Thanksgiving

Thursday is Thanksgiving Day.

 

In this time of political pugilism, pandemic pestilence and social stratification, I thought it might be beneficial to just take a step back, look around us and truly assess our ability to be thankful. We still have that capacity in us, do we not?

 

Shawn Blanc, who writes about productivity and work on his site thesweetsetup.com, uses the concept of a flywheel to illustrate how one approaches work and productivity. He talks about the ability to identify what needs to be done, then how to plan to attack that need, and finally how to act on that plan. The fourth and final step on his flywheel is celebration. He coaches that no matter how much work is done, no matter how many milestones are reached, we still need to be able to celebrate our victories. Without that, without the acknowledgement of hard work well done, a plan well executed and a problem solved, we may as well toil on forever in a mindless morass of effort that gets us nothing and nowhere. The celebration, which I look at as a thank you to yourself, is paramount. You must celebrate, you must thank yourself, for the hard work you put in and the milestone you reached. Else, why strive to reach them at all? I talk with patients every week who always put others above themselves, who never think to give themselves a pat on the back for how they use their ingenuity, brains, energy and creativity to make their life and the lives of those around them better every single day. How very important that is in this dark time, when laughter and thanksgiving and celebration have been so rare for almost two years.

 

Can you thank others for what they do for you as well? Of course you can. Even a masked man can utter a thank you when passing his colleague in the hallway at six feet distance. Penning written notes or letters is almost a lost art but is still an effective way to express your gratitude. Texting? Yes, we do live in the twenty first century after all, so even the humble text is better that nothing. The point is, that thanksgiving is not the only time that we should give thanks. In times of great stress, anxiety and upheaval, a simple token of caring and esteem acts as a life jacket for the drowning man.

 

How can we thank those who went before? They are long since dead and gone, I hear you say, so what is the point in thanking them for anything? They will not know if you thank them, but you will. How do you do it? Learn from them. Read their stories, their diaries, their memoirs. Get inside their heads and know what they knew. This is not the first pandemic the world has ever faced you know. The Great Influenza:The Story of the Deadliest Plague in History is a 2004 nonfiction book by John M. Barry that takes a close look at the 1918 flu pandemic, including the back biting, infighting and political struggles of those who strove to rid the world of the plague that killed up to 50 million people or more worldwide. Does that sound familiar today? Of course it does, but we are no less grateful to those pioneers who helped pave the way for the studies that brought us vaccines and public health measures that so far have insured that this go round is not nearly so deadly as that one was. When you gather for this Thanksgiving holiday, remember those who went before, tell their stories, laugh at their eccentricities and gird yourself with the strength that got them through the trials of their own times. Our mentors, they have much to teach us, and we in turn can mentor others who will carry on long after we are gone.

 

This Thanksgiving season, start a gratitude journal. Write letters. Read daily affirmations that build you up, not vitriolic writings that tear you down. Increase your social connections safely as the pandemic wanes, and learn to be socially graceful again. Connect with others, and be thankful that you are here, now, living out this time in history that no one else but you can claim.

 

I am thankful for you, my readers. Happy holidays.

Who Was That Masked Man?

What do the Lone Ranger, the Mandalorian, the surgeon who performed my surgery a month ago, and I all have in common?No, I cannot ride a horse, at least not very well, and I don’t think I would want the Mandalorian entering an operating room with The Child in tow, cute as he is. The horse I never ride is not named Silver, and sterile technique was probably not one of The Lone Ranger’s major weapons. So, what is it that binds us all together? We all wear masks. 

Now, this column has never been political, and I see no reason to start down that path now. It is not an extension of the CDCwebsite, which I trust you can search for and read yourself if you are so inclined. I am not writing this week to browbeat you about vaccines or positivity rates or partial vaccination percentages. I am going to talk about masks, but not in the way you might expect. This is after all a column that deals with the mind and mental health, so I’d like to share a few observations with you about mask wearing and its effect on interpersonal interactions, as seen from behind the desk of a psychiatrist. 

Like many of you, I was abruptly sent home to work at home in mid-March of 2020, and there I would stay for the next year, learning to turn a guest bedroom into a functioning office, trying out chairs and tables and bookcases, setting up new printers and laptop stands, attaching clackety keyboards and positioning phone stands at just the proper angle for Zoom or Doximity or Doxy.me calls. I made it work, like a lot of people have, for over a year, when I was then gradually allowed back into the clinic building, and even more gradually allowed to see real live breathing patients back in my office, face to face. Well, sort of. The mask thing, you know. We were and still are under a department directive to wear masks when indoors, in our offices seeing people, or when we are out and about in the building’s public spaces. We are still physically distancing, but we are not as gung ho about cleaning every single surface after every single visit as we were back in the early days of the pandemic. We know a lot more about the virus that causes COVID-19, but we are still diligent, even after vaccinations, even as we feel that the end of this awful pandemic is finally in sight. 

How has mask wearing affected us? I have some thoughts. You may agree or disagree but bear with me, and see if any of this resonates with you in your daily life. 

We wear masks first to protect ourselves and others from the spread of viruses like coronavirus or flu. The science bears this out, that high quality masks worn correctly can indeed slow or virtually eliminate significant transmission of virus particles that can make you sick. That being said, when we wear a mask we can feel pretty confident that we are doing something that helps us protect people. At first this felt very odd, unnatural and even silly. When virtually everyone started to wear a mask in certain situations, it felt much less so, much more normal and much more expected. Like remembering your keys on the way out the back door, you needed to stuff a mask into your pocket or make sure you had a spare one in the car before you got to the store or the restaurant. In places like family homes or even workplaces, where we knew people “B.C.”, or before COVID, we remembered their faces and it was not a great stretch to “see” them smiling or frowning or otherwise emoting behind those cloth coverings, because we knew their facial expressions and reactions so well from before. 

Going into new places or situations was different. If you do not know a person and all you can see and read is his body language and his eyes, it is much harder to gauge what he is really thinking or feeling behind his KN-95. The social dance becomes much more cumbersome, with us straining for physical cues, sounds, or anything else that does not involve a smile or a frown. In my field of psychiatry, being able to see a person’s body language, watch her facial expression, hear her voice and see if all of the above match up in a meaningful way is a big part of what I do every day. A mask, small and unobtrusive as it is, makes this much, much harder to do in a meaningful way. A mask also gives us something to hide behind, for better or worse. I have found that in some ways it is easier to be myself, crack jokes, be more personable with my patients, and they with me, when we are wearing masks. I believe that some patients have found it easier to speak freely when masked than not. Paradoxical, yes indeed. 

When sitting across the table from two accreditation surveyors who were visiting our center last week, we all found it a little odd to be presenting ourselves, our programs and our achievements while masked. Even one of the surveyors commented that we didn’t really know each other, or our features, while interacting in this way, and how odd that was. 

So in summary, masks can be physically protective against pathogens that can harm us. They can quickly be assimilated into everyday life and provide minimal barriers against interactions with those we know well. They can also be barriers, literally and figuratively, that prevent knowing others and assessing their emotions and interactions if we do not know them well. They can be something to hide behind, which might make it easier for some to interact, or harder for others to be themselves. They can make it much harder to get to know someone new. There is also one more thing to consider. Though we are all so tired of the pandemic, the quarantines, the isolation, the distancing, and the mask wearing, it may be harder to give up the latter than we think when the time comes. One previous life experience reminds me of how hard this might be when we are told we really, truly do not have to wear masks any more.

I can remember playing in a staff/patient softball game many years ago. I had just hit a driving single that I was sure I could stretch into a double, so I rounded first base and raced towards second, sliding in a cloud of dust. It was an ill planned slide, and my left leg caught the bag, which decided that it would not move. I heard a snap, felt immediate pain, and looked down to see my lower leg in a weird angle that was certainly not natural.(I was safe, by the way) After a trip to the emergency room, I headed home the proud owner of a new set of crutches and a cast that encased my lower leg to my knee. I hated that cast, though it allowed my broken bone to mend over the next six weeks, because I could not take a shower easily and could certainly not carry my own coffee cup while rocking crutches. However, as my bone healed and strengthened and the muscles of my leg dwindled to half their pre-slide size and power, it soon was time to shed the cast and go back to supporting myself without an exoskeleton. I was afraid to give that cast up. Why? Because I knew that while I wore it, I was relatively steady on my feet, my leg was strong and supported, and I would be able to walk and not fall. Without the cast, as soon as it came off, I felt vulnerable and weak. It took a few more weeks after that to get back to my normal strength, confidence and steadiness. 

When it comes time to shed our masks, how will we feel? Will we smile, timidly at first? Will we avoid others, wondering how vulnerable we are to illness and disease? Will we relish the ability to gauge someone’s delight or anger or sadness from their facial expression, or will we find it hard to open up again? Time will tell. I just know that one day, and soon, we will pass someone in the hallway at work or in the store or at church and we won’t need to ask, “Who was that masked man?” Because we’ll know.

A Lock on Mental Health

Mental Health America states that 1.2 million people living with mental illness sit in jail and prison each year, according to an article titled Stepping Up in the Wednesday, October 13, 2021 Augusta Chronicle, written by Josef Papp and staff writer Susan McCord. Vera Institute of Justice, a nationwide nonprofit research and policy organization adds that based on data collected by the federal government on local jails, about 14.5 % of men and 31% of women in jails have a serious mental illness compared to 3.2% and 4.9%, respectively, in the general population. Elizabeth Swavola, director of the jail decarceration initiative at Vera stated in this article that “people with seriousmental illnesses are dramatically over represented in jail populations”. The article outlined the local scope of this problem at the Richmond County jail and the initiatives that are underway to fine tune understanding of the magnitude of the issue and how to tackle it. One serious issue in Georgia is that availability of mental health services is very limited. According to Papp and McCord, the state ranked last in access among the fifty states and DC, according to a 2021 report by Mental Health America. 

Another issue that was considered in dealing with this problem was the use of intercepts, points “in the criminal justice process where an individual could be diverted to mental health resources rather than continuing to cycle from street to jail”. Richmond County is working hard to maintain a robust mental health court, and currently has forty two people with mental illnesses assigned to their program. One of the rate limiting steps for them right now is to really get a handle on the scope of the problem and the needs that currently exist. 

I wanted to share with you what we are doing in Aiken County to address similar problems on this side of the Savannah River. According to Varney Hodge, who helps to coordinate and administer mental health services and mental health court services at the Aiken County Detention Center (ACDC), “Mental health courts were developed in response to the inability of traditional courts and jails to address a defendant’s underlying mental illness, in cases where prior diversion efforts have failed, but the nature of the charge is not so serious that prosecutors are unwilling to relinquish control. Similar to other specialized court systems such as drug courts and veterans’ courts, mental health courts are an alternative to navigating the criminal justice system for people with a mental health disability.” Tamara Smith, Executive Director of Aiken Barnwell Mental Health Center, stated that the mental health court is a partnership with Aiken County government, the Aiken County Probate Court, Solicitor-2nd Judicial Circuit, the Public Defender’s office, SCVRD, ABMHC and the ACDC. 

Angela Little , Associate Judge of Probate in Aiken County, told me that she as quite encouraged by the program in Aiken County thus far. She said that the mental health court helps to find housing if needed, retrains and certifies for job positions, helps participants reconnect with their loved ones, and provides other services as needed. She emphasized that inmates must volunteer for this program, plead guilty to their charges, sign releases of information so that all involved may pool and share information to better help them succeed, and agree to attend court meetings as mandated. Terms of this arrangement may range from six to twenty-four months, said Judge Little. She told me that there have been approximately six people in the program over the last year, and that three more people are being examined as possible good candidates going forward. After starting the conversation and planning for this program almost three years ago, Judge Little says she is as pleased with the interventions it provides as she has ever been about any of her work with the Probate Court. 

Tamara Smith provided further insights into the workings of the mental health court in Aiken County. It reserves space for violent criminals and others for whom incarceration is the only reasonable alternative. It reduces arrests, reduces days spent in jail, cuts down on recidivism and the overall burden on law enforcement, who often need to provide more direct observation, assistance with medications and suicide watches for inmates with mental illness. To be considered for the program, offenders must be charged with a misdemeanor or non-violent felony and have a diagnosable mental illness. They must understand and be able to commit to the program, usually for a year. They must be a resident of Aiken County and not be a threat to the public. The members of the mental health court team must agree that the person is appropriate for the program. The offender must admit guilt and voluntarily enter the program. Mental health services are provided by a mental health professional. The offender must complete community service, pass drug screens and report to the court as required. If the offender does not meet program guidelines, they may face sanctions, including weekends in jail, additional community service, or increased mental health services. Multiple sanctions may result in return to jail to serveout their sentence, and as Judge Little told me, time spent in the mental health court would not count against the time of the sentence needing to be served in that case. 

All of these pieces of the existing mental health court program in Aiken County are designed to screen for people who are likely to be successful in the program and return to being productive citizens, all while treating their mental illness at the same time. It is an exciting and innovative way to provide the services that offenders need in order to minimize incarceration time, maximize training, support and productivity, and put them on a trajectory to success. Let’s hope that the programs in Richmond and Aiken counties can continue to succeed and grow.

Awe

My wife and I went to the symphony the other night. The opening performance for this year’s Symphony Orchestra Augusta season was entitled Under The Stars, and it featured several very good pieces of music that entertained us and made us forget our troubles for a little while. I have been recovering for the last two weeks from surgery that I had put off for months because of the pandemic, and this was my very first foray out of the house. I was feeling that odd combination of pain and boredom and discomfort and cabin fever and pandemic drag that at the same time dampen one’s resolve to do anything and leave one open to do anything. We had the tickets, the show was on, so we went.

 

Now, one of the pieces was a violin concerto that featured a young artist who played an instrument crafted in the 1700’s. He was obviously so at home with the music, felt it, breathed it, and then translated it through his fingers and the strings under them back to us that it made us just sit in awe for a few long seconds after the piece had concluded and the standing ovation had subsided. He had performed the piece, yes, technically almost flawlessly at least to my ears,  but he had done so much more than that. In this first time back in the theater, masks on and making cumbersome attempts to still physically distance from those we did not know, we were treated to something magical. In this time when seven hundred thousand of us have died from COVID-19, one of us, one very talented, gifted, emotional, breathing, feeling one of us was willing to share something so profound that it left us gasping, and not because we could not breathe behind our KN95s. We felt appreciation for his talent. We felt gratitude for his presence. We felt love for the music. We felt awe.

 

In her September 29, 2021 Wall Street Journal article titled Ways to Find the Awe in Daily Life, Elizabeth Bernstein said that “awe is the “Wow!” emotion, that feeling we get when something is so vast it stops us in our tracks.” You remember it from the pre-pandemic times, don’t you? That feeling you get when you first hike in Arches National Park in Moab, Utah. The joy you feel every time you get up early enough to see a sun rise at the beach on a beautiful late summer day. The deep down satisfaction you get when you hear a piece of choral music written hundreds of years ago that speaks to the mysteries we still seek answers for in the twenty first century. All of these things and more can cause us to simply say “Wow!”. We have no other words.

 

According to Dacher Keltner, a professor of psychology at the University of California, Berkeley, awe experiences decrease stress and anxiety and increase positive emotions and overall satisfaction in life. They might even make us feel more compassionate towards others in our lives, less greedy and more supported, therefore more likely to help others. What a sorely needed concept in these trying times. Now, most of us, and I count myself here, tend to “associate awe” with something that is one of a kind, “rare and beautiful”, or so intense that it is seldom felt or heard or experienced, says Bernstein in her column. Of course, there is more. People can trigger awe, even those we are closest to and most familiar with, she says. David B Yaden, a research fellow at the Johns Hopkins University School of Medicine, says “you don’t need to go into orbit, or to a museum or a national park. It’s in your home.” Sorry, William Shatner. (I do hope you enjoy those few minutes of awesome weightlessness tomorrow though)

 

Awe can come as “a response to life’s big, sweeping changes”, says Bernstein, “but interpersonal awe happens in small moments, too.” We can’t really make others behave in ways that are awesome or call up awesome events at our whim, but we can prime ourselves to always be on the lookout for these things and people and events that bring this feeling forth in us. We can even boost the positive effects that come from the awe experience. How?

 

Bernstein suggests that we do several things but a couple of them stood out to me and I want to share them with you. First, name awe when you see it. Identify awe. Remember the experience, she says. Savor the moment. Tell others about it. This will both cement the feeling for you, and share it with others. Most importantly, thank the person who awed you. Whether it is an artist or musician or thespian or storyteller or cashier at your local grocery store, if you catch someone in the act of doing something that truly awes you, stops you in your tracks and makes you whisper “Wow!”, let them know what they just did. “People who practice gratitude have higher levels of happiness and psychological well being than those who don’t.”

 

Keep your eyes peeled this week. What will you experience that will be awesome? Who will you be able to thank for helping you to feel that way?

 

Hit Me

Hit Me

 

 

If you have ever gambled (and who among us has not gambled in some fashion, whether with dice, chips, cards, or love) then you know that feeling that you get when you hit twenty one, you roll sevens, or she says yes. It is unmatched. It is intense, pleasurable beyond anything else you’ve ever felt, and a feeling that by its very fleeting nature begs you to chase it again and again. So you do, and what happens? Inevitably, you lose. The cards are not there, the house wins, she moves on to someone else, and you are left poorer in pocketbook and spirit, and one more very important thing. Dopamine. Yes, your poor brain, once so full of brightness and light and possibilities, is now devoid of that thing that was making it feel invincible before. The neurotransmitter dopamine.

 

If you haven’t figured out from reading my column, and dozens of others, we are (still) in the middle of a worldwide pandemic, a gripping medical drama so intense that it sucks the pleasure out of our lives, takes the mundane and makes it unbearable, and strips us of our hopes, dreams, and reasons to strive for more. It is literally making us bad, mad and sad. It is leveling the daily playing field so much that we have a hard time finding joy in anything anymore, even the things that used to make us so very happy. So what do we do? Lots of things, of course, but in this day and age the one thing that binds us together is our collective use of technology, and the one piece of technology that all of us above the age of five seem to have in our fingers or our purses or the pockets of our jeans is the cell phone. The video phone. The smart phone. The gaming device. What Steve Jobs called as he unveiled that first iPhone  “a phone, an iPod, and an internet communicator”. I would venture to call these shiny, expensive gadgets that we love so much dopamine generators. “Are you getting it?”

 

We wake up and our hands instinctively reach for the bedside table, where our precious has been patiently charging overnight, readying itself for the hundreds or even thousands of times we will touch it throughout this new day. We will ask it about the weather this morning, use it to schedule our workday, order lunch on it, entertain ourselves with music in the afternoon, use it to search for mindfulness in the evening, and take in a Monday Night Football game to cap the day. We play games on it, tweet with it, send emails, take pictures, share pictures, manage our money and express our political views on it. We get instant feedback on what we say, how we say it and how it makes others feel. We are in search for the likes, the checks, the hearts. Why? Dopamine. Lots of little squirts of that lovely little chemical that makes us look up and say WOW, many many times per day.

 

In her August 14-15, 2021 article in the Wall Street Journal titled Digital Addictions are Drowning Us in Dopamine, psychiatrist Anna Lembke tells us that the brain likes to keep itself in a state of balance called homeostasis. This means that every time a little hit of dopamine comes along, the brain downregulates the receptors that recognize it, trying to restore balance in the Force. She says that “there is a natural tendency to counteract it by going back to the source of the pleasure for another dose”. Another tweet. Another email. Another like. Another heart. If we keep this up for weeks or months, she tells us, “the brain’s set point for pleasure changes. Now we need to keep playing games not to feel pleasure but just to feel normal.” If we decide to stop, what happens? We feel irritable, anxious, don’t sleep, get depressed and crave the activity that made us feel good. Addiction? Yes sir, you betcha. Hit me.

 

Dr. Lembke tells us that there is now a whole new class of electronic addictions that did not even exist twenty years ago, and they are primed to keep us coming back with their “flashing lights, celebratory sounds and likes to promise ever greater rewards just a click away”. Funny thing is, even though we all have ready access to these addictive devices and processes, “we are more miserable than ever before”. “Rates of depression, anxiety, physical pain and suicide are increasing all over the world, especially in rich nations.” It’s hard to take an objective look at all this when we are still “chasing the dragon”, as it were. Dr. Lembke says “It’s only after we’ve taken a break from our drug of choice that we’re able to se the true impact of our consumption on our lives.”

 

So, the answer to this whole dopamine dysregulation question might be to ease up on the addictive devices, games, social media and other aspects of modern life that are in fact making us less happy than we were ten years ago. Avoid high potency stimuli. Regulate how much time you spend in the presence of the little glass god. Dr. Lembke calls the smartphone “the equivalent of the hypodermic needle for a wired generation”. Ouch. Reducing phone time is hard, as it makes us feel deprived, irritable and cranky at first. “If we keep it up long enough, the benefits of a healthier dopamine balance are worth it. Our minds are less preoccupied with craving, we are more able to be present in the moment, and life’s little unexpected joys are rewarding again.

 

Sounds like a very good prescription for happiness. I’ll take it. Hit me.

 

 

Finally

I love to read about, think about, and practice new productivity methods. I am always on the lookout for that wonderful new notebook, calendar app, pen, pencil or gadget that will make me more efficient, help me get more work done, and help me to feel that I have reached a new goal or accomplished a big task. Do you ever feel like that? Do you search for that one thing that will help you get where you want to go? Better yet, in the time of COVID-19, do you ever wonder when you will get to the finish line, to the end of some project, or to the end of this new world that none of us likes that much anyway? Do you hope that, finally, this pandemic will be over, and we will be there, wherever there is?

 

Shawn Blanc writes about productivity and teaches some crazy good classes at his website thesweetsetup.com. Check it out if you have the time and the inclination. Now, he also sends out inspirational and instructive emails once or twice a week that drop a little knowledge, tell about a cool gadget, or offer some productivity hack that us mere mortals might find helpful. He sent an email out this week that hit me at exactly the right time in exactly the right way, and I thought I would share what I learned with you.

 

He started the email by telling the story of his journey to earn a black belt. The training was mentally, emotionally and physically exhausting. When he got to the testing day as one of twelve who were going through this rite of passage, he thought that finally earning the black belt would be the goal that all aspired to get to. After completing this and coming back to the studio just two days later to continue his training, he quickly realized that the black belt had been a goal but not the goal. He learned that when something in life is important, you don’t simply show up every day until something happens. You simply show up every day. As Shawn said in his email, life is lived in the day-to-day.

 

He made the point that there is a great deal of “satisfaction (to be gained) in the small daily wins and the joy of consistently choosing to do the the things that are meaningful, valuable and important.”  We all seem to think that if we strive for the huge goals and the big flashy wins that they will somehow come faster or easier. In fact, says Blanc, “if you’ve got a habit of showing up every day then I guarantee you that along the way you’ll pass milestones and accomplish big goals.”  Milestones are wonderful things, but once you reach them, “you get back to living your life”.

 

During this past eighteen months, we have all felt that if we could just get though to Easter, to the summer, past the holidays, to the next summer, or to the next fall, that somehow we would have arrived and everything would be okay and back to normal again. We are fooling ourselves. We may be looking at a normal that bears little resemblance to the one we had in 2019. Is that bad, tragic, depressing? No, it just is. If we are committed to showing up at work, for our kids, for our spouse, or for others just until the pandemic is over and we can go back to our own lives the way they were, we are going to miss a lot of nows, a lot of our life in the present that we are squandering while waiting for that elusive “normal” that may never return. If we are waiting for the until, the finally, we are destined to be disappointed.

 

“If you are doing something that matters”, says Shawn Blanc in his email, “ there will always be resistance. Distractions, excuses and challenges will always be right at your doorstep. Don’t wait for the fear to go away, because it won’t. Don’t wait for the risk to disappear, because there will always be risk.” He admonishes us to “show up every day when it’s frightful. When it’s risky. When it’s tense. When it hurts. Because it will always be that way. The finally moment never comes.”

What are you doing during this terribly stressful time? Caring for an elderly relative? Teaching your kids? Working two or even three jobs to make ends meet? Learning to spend more time with your spouse? Trying to figure out how to take better care of your own body, mind and soul? I hope that whatever it is that you are doing, that you are not just showing up until. When the pandemic is finally over, I hope you will see it not as the end but as the beginning of your new life, with all of the joys and challenges that time will bring.

So Much Is In The Doing

My wife and I both work in service industries. We both do a lot of listening. She is a flight attendant who travels all over the world, walking up and down the aisles of Boeing and Airbus airplanes at forty thousand feet, listening to stories and responding to requests. I am a psychiatrist who is usually found sitting behind a desk, tapping away on a laptop, listening to stories and responding to requests. We have have many conversations about how people interact with each other, how they talk, how they ask questions, how they respond to demands and rules, and especially how they function under stress. I know you have seen the various YouTube videos of enraged, unruly passengers who have attacked cabin crew members over issues of mask wearing or alcohol consumption or some such. My wife has never been on the receiving end of one of those attacks, thank goodness, but she is aware of the possibilities every time she signs in for a flight. I have been hit twice and lunged at several other times but never seriously injured while doing my job. We do realize, as I am sure you do, that the last eighteen months has brought out the best and the worst in all of us, and part of that is the lack of attention to the social graces and the simple interactions and courtesies that we once paid each other as a matter of course.

In her recent 8-14-21 article “COVID Anxiety and Fear of the Base”, Wall Street Journal columnist Peggy Noonan addressed some of this. Now, my own column is not political, so some of her writings in the beginning of her piece are beyond the scope of what I want to discuss with you. However, she does start out by stating that people now have mask fatigue and other associated side effects of living through the first serious global pandemic in a century, and that issues such as mask wearing are pushing people to pick a side. Moderation, which in my book went hand in hand with politeness and social grace and simple courtesy, has now become only “for the gutless and insincere”. My wife and I have both noticed, in our very different but very similar worlds, that moderation, patience, respect, and tact have all become signs of weakness. As Noonan put it in her piece, “nothing has been so damaged by the pandemic as what had remained of American tact”. We pick sides of an issue or an action, then demonize and vilify those with different opinions. Noonan suggests that we “make a decision, then encourage, persuade and and exemplify helpful behavior” to win over our fellows who may have opposing views. We all tend to talk and rage against one another, but she says that instead of emphasizing the verbosity, “so much is in the doing, especially in a crisis”. Why are we this way? We are tired. Very tired. We are irritable, and we are much less confident than we were even a year ago because we simply do not know what is coming at us next. We cannot predict the future of this pandemic, and that now makes us gun shy about predicting anything that has meaning in our lives.

Now all politics and divisions aside, the part of her column that I liked the most was the part where she asked, “What rules of the road might help us…….what general attributes?”

First, she challenged us to “regain a sense of give”. We should stop pushing each other around. We should strive to have a generous and sympathetic sense of who our fellow Americans are. Those people that you so vehemently disagree with? Have you ever thought, asks Noonan, that they might be thinking about things that had not even occurred to you? We should be patient. I am always looking for signposts in my own life and work. Two recent events assured me that patience was a virtue that I sorely needed to pay attention to. First when my seven year old granddaughter stayed with us for five days, we learned that operating on her schedule and living life with her level of energetic intensity requires planning, stamina, and yes, patience! The other was when a patient told me the story of living with an incurable and potentially fatal disease, while caring for an elderly relative with their own serious health issues, and how this had lead to a major upheaval in schedules, vigor, and enjoyment of life that was not as it used to be, but as it now was.

Second, Noonan challenges us to stop picking on each other. Does it help to ostracize others? To demean or fight or assault? No. Once again she asks us to empathize, teach, educate, and lead by example. Third, we should admit that there most likely reasons that people do not trust the experts. (This could hold for virologists, and psychiatrists and flight attendants too, I suppose!) If you are ever in a position where you are the designated expert, and believe me, almost anyone who reads my column is more than likely in that camp at some point, play it straight, says Noonan. If you don’t know, say you don’t know. (It took me years after I finished medical school to get comfortable with this very simple but extremely difficult act) Do you like your fellow Americans? Are they “other”, “imbeciles”, or dare I stray into the political quicksand and use the term “deplorables” to you? Or are we all Americans, with different ideas and beliefs and values, and through our differences, embody e pluribus unum? Noonan tells us that if we do not like and respect each other, no matter how hard we try to hide it, “nothing is more obvious than a lack of affection”.

Lastly, she says we must “adjust our sense of proportion”. Put quite succinctly, “COVID now is part of life; it’s not life.” There are so many pressing issues in the world right now, war and famine, and climate change and heart disease and cancer and poverty and mental illness and we focus just on this pandemic and lose sight of all the others at our own peril. We will be dealing with emotional stress of these times for the foreseeable future. Life is hard. Illness is hard. But as the WSJ column concluded, “Life has to be lived.”

Taking One for the Team

Simone Biles knew that something was wrong. She had pulled herself out of the team gymnastics competition at the Tokyo 2020 Olympic Games after she developed a case of the twisties. This condition severely impairs a gymnast’s ability to know their position in the air and relative to the ground, something that could lead to serious injury if not addressed. She also decided not to compete in some of the individual events in the days afterward, citing mental health issues. Rather that find herself lost in the air, unable to add to her team’s scoring and possibly injuring herself, she decided to withdraw. “I knew they could do the job.” She wanted her teammates to medal, and she saw herself as a stumbling block. In an interview, she said, “We aren’t just athletes or entertainment. We are humans too. We have emotions that we don’t tell you about. I felt embarrassed at first. You have to put your mental health first. It doesn’t matter if you are on the biggest stage.”

There was mixed response to this turn of events from around the world. Some mental health advocates were very supportive of Ms. Biles. Some of her peers, such as Michael Phelps and Naomi Osaka, called her to offer their support, in that they had also struggled with mental health issues that affected their performance at times. They applauded her decision to put self care first and to keep herself safe. Others, not very sympathetic to her struggles at all, said that she should have “taken one for the team” and pushed on to compete in all the Olympic gymnastic events.

“Taking one for the team” means willingly undertaking an unpleasant task or making a personal sacrifice for the collective benefit of one’s friends or colleagues. It derives from baseball in the 1970s, when a player was asked to take a pitch on the body to get to first base for the benefit of the team.

The path that Simone Biles chose was self care.

In an October 22, 2020 Harvard Business Review article titled “Serious Leaders Need Self Care Too”, Palena Neale PhD addressed this very issue. She asked questions such as “Why are so many leaders so resistant to taking a bit of time for themselves?” She found that “it usually boils down to misperception around what good leadership is, what self care is, and how self care actually works.” One thing that is often lost is that “self care is an investment that can increase overall productivity and effectiveness as a leader.” Ms. Biles had faced similar circumstances before in her career, and I am quite sure that she expected her competitive days to go forward as well, so getting past a temporary block in her overall journey just made sense for her at that time.

Diet, exercise and sleep are three components of a healthy life that we already know about. Then why is it so hard for most of us to eat right, exercise daily and sleep enough hours? One of the answers that Dr. Neale found was “I don’t have time for that!” The feeling of constant stress to manage a busy life, perform, always be on, and to juggle too many tasks is “sadly all too common.” “Taking breaks can prevent decision fatigue, renew motivation, increase creativity and improve learning.” Could Simone Biles have accomplished all of her key priorities, including tying Shannon Miller with seven Olympic medals after coming back to win bronze on the balance beam this year, without paying attention to her health and sense of wellbeing?

Another response found by Dr. Neale was that “leaders need to be strong. If I’m a good leader, I shouldn’t need self care.” This is simply incorrect. Leaders are often taught to not show any vulnerability. They feel that they should have all the answers. I think that many medical students and newly minted doctors feel that they know everything that is to be known when they finish their training. It is only later, when one has practiced in the real world for a time, that one realizes that learning never ends, and that the correct answers are constantly changing. Leaders sometimes feel that if they do not meet these criteria that no one will follow them at all.

How do we follow the example of Simone Biles and make self care a priority in our lives? According to Dr. Neale, we should integrate self care into our daily routine. Make it your own. Make time in your agenda for self care. Experiment with different things to keep it fresh. Share with others when you have found something that works for you that you think might benefit others. After all, Simone talked with Michael, Naomi and even Oprah! Your team will see these activities and actions and resolve and will follow you. Everyone wins.

What lessons can we take from the experience of Simone Biles in the 2020 Tokyo Olympics?

First, if you see that taking one for the team will lead to injury to you or disaster for the team, then stop and reevaluate. Biles stated in an interview that “it didn’t go like I wanted it to go, but it will open doors for bigger connections”. Pause for self care when you need it. Almost everything can wait. Model your decision making and share with others what worked for you. Encourage others to follow your lead.

Come back stronger and achieve even more because instead of taking one for the team, you decided to take some much needed time for yourself.

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.