 10 experiences which, if encountered frequently before the age of 18, have been shown to significantly reduce lifespan. One wonders whether living through lockdown might add an 11th.
Because pandemics have ebbs and flows making them quite unlike typical natural disasters with a beginning and end, it has long been understood that successful interventions to help communities recover from disasters rely on recognizing and building upon the resiliency inherent in communities.
There are three overarching priorities, in no particular order for planners and designers to mitigate the negative effects city living can wreak in mental health post-lockdown.
PRIORITY 1: Optimise access to green spaces
We already know that being in nature radically enhances our mental wellbeing. Let’s think about what good mental health brings to a city. It’s an absolute asset when it comes to cities being interconnected hubs of creativity, where people who might not typically encounter one another can grow ideas together. The simplest and most democratic way for that to happen is outdoors. It’s a characteristic of resilience to have cities where no one faces access barriers, where young can meet old.
While access to green space proved vital for the city residents’ mental and physical health during the height of the pandemic, overcrowding caused some local authorities to close those pressured spaces and disperse park-goers. Every scrap of grass, even verges by the side of roads, were used by those desperate to escape their four walls. The changes don’t have to be that radical or expensive – they have to be smart and with a focus on health, like reducing access to motor vehicles outside rush hours to create more space, installing handwashing facilities or making sure there are more bins to instill local pride in the park.
PRIORITY 2: Design health centres and surgeries to be more inclusive
Designers of health centres and GP surgeries need to ensure they’re culturally sensitive and visually encourage and help those most in need to access services. Marked racial disparities in accessing mental health care raise numerous concerns about underlying social drivers of wellbeing.
The second wave of the Black Lives Matter Movement has drawn attention to how systemic racism affects health as well as housing, education and financial stability – the key factors in recovery from COVID-19. My organisation has heard testimonies of people of colour but also middle aged working class men, who were least willing to access services because they were put off by their first encounter.
Much of this is organisational and systemic, but there is much planners and designers can do about the visual iconography of mental health support. The location of services in overtly medicalised surroundings can alarm and stigmatise. The visual iconography representing caring professions is overtly female and white.
There are some good exemplars already out there. For instance, The Caravan Drop In is a therapy service situated in St. James’s Church, Piccadilly, right in the centre of London. It is run by the CCPE (Centre for Counselling & Psychotherapy Education) in partnership with St. James’s Church, which has provided a home for the Caravan since 1982. The service is open seven days a week, therapy is free or by donation.
The Men’s Shed movement has been a terrific initiative to provide safe social connection for males in a non-clinical way. According to Age UK, loneliness amongst older people is as harmful to our physical health as smoking 15 cigarettes per day.
Psychotherapists don’t ask ‘what’s wrong with you’, they ask ‘what’s happened to you’ and meet you where you are. This kind of creativity is vital to meeting an existing need and catering for the significant rise in mental health concerns. Access to mental health support has been bleak for many, with MIND finding that a quarter of those who reached out for help during a fortnight in April failed to receive any support. Planners need to be consulting those amongst us with the least resources – they hold the key to urban transformation.
PRIORITY 3: Prioritise active transportation
Exposure to traffic pollution during early years has been proven to increase a child’s odds of experiencing mental health issues. The cost of lost potential is catastrophic.
City dwellers across the globe relished the clean air during lockdown, posting images of clear skies on social media. But as lockdown was eased, most people jumped in their cars rather than risk exposure to COVID-19 on public transport.
There’s no doubt that cycling, walking or taking public transport are better for our physical health but there’s plenty of evidence showing that active transport is better for our mental health and social interactions. London has installed more cycle lanes to meet demand following a huge rise in cycle sales during lockdown.
Planners need to ensure pedestrians can access shops and services conveniently and safely. It isn’t just ‘nice to have’, it makes absolute sense in economic terms, by bolstering local high streets and reducing the health and social care bill.
If COVID-19 has taught us anything, it’s that we can bring about incredible, previously almost inconceivable transformations virtually overnight. Never have we had such an opportunity to radically and rapidly optimize our urban spaces to maximise our wellbeing and the resilience of future generations.
Not addressing the widening mental health gap could affect people who have previously not reported issues. Failing to invest in mental health, be that services but also good planning and design, simply kicks a costly can down the road at even greater financial and human cost.
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 Norris FH, Stevens SP, Pfefferbaum B, Wyche KF, Pfefferbaum RL. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am J Community Psychol. 2008; 41:127-150.