Mentors

My six year old granddaughter was getting frustrated. It was very hot as we played a round of nine holes of miniature golf under the blazing sunshine at Topgolf, the first such round for her. She was doing quite well, all things considered, until we hit one of those holes that required a tricky shot into one of two small holes at the end of a log which then allowed the ball to roll downward to the green and cup below. She lined up, struck her pink ball up the gentle incline, and down it rolled again. When she was finally close enough to attack the shot through the log, she stood with feet pointing in two different directions, putter head at a strange angle and an aim that was obviously going to send the ball upwards to ricochet back toward her and perhaps down the hill again. Golf that only Sisyphus could appreciate.

I approached her and gently asked that she let me help her with her stance, club alignment and swing. “No! I can do it myself! I want to do it myself!” I tried to remain calm but finally said, “No, you can’t, and I would like to show you what might make it easier for you to get this ball in that hole and down to the green.” After a little more bluster and vague noises of discontent, she allowed me to guide her hands. After a couple more tries, the ball entered the log, came out the other end as expected and a stroke or two later she had successfully completed the hole.

We all need a little help at times. There are things that we have never learned to do, things that we have learned to do incorrectly and things that simply require learning skills that we do not yet possess due to age, or training, or experience. As a young medical student, I remember thinking that I knew more things about more things than I had ever known in my entire life, but also having a vague inkling that most of this knowledge was absolutely useless without primary experience and the guiding wisdom of teachers that had my best interest at heart. Like my granddaughter, I wanted to cry out, “I can do this myself! I want to do it myself!” Fortunately for me, I was surrounded by learned men and women who were patient, skilled and who wanted to teach me how to be a doctor, an excellent doctor. I listened to most of them (I think!) and am the better for it every day of my working life now.

Over the last couple of years, I have lost several of those mentors. Some were ill and died too soon. Some were old and it was just their time to pass the baton along to my generation. One taught me general medicine mixed with psychiatric consultation, one taught me rheumatology, and one taught me how to approach problems in medical ethics, still one my all time favorite courses in any of the schools I have attended in my lifetime. I was shaped by these teachers, in ways that not even they fully knew, and they will always be a part of me and the way I approach medicine and patients who need my expertise. They not only taught me the facts, but how to think about the facts, and then how to take that thinking one step further and formulate a viable plan that would help my patient recover from whatever ailment they presented with. There are still times that I cannot do it all by myself, and I turn to those who can help when help is needed.

We are still battling the coronavirus pandemic, like it or not. As we have discussed here in several previous columns, this illness has lead to both physical and mental illness in thousands of people. It has cost hundreds of thousands of lives. In this fight to better understand this illness, to learn how to treat it and to save lives, we have desperately needed mentors who could guide us in our endeavors. Whether it has been the pure science of the vaccines, the protocols involving ICUs and ventilators in acute care hospitals, or mental health and substance abuse issues we have sorely needed words of wisdom and tested treatment measures. Unfortunately for us, this is the first such pandemic in one hundred years, and no one alive has been able to act as such a mentor.

Now, we are at a crossroads where science and facts learned over the last eighteen months are in juxtaposition to fears, misinformation and rigid dogma. We must, like it or not, allow someone to come in and guide our hands. We need those with facts and tests and procedures that will help us to beat this illness modify our grip on our own fears, align us with solid scientific facts, and insure that our steady and confident swing is complemented by a fluid and smooth follow through. We need the mentors that this crisis has created in real time. Like my granddaughter, we can learn to make the shot, but we cannot do it alone.

Mercy

“Woah, ah, mercy, mercy me

Ah, things ain’t what they used to be.” Marvin Gaye

I have another podcast that I want you to know about in this week’s column, but first I have a few questions to ask you. Better yet, I want you to ask them of yourself as you read this and think about it today. We have been talking a lot, a lot, about the COVID-19 pandemic and how it has affected us physically and now mentally as we struggle to find the finish line of this biological disaster. Many of my family, friends, colleagues and patients have been dealing with issues of isolation, depression, anxiety and stress for well over a year, and the dilemmas that have come up have not been easy to resolve.The questions I have for you?

Has the pandemic made you reevaluate your associations and friendships with others?

Do you find that you have been carrying grudges based on old wounds that now feel just a bit trivial in the shadow of six hundred thousand deaths?

Do you struggle, amid the pandemic, with wanting to unburden yourself of hurt and anger but somehow find it easier just to keep carrying them after all these years?

The podcast suggestion I have for you this week is Hidden Brain, hosted by Shankar Vedantam. This is a wonderfully rich podcast that takes deep dives into emotions, motivation, relationships, stress, coping and everything in between. On a recent episode, Shankar welcomed Charlotte Witvliet, a psychologist at Hope College in Michigan. They had an in-depth discussion about grudges, holding them, dealing with them, letting them go, and the emotional stress and strain involved in all of that.

Dr. W, if I may be so bold, started out by telling us that we often go about our lives with a detailed ledger of all the wrongs that have ever been done to us, all the betrayals and hurts that we keep meticulous records of. Our anger over these can fester and grow stronger with time, not fade as we might think. It can feel both good and bad to hold a grudge. It is sometimes easier to keep it and nurture it than it is to let it go once and for all. Grudges, she says, may take the edge off of our profound sadness, and help us feel that we have a tiny bit more control over our emotions and lives.

We may always be on the lookout for clues that justify why we feel the way we do, clues that feed our anger. We sometimes dismiss things that might get us out of our destructive loop and actually make our lives better. Sound familiar as we navigate the treacherous waters of this pandemic? As we get more inflexible in our responses to a pandemic or an old grudge, we tend to get stuck in a do loop of bad behavior and anger that brings us further down. This rumination on negative emotions can actually affect us physically, according to Dr. W, in that our blood pressure rises, our heart rate increases, and our beat to beat variability ( a measure of healthy heart function) may be off as well.

Have you noticed that your response to that old friend or even a new acquaintance may sometimes be out of proportion to the thing that they said or did that set you off in the first place? Dr. Witvliet says that focusing on the humanity of the person, the fact that they are a person just like you, with a story, stress of their own, and their own baggage, may help you deal with them in a more positive way. The interesting thing about this to me was that even if you cannot completely give up the thoughts and hurts that might haunt you, if you truly try to understand the person that offended you and truly try to forgive and show mercy, your actual physical response will be very real, in a very positive way. She goes one step further (and you may or may not agree with her here) and says, “Forgiveness is a moral response to a relational breech.”

Now, you might tell me that in your case, you can just distract yourself with other thoughts, other activities, other pressing issues and that the grudge is dealt with in that way. You might be right to some superficial degree, but real forgiveness trumps distraction every time, says Dr. W. The real physical effects that I mentioned above, such as lowering your blood pressure, tend to be much more long lasting if the forgiveness, the grace, and the mercy are sincere and real.

Forgiveness is a process, says Dr. Witvliet, a journey. It unfolds over time. It’s like grief in that way, in that it is not a linear, A to Z process, but more a series of rolling waves. We have all had deep hurts from losses. All of us. That’s being human. Where we fool ourselves sometimes is that we tend toward decisional forgiveness, which is based mostly on our cognition, instead of the truer emotional forgiveness which involves a change of heart. The psychologist says that the two are not equal.

The trick to dealing with these relationships that you are struggling with now that things are opening back up? The way to deal with the hurt, the anger and the wounds that have been allowed to fester for over sixteen months now? Generate positive, empathetic responses to other people, says Dr. Witvliet. Empathy is key. Think about the gift of grace, forgiveness and mercy that you can give that person, and then think how wonderful it would feel to receive that kind of gift. Commit to giving the positive, not committing the negative again.

The hardest relationship, hurt, offense or slight to deal with? One that is truly targeted, evil, or destructive. These kinds of hurts are not just subjective or a matter of having our feelings hurt, muses Dr. W. They are objectively terrible wrongs that are terribly hard to forgive. One example that hits close to home for us in South Carolina? The shooting of nine innocent churchgoers at Mother Emmanuel AME Church in Charleston, South Carolina. The tragedy that occurred there that day was unspeakable, but the responses from the families of the victims, a commingling of grief, sadness, anger and profound love and forgiveness towards the shooter, was almost unimaginable. But, as many of you might know more than I, it was about as real as it gets.

So, back to my questions. In this time of reentry into the almost normal of a post pandemic life, are you struggling with relationships, grudges, long ago hurts and injuries, or the inability to let destructive issues in your own life go? Were these magnified or made center stage by the isolation and stress of lockdown, working at home, more time with your family or wearing multiple hats between work and home and schooling your kids? Do you harbor and carry those heavy grudges towards someone and wish you could unburden yourself? As the psychologist in this podcast episode about the power of mercy instructed us, thinking about the humanity of the transgressor, truly forgiving them, and approaching the coming days with positivity and creativity will surely help you to experience less anger, stress and physical ills than you ever did before. Find this episode, listen to it, and ponder. You will be glad that you did.

Sleep On It

I love listening to podcasts, and one of the best new ones is Chasing Life, by Sanjay Gupta MD. Dr. Gupta is the chief medical correspondent for CNN, and he did a year long podcast before this one that gave us daily updates on the coronavirus situation as it unfolded. He is smart, well educated, insightful, and interviewed many different kinds of people who offered insights into the pandemic and our responses to it.

Chasing Life is the logical continuation of his first offering, looking at how we are trying to get back to our lives as the coronavirus pandemic winds down slowly. In the Tuesday, June 22nd edition of this podcast, he looked at sleep and how it has been affected by COVID-19 and related problems. He began this podcast by talking about Cliff Luther, a man who functioned quite well on no more than four hours of sleep routinely, and who had also managed to get three graduate degrees, start work on a doctorate, and coparent his children all at the same time. It was a mixed bag to Mr. Luther to be able to function well on so little sleep, knowing that it might be affecting his brain adversely in some way. It turns out that he did indeed have a rare condition that lead to his needing so little sleep compared to the rest of us.

In 2016, the CDC had found that more than one third of Americans got less than seven hours of sleep per night. As the coronavirus pandemic unfolded, it was noted that people on average were sleeping 14-20 minutes more per night in March and April of 2020, compared to the same period the year before. The pandemic seemed to throw sleep patterns off for many of us. Some people were sleeping more, some less, some got up earlier and some went to bed later. Someone during that period coined the term “coronasomnia” to describe these changes in normal sleep patterns. Some people who had COVID-19 infections have noted ongoing problems with sleep that have lasted varying amounts of time.

Rebecca Robbins, who is a sleep researcher at Brigham and Womens Hospital and has an affiliation with Harvard Medical School, told Dr. Gupta that sleeping less than six hours per night can cause a decrease in mood, increased irritability, brain fog, and decreased ability to focus. It might even cause us to make unethical or foolish decisions, or take risks that we might not otherwise take. One study in February 2021 hinted at a possible increased risk of Alzheimer’s Disease and dementia bought on in part by insufficient sleep.

If you trained in medicine like Dr. Gupta and I did, you remember being told something like “you can sleep when you’re dead”, meaning that you needed to be awake, active and doing something productive almost every minute of your day. But are there reasons that we should be sleeping, and sleeping the seven to nine hours that we hear is the prescribed amount for most of us? According to Rebecca Robbins, when we sleep our glial cells expand, allowing an increased flow of neurotoxins to flow out and away from our brains. Satiety hormones like leptin work the way they should, signaling when we are full and keeping us from overeating. One study found that when people slept less than five hours, the effect on the functioning of this satiety hormone caused them to eat two hundred more calories that they normally would have.

Who is at risk for poor sleep? Older adults, in that our best sleep habits and functioning occur in our thirties to forties and change for the worse after that. Women tend to have sleep issues more than men across the board according to Robbins. There may even be some economic correlation to quality of sleep, in that those who are in poorer socioeconomic groups might live in areas where unbroken sleep might be an impossibility.

What helps us to get better sleep or learn better sleep habits? According to Robbins, cognitive behavioral therapy for insomnia can be very helpful. Relaxation training can be beneficial. She also spoke of the necessity of stimulus control. This includes using the bedroom only for sleep (or sex), only sleeping in the bed (not on the sofa or in the recliner), decreasing the temperature of the bedroom toward seventy degrees, and making sure that you are sleeping on a good quality mattress. Despite the holy grail of trying to get the most beneficial effects out of the least amount of slumber, conventional wisdom still tells us that most people do best if they get from seven to nine hours of sleep per night.

I would encourage you to check out this podcast, Chasing Life with Sanjay Gupta MD, for more interesting insights into the pandemic, our responses to it, and how we are entering the post pandemic phase and are beginning to figure out what is means to live normal lives again.

Flag Day

It was the Wednesday or Thursday after the worst ever terror attack on US soil. Our area, like many parts of the United States, was in shock. We did not know much yet, just the sketchy details of what lead to two planes crashing into the Twin Towers in New York City, another into the Pentagon in Washington, and another that was diverted downwards into a field by the brave passengers who learned that it was headed for the capitol rotunda. We were in shock, yes. Were more attacks imminent? Would something happen in our town? Were we safe? Were we at war? So many questions, and precious few answers to ease the anxiety we all felt that day and the days that followed.

What did we do to keep ourselves sane that week, to keep the thoughts from screaming inside our heads and the tears from flowing down our cheeks? We sought out home, family, and churches and other houses of worship. We went for comfort food, warm gatherings with friends and family in places and with items that made us feel safe, secure and more at peace. And we did one more thing.

We wrapped ourselves in the flag. The American flag. Old Glory. The Stars and Stripes. Flag stickers quickly sold out everywhere. No flag decals for car windows could be found in stores, but were displayed proudly on almost every car you encountered on the street. Those flag sets that you can buy at Lowes? Sold faster that they could restock them. Flags popped up everywhere. It was amazing.

At my house, we had a large flag that had been flown over the capitol, and it had never been displayed after that. I found it, unfolded it carefully, and then with great pride and great care managed to hang it on the front porch of the house, in front of the double set of French doors. It took up about a third of the facade of the house, and wrapped us like a red, white and blue security blanket for weeks if not months after that. We displayed it as a point of pride. We displayed it as a celebration that the country was still sound and running and cohesive and strong, even after those magnificent buildings imploded, sending showers of concrete and steel and glass and bits of paper, thousands of bits of paper, swirling into the streets of Manhattan. We displayed it as an answer, as a rebuke of terror and fear and hate. We displayed it as the embodiment of the American spirit, still strong even after losing so many of us on that dazzlingly bright blue September morning.

As Abraham Lincoln might comment if he were with us today, we are now met on another great field of battle, not one with planes used as bombs but one that sickens and kills the most vulnerable of us, a battlefield that starts with an invisible enemy and leads to the whoosh whoosh whoosh of a ventilator and the last FaceTime call a weeping relative will ever make. So many questions, still so few answers, though we are further along than we were just fifteen months ago. In this column, I have been talking for a year about the grief, the pain, the depression, the anxiety, the reentry, and the coping skills that have been involved with seeing us through this worst pandemic in a century in America. Many of you have been ill. Many of you have lost someone close to you.

Now, on this Flag Day, we are again in need of a rallying cry and a symbol or two that will help us go the last mile to make it through the last phase of this viral pandemic. We need to proudly display the flags of knowledge, good judgment, well thought out decisions, and good will. We need to wrap ourselves in the red, white and blue of science, teamwork and determination. We need, just as we did on those days after 9-11, to get the facts, grieve if we must, fight because we have to, and move forward in lockstep as only America can to see the dawn through the settling ash and mist of illness and death.

On this Flag Day, be proud, be compassionate, be helpful, be smart, and be resolved that there is nothing, given enough time, resources and indomitable will, that Americans cannot do. The end of the pandemic in our country is in sight. Carpe diem.

Reentry

Reentry

 

 

Did you watch any of the comings and goings of the Crew Dragon capsule as it went up and down from the International Space Station? It’s a sleek, slick, dazzling white, truly space age looking piece of hardware that has now ferried several astronauts to space and back as part of the partnership between SpaceX and NASA. I decided to watch a video on the You Tube channel Everyday Astronaut to learn more about how this tiny capsule gets back to earth once it has been in space and docked for a while. I would encourage you to check it out.

 

Spoiler alert: this last mission resulted in the first successful water splashdown since 1976. That being said, what were some of the most interesting facts about the timeline and process of bringing this little capsule and its human cargo home safely to earth? First of all, once the Crew Dragon backed away from its home away from home, it had anywhere from six to thirty hours until possible splashdown. That’s quite a range! As it entered  the atmosphere of our planet, its heat shield was turned to face forward in the direction of travel, having to withstand temperatures of 1900 degrees Celsius, and G forces of three to four times earth’s for the crew inside. The air that rushes towards the speeding capsule has little time to get out of the way, is superheated to half the temperature of the surface of the sun, and is compressed into what is called plasma, all of which puts tremendous pressure on the capsule and its contents.

 

Once the capsule did make it past the blistering heat of the atmosphere and was free falling towards the water, it had to be further slowed down, first with two small parachutes that oriented it for its final descent. Then, four main parachutes partially opened, then fully opened to help the capsule gently settle onto the surface of the water. The exact timing and manner of deployment of these chutes is critical. Too fast and they simply won’t open, too slow and they will not slow the craft enough to prevent a hard landing on the water. It was picked up, placed in a “nest” on the recovery ship, and saw the extrication of astronauts who had been in space so long that they could barely negotiate one atmosphere of pressure and could barely stand without support. As the host of the Everyday Astronaut video stated, “The entire system makes reentry safe.”

 

Now, think about where we are today in this pandemic cycle, which officially started in March of last year. We are battered, bruised, tired, grieving, and so ready to re-enter our prepandemic lives. We would like to think that we can just magically return to what we did, how we acted and talked and functioned in January 2020. The truth is, just like Crew Dragon, we have been docked for over a year, in one way or another, stuck in our homes, working out of closets and bedrooms, teaching kids at the dining room table, talking to coworkers, friends and family by Zoom, emotionally weightless. Now, we are ready to suit up, get back into the capsule, back away from being forcibly tethered to pandemic life, and head for freedom. What will it take to do this? What will it cost us to get back on the ground?

 

First, just like the crew leaving the space station, we must be protected. We cannot do this alone. We must orient ourselves in the proper way so that we can face the onslaught of heat that will be coming our way in the form of social gatherings, parties, dinners, school activities, sporting events, church gatherings, and family outings. It is going to be wonderful and brutal all at the same time. Is your calendar already filling up like mine? We need a heat shield. This may come in the form of a good support system, good self care and good habits like exercise and getting enough sleep. The events and obligations, like the air that cannot get out of the way of the capsule and is compressed into super hot plasma, will rush at us so fast that all we think we can do is say yes and hang on for the ride. I would counter with the fact that if we have learned only one thing in this time of pandemic, it is that we can say no.

 

What are your parachutes? What will gently place some directional drag on your descent back into the helter skelter that was your pre-pandemic life? What will slow you just enough so that you can take your time, pick and choose your commitments and activities and interactions so that they will make you stronger, not dash you against life in a rush? Think about that now as you get vaccinated, as your mask comes off in more and more places, as you begin to hug friends and family again, and as you feel more comfortable in your own skin outside your own home.

 

Like the Crew Dragon astronauts, we will miraculously come through the fiery descent, get ourselves oriented in the right direction, gently slow things down to a manageable speed, and come out of our confinement a bit unsteady, but ready to accept the support that will get us back to our best selves for the years to come.

 

Happy reentry!

Cast Off

It happened too many years ago to remember now, but I still do. It was a time when we who labored in mental health could be more real, could actually connect with our patients in meaningful ways and even let our hair down from time to time and have some fun. A group of staff members were playing a group of patients in a friendly softball game in Aiken, a few miles from the mental health center. I was old enough to know better but still young enough to think that the teen athlete still lived in me, and you know how that always turns out.

 

I was taking my turn at bat, connected with the ball and drilled what should have been a solid single to right field. I should have been more than satisfied with that, but of course I wasn’t. I rounded first, saw that the outfielder was fumbling with the transfer from glove to throwing hand, and made a split second decision to stretch a sure single into a maybe double. Getting to second was easy. I was still moderately fast in those days. The next decision I made was not a good one, however. Without a clear need to do so, I decided to slide into second in a blaze of dusty glory. Bad move.

 

I knew that I had really screwed up when my left leg made contact with the base, which felt at that moment like a concrete block. The snap was audible, the pain immediate and the shame followed close behind. When I tried to get up, I saw an acute angle between leg and foot that was not at all natural. Not good. A short ride and check in at the emergency room later, I was not at all comforted by the well meaning nurse who told me that “only really active people get injuries like these”. You know the drill. Ortho tech, clean it up, put it in a cast to the knee, get fitted for crutches, see ya in a few weeks.

 

The hardest part about being in a cast for those long weeks, besides not being able to take a real shower without wrapping my leg in plastic bags? I couldn’t walk with crutches and carry a coffee cup at the same time. This, my friends, is the definition of crisis. But, of course, like many weekend warriors, I made it through.

 

Fast forward to the doc’s office on the day that the cast was coming off. I had lost about half the muscle mass in my leg, and I was more than a little worried about taking away the plaster exoskeleton that had held me up for those weeks. Would I fall down? Rebreak the leg? Be able to do the things that I could before the injury? Getting the cast off felt so good in one way, with cool air on skin and mobility that I had missed terribly. But the worry about reinjury or weakness or worse still gave me fits for a few days, until I knew things would be okay again.

 

Now, forward to March 13, 2021. The CDC decides that after more than a year, those who are fully vaccinated against COVID-19 can shed their masks indoors and out, around people who are also fully vaccinated and those who are not. This seems to come so suddenly that it catches us off guard.  After being so careful for so long to avoid exposure, protect ourselves against infection and illness, we are now told that all is clear and safe! To me, it almost instantly brought back memories of taking my cast off, something that I was more than happy to shed, but with the anxiety of what my health would be like after it was gone.

 

Protections, even if restrictive and painful in the short term, often make us feel safer in the long run. Removal of these restrictions is exhilarating but can be frightening at the same time.

 

When I was recovering from my broken leg, just as we are now seeing the beginning of the end of the COVID-19 pandemic in the United States, letting protections fall away was the only sure way to test ourselves and our safety going forward.

 

The second half of that lesson is also clear: testing ourselves is the only way to grow.

Languishing

How have you felt lately? Really?

Good? I am happy for you. Depressed and hopeless? I sincerely hope that you are seeking help and on the road to recovery. The rest of you? My hunch is that you may be feeling a little flat, not motivated, and “meh”. This is weird, right? Vaccines are here, many of us are back to work, things are opening up a little bit, and the warm sunshine of spring and the promise of summertime should be brightening our days. Why then, do we still feel a lack of motivation, have trouble concentrating and find it challenging to focus on the things that matter to us?

Adam Grant, an organizational psychologist at Wharton, addressed all this in his April 19, 2021 article There’s a Name for the Blah You’re Feeling: It’s Called Languishing. He pointed out that we are not depressed or hopeless. We are not impaired. We are functioning daily. We are not burned out. There is just little joy and we feel aimless at times. We lack anticipation for the good things that we used to look forward to.

According to Grant, languishing is a sense of stagnation and emptiness. We are muddling through, and as some of my patients have said in the past “existing but not really living”. Many of us who have had COVID and recovered or those who have not had the illness at all are struggling not with long COVID syndrome, but with “the emotional long haul of the pandemic”.

Think back to early spring 2020. We were all a bit frightened, unsure of what was happening in the world around us that was heading our way. Back then, according to Grant, our natural threat detection system was “on high alert for fight or flight”. We learned that masks were helpful, but we were still scrubbing surfaces and sanitizing our groceries. We developed crude routines that “helped ease our sense of dread”. The problem is that as time has gone by, our acute state of anguish “has given way to a chronic condition of languish”. As languishing is squarely between depression and flourishing, we don’t feel bad but neither do we feel back to our pre-pandemic good either. Grant says that “you’re not functioning at full capacity. Languishing dulls your motivation, disrupts your ability to focus, and triples the odds that you’ll cut back on work”.

The term was coined by a sociologist named Corey Keyes. According to the article, his research suggests that these who are languishing today are going to be at much higher risk of developing depression and anxiety over the next decade. That second great pandemic wave you’ve heard about? It may be psychological, not purely medical. Grant also says something about languishing that hit me: “You’re indifferent to your indifference.” You may not even realize how slowly you are sliding into the malaise.

So, what do we do with all of this? Grant says that one of the best ways to handle emotions is to name them. In the spring of 2020, we were all obviously experiencing acute grief, from loss of loved ones to loss of freedoms to loss of routine to loss of income. So many losses. Now, we learn that we are languishing, and naming it may be the first step in battling our way out of it. Languishing is “common and shared” and just knowing that may give us the ability to bestow a little grace not only on others but on ourselves.

What next? Focus. Relearn, if you must, how to pay attention to the things that are important to you. I am the worst when it comes to this, so believe me when I say I am not preaching to you. Grant says in his article that “computers are made for parallel processing, but humans are better off serial processing”. Simply put this means do not try to multitask! Again, I have five or ten or fifteen things that I must do, want to do, love to do, and I delude myself into thinking that I can do five of them at a time extremely well, but this is simply not true. Pick something, make it realistic and doable, and put your whole focus into it. You’ll feel much more accomplished and maybe even happy if you do!

Set boundaries and block out time for yourself. A colleague and I were talking about this by email just this morning. We need processing time, thinking time, planning time. I know it is hard to come by when you are working from home, taking care of the kids and responding to emails and Zoom invitations all day, but it is worth aiming for.

Grant tells us to focus on small goals. “Try starting with small wins”, because the pandemic was such a big loss to us all. Don’t be too easy on yourself though. Pick something moderately challenging sometimes. “The most important factor in daily joy an motivation is a sense of progress.” Do things that matter to you.

The article finishes up by acknowledging that “languishing is not merely in our heads-it’s in our circumstances”. “Not depressed doesn’t mean you are not struggling.” As one of my patients told me that other day (I told him I would steal this and he agreed), “Just because I am smart and can articulate what is going on with me does not mean that I can fix it.” Don’t let yourself languish, isolate and fall into the pandemic abyss. Use the tools outlined in this article, use your support systems, and get professional help if you need it. We are so close, and we will get there together.

Closure

When one door closes, another opens.”

Alexander Graham Bell

 I have heard it so many times in the past.

“I had so much more to say”, the grieving mother tells me. “I didn’t know that we were drifting apart”, the middle-aged man says. “I didn’t know that it was going to turn out this way. “

We have witnessed a terrible year of political unrest, a raging pandemic, and social upheaval. With the conviction of Derek Chauvin in the George Floyd murder trial this last week, many said that they felt they could finally sleep, rest, and feel more at ease with the completion of a long, arduous year of pain and wondering. What did all these people have in common?

They needed closure. They needed to know that all that should have been said had been said. They needed to understand the division and come to terms with the reasons for it. They needed to come to grips with how it actually came out in the end. They needed a verdict to know what to do, how to feel, and how to act next.

What is closure?

Abigail Brenner MD writes about closure in her article 5 Ways to Find Closure From the Past in Psychology Today. She says that “closure means finality; a letting go of what once was. Finding closure implies a complete acceptance of what has happened and an honoring of the transition away from what’s finished to something new. In other words, closure describes the ability to go beyond imposed limitations in order to find different possibilities.”

What does it take to achieve that state of closure that we all long for after a particularly tough situation or problem? We must navigate many sometimes conflicting emotions such as sadness, grief, anger, fear or hate. We may literally lose sleep over it. We may not eat. Our usual routines and comforting daily activities may not be enough to keep us on an even keel any more. We may delay going on with our lives because we simply cannot let go of the past and close the door on what was painful.

If we have lost a job, experienced an assault, had significant family issues, had financial setbacks or myriad other stresses, we may feel that there has been an absolute lack of resolution and that we simply cannot process what happened all the way to its logical end.

What does closure do for us then? It helps us to put a marker down, to delineate the before and the after so that we can decide from which point we actually need to move forward. It closes a chapter on what may have been a very painful part of our lives, but it never closes the entire book. There is always more to be written. Closure allows emotions to pour out, to be expressed and laid bare and dealt with where they are, how they are, for what they are. It allows us to make peace with something, move forward, and to go on with life.

Dr. Brenner states in her article that the ways to go about seeking closure include the following five things: taking responsibility for yourself; grieving the loss; gathering your strengths; making a plan for the immediate future, and creating a ritual that helps you move forward.  

Most people have heard the quote I began this column with, but many do not know the quote in its entirety. Bell supposedly said, “When one door closes, another opens,  but we so often look so long and so regretfully upon the closed door, that we do not see the ones which open for us.”

Do you need to seek closure today? If you find it, will you be able to look for the open doors that beckon?

Suffer the Little Children

We are all happy that with the arrival of three vaccines against COVID-19, the end of this long, stressful pandemic might finally be in sight. However, I read two articles recently that gave me pause. I wanted to share them with you .

The first, entitled Kids’ Mental Health is Still Pediatricians’ Greatest Concern, was in the Sunday, March 7, 2021 edition of the Augusta Chronicle. In it, Steven Shapiro, Chair, Department of Pediatrics, Abington Hospital, Philadelphia, PA, stated that “20% of calls are now to put kids on more medications for panic attacks and anxiety.” He was quite concerned that the uncertainty and anxiety spurred by the pandemic, coupled with a lack of social contact, may be having lasting effects on the mental health of children and teens. As we have all seen, children seem to be less likely to have serious physical illness from COVID-19, but the emotional toll of this ongoing pandemic may be affecting them more than we know. Vaccines are super and many of us have already had at least one dose, but they are not yet available for children. Moderna began testing its vaccine for young children just recently, so there is hope that this age group may soon be part of the more fully protected when a vaccine is deemed safe for them to take.

What kind of emotional affects does the pandemic have on kids? For one, they worry about somehow getting infected, then making their parents, grandparents, and teachers sick, according to Stephanie Ewing, Assistant Professor in Counseling and Family Treatment at Drexel University College of Nursing and Health Professions. Routine health appointments and follow up visits for well checks and vaccinations, among other things, fell drastically in the first few months after the pandemic was discovered and stay at home orders became more common. According to a November 2020 Blue Cross/Blue Shield report, vaccinations for measles and whooping cough fell 26% compared to the same time in 2019. On the positive side, there has been a decrease in the number of cases of strep throat, flu, and ear infections due to social distancing, says Jonathan Miller, a pediatrician at Nemours/Alfred duPont Hospital for Children. Dr. Miller also notes that children have been much more inactive, they have had an increase in screen time, and they have been home for a much longer period of time than pre-pandemic times. He wonders about the impact of these on overall wellbeing. There has been an increase in depression and anxiety symptoms in his practice as well, and he has shifted to a more proactive stance and an emphasis on preventative care when dealing with behavioral and mental health issues.

The second article, MUSC Doctor Says Pediatric Suicide , Suicide Attempts “unprecedented” Amid Pandemic, appeared in the Post and Courier on 2-19-21. It continued to look at the issues we’ve already outlined but went a step further to drill down on the issues of suicidal ideation, suicide attempts and completed suicides. It also made this issue much more real for me, as these doctors live and work on the South Carolina coast in the Charleston area.

Dr. Elizabeth Mack, Chief of Pediatric Critical Care at MUSC, says that the number of these suicidal kids has reached a crisis in Charleston during the pandemic. What they are seeing inside the pediatric intensive care unit is much higher than normal and unprecedented. “We’re seeing a twin pandemic in many different ways. The isolation is really amplifying the inequities that have been laid bare for us.”

What are some of the factors that are contributing to the rise in pediatric suicide attempts and suicides? Isolation, grief secondary to the loss of loved ones, and financial insecurity are just three. Delayed return to school, which of course may be rectified in the coming months for many students, has lead to increased anxiety and depression. Schools are also safety nets for kids who don’t have enough food, who get most of their social needs met there, who have better access to physical and mental health care in school, and who sometimes are rescued from various kinds of abuse when a teacher or counselor sees warning signs and investigates further. Even when they are in school, some children worry about getting infected with COVID-19 themselves. Plexiglass barriers, mask wearing and social distancing also lead to odd emotional reactions in some children.

What can we all do to help?

Parents, teachers and counselors can be as open as possible with kids, including sharing some of their own healthy emotional responses to the pandemic and how they dealt with them. Focusing on the future can be very helpful. All of us can be vigilant, and if a child acts or sounds or interacts differently than usual, taking them to their pediatrician is a good first step. One more potentially lifesaving thing we can all pay attention to? Gun safety.

Dr. Annie Andrews, Director of Advocacy in the Department of Pediatrics at MUSC, noted that pre-COVID-19, thirteen million children lived in homes with firearms present, and four million of these in homes where the firearms were not secured. Children in homes with guns are three times more likely to die from suicide. Eighty per cent of children who attempt suicide with a gun will die. Only 2% of those who attempt to kill themselves by ingestion/overdose will die. Gun safety means unloading, locking up, and separating ammunition from firearms. As many as five children a week have been brought to MUSC with self-inflicted gunshot wounds, either accidental or intentional, and many of these kids die.

As Dr. Andrews and others in these articles said, these data are still anecdotal, but more data will be forthcoming as we go forward. As I started this column by saying, we are very happy that one pandemic seems to be heading towards its latter stages. Unfortunately for our children and teens, another pandemic may just be beginning, and we will be wise to watch for it and confront it wherever it arises.

The Right Thing to Do

I was walking back to my car from the pay station in the public parking lot when she pulled into the adjacent space. The front of her white Honda Civic, which she guided too widely into the space, scraped and clipped the front wheel of the car to her left. I saw it and cringed, and I am quite sure she saw me see it. I also saw that there were already scrapes on her bumper from previous encounters. I walked on to my car. I watched,

She did not get out for quite some time. When she did, she glanced my way. She got back into her car. The owners of the adjacent car arrived, got in, and prepared to leave. She did not get out. She did not tell them what had happened. She did not apologize for the assault on their vehicle in their absence. They backed out and left.

She got out of her car again, looked back my way, then walked over and paid her parking fee. She walked away.

If one is dishonest or irresponsible in small things, how does one expect to be honest and responsible in larger, important things? This is a lesson that bears learning and relearning daily.