Boredom

We have been in this pandemic for months that feel like years. Have you reread all the books from your childhood and college years? Have you put together every jigsaw puzzle from the storage closet under the stairs? Have you binge-watched every Netflix series that caught your fancy? If you have, then you have probably hit that emotional, physical and temporal wall that is boredom. I don’t have anything to do. I just want to go to sleep. Maybe I can find a snack in the kitchen. I should be cleaning or cooking or…
I think we’ve all felt it, experienced it, and dreaded it, but boredom is not something that is to be feared or even endured. I read a January 4, 2019 Time article by Jamie Ducharme recently called Being Bored Can Be Good For You-If You Do It Right. Here’s How. It made some good points and made me think more about how we can embrace boredom and even use it as a jumping off point for creativity and productivity if we just open ourselves up a bit.
Why is boredom, and the act of being bored every once in a while, so important? According to the Time article, boredom “is a search for neural stimulation that isn’t satisfied”. I believe that we sometimes panic when we have nothing to occupy our minds or stimulate us or provide novelty, but being bored pushes our own brains to create the novelty and stimulation from nothing. It forces us to be creative. I love to write, and some of my best ideas to explore have to come to me in such unlikely places as the hot shower on a cold morning, on a steamy trail walk by the river, or when sitting drowsily in the early summer sun in my front porch rocking chair. These down times can be a resting period, a respite from the daily grind that we sometimes do not realize we need. They can happen spontaneously. That being said, can one plan to be bored?
Absolutely. Now, I should say here, as did the author of the Time article, that one should not confuse boredom with relaxation. Acts that require concentration like yoga, meditation, or even putting together a puzzle, do not lead to boredom, even if they are relaxing. Boredom requires that one let the mind wander. No stimulation is necessary. Another crucial aspect of allowing yourself time to be bored is that you must unplug. Having a phone in your hand keeps you from ever reaching true boredom, while it paradoxically fails to truly entertain most of the time. What do I mean by this? Endless scrolling keeps our brains from working out their boredom and coming up with novel stimulation and creative thoughts. At the same time, the quality of entertainment we get from such unstructured time is nowhere near the quality of entertainment that we might get from diving into a good book with characters we truly care about and invest in.
Sandi Mann, a senior psychology lecturer at the University of Central Lancashire in the UK, says that we can become addicted to the tiny dopamine hits we get every time we pick up our devices. “Our tolerance for boredom just changes completely, and we need more and more to stop being bored.”
Planning for times that you will be bored may lead to increased creativity, new ideas to explore, and thoughtful reflection about the things that are important to you but that get pushed back by technology and busy schedules. Being bored may help you become more resilient. You may even find that this new creativity and idea generation gets you outside your own head and thinking about doing something that might benefit others. Read, doodle, listen to familiar music, doze in the sun, anything that will free your brain to be quiet, attentive and open to new things. You may be amazed at what you come up with.

Patience, Grasshopper

Another thing this pandemic has taught some of us? 

Patience.

We were all on hyperdrive seventy days ago. Work, church, school, lessons, clubs, dining out, vacations to schedule, family visits to make, shopping runs, gas fill ups, oil changes, clothes to buy.

Now, we’re not.

Working from home, some of us not working at all.

Not able to go to church, at least in the physical sense of the word. 

Kids homeschooled. All of them. All the time. 

No dining out, at least not in the same way it was just three months ago.

No unnecessary travel. 

Filling up with gas every two weeks, three, once a month?

Family visits by FaceTime. 

Nobody buying dress clothes anymore, as Zoom meetings require nothing more than shorts or sweatpants. 

Over the last few weeks, I have learned to be a little more patient. What has it gained me?

I have made friends with the most wonderful little fellow, a ruby throated hummingbird that loves the salvia by our front porch, in front of our rocking chairs. Before this week, I had never been as close as one foot to a hummingbird. Now, I have. 

I got up early and went into the kitchen to make coffee on one of those mornings that I didn’t really have to. I looked out the kitchen window and saw an Eastern box turtle under the bird feeder. He (she?) seemed to relish the coolness of the pine straw that had just been hit by the sprinklers minutes before. I watched the turtle walk off down the straw bed, a little faster than I thought he would! 

I have been able to watch at least two doves on the nest on the brick wall by our courtyard, sitting stock still over several weeks, never moving, always watching, never being startled by our comings and goings. 

The pandemic has changed our lives in many ways. If we let it, it can make us sad, disillusioned and irritable. If we practice a little patience, we may just see some things that we never even knew were there. 

Marking Time

Is it just me, or has time felt different in the last ten weeks? Do you feel that time has sped up, giving you a decreased ability to accomplish the things you need to get done, or does time feel slowed down to you, making each day feel longer and harder to fill with constructive tasks? Do your protracted days feel full of dead space that is buffered by countless hours of Netflix? I have been doing some thinking about time and schedules and orderliness and routine lately and thought I would share some of that with you this week.

Time is measured in several different ways by us and for us. First of all of course is our natural, biological circadian rhythm. According to the National Sleep Foundation at sleepfoundation.org, your circadian rhythm is basically a 24-hour internal clock that is running in the background of your brain and cycles between sleepiness and alertness at regular intervals. It’s also known as your sleep/wake cycle. A few important things about this cycle. It’s pretty regular, but it can be altered or disrupted if you are a night owl or a morning person, or if you are caught up on your sleep or sleep deprived. Light and dark tend to coincide with this cycle but shift work or other alterations in usual patterns of activity also can make things interesting. Lastly, your circadian rhythm may change as you age. You may not have the same sleep cycle as your partner, children or parents.

How has this affected all of us during this pandemic? We tend to get into a pattern that involves going to bed at about the same time every day, getting up at the same time (albeit prompted by that dreaded alarm that always goes off earlier then we like), having a relatively fixed commute time, and eating meals at the same time. We mark time during our days by these fixed events and behaviors and we can almost set our clocks (internal and external) by them. Now that many of us are working from home, or might have even lost our regular jobs, these temporal signposts have been disrupted. We might get up an hour later. We might have more time for lunch at home. We have a shorter commute, or no commute at all. Light and dark might not be the biological bookends that they were before, in that we get up and go to bed at different times that before the pandemic. Our internal clocks, our circadian rhythm, has been slightly altered just enough to make us feel odd, tired, irritable and out of sorts.

What about our self-imposed schedules, our calendars, alarms, reminders and other ways that we mark time during our days and nights that helps us make sense of our world and our place in it? These have always been the ways that we choose to structure our days. For example, my wife is a very analog person who has a calendar in the laundry room, another in her art room, several ongoing Post It note lists for groceries, phone calls and projects that live between the bathroom, bedroom, kitchen and art room. I choose to structure most of my life digitally, with a to do program called Things, a digital family calendar for our stuff and Outlook for work related time, and reminders that are pre-programmed for months and years to pop up and tell me what to do when it’s time to do it. Both of these methods of marking time work very well, depending on the person and their needs. Even in the time of this pandemic, these ways of controlling our day and the time allotted to various events and projects maintains a fair amount of integrity.

That being said, even these physical manifestations of our time have been altered by COVID-19. How? She is going to the store less. I am ordering things online as I always have loved to do but finding that I need fewer things now that I am home the majority of my time. Seeing and visiting our families has become an entry to FaceTime on the weekend to catch up. My routine management team meeting with my coworkers is now done on Skype for Business, instead of around a table. Church is at ten AM, but we now go there via Facebook Live. The events on our calendars are exactly the same, but the way the events happen is vastly different.

How about the big external ways that we mark time or have it marked for us? I’m thinking about birthdays, graduations, holidays, sports seasons and events, changes in the seasons, and other major delineations of time that we experience collectively and socially. What has happened to these during the pandemic? We know that we have not been able to travel to visit with parents, siblings, children and grandchildren. The joy of a hug and blowing out the candles on a birthday cake has been tempered by the possibility of being an asymptomatic carrier of the coronavirus and inadvertently infecting a loved one. Easter came and went with virtual celebrations, family Zoom calls and personal egg hunts. As I write this, a NASCAR race will be held at the speedway in Darlington, SC, but no spectators will fill the stands to watch it. Seniors are graduating without public fanfare. Baseball will play a shortened season starting in July, without fans. The celebration of summer will start as it always does on Memorial Day, but pools will not open and beaches may still be closed.

We count on our internal clocks, our personal calendars and the changing of seasons to guide our behaviors, set our moods and keep us connected as we celebrate the moments of our lives. We mourn the loss of these tangible ways to measure time. It is not the same today, and it may not be the same next week or next month or even next year. Will we get back to the security of a routine, a calendar filled with events and being able to celebrate life’s many milestones?

You can bet on it. Mark it on your calendar.

Certainty

“Have you ever heard a story like mine before?” she asked me, a pleading look on her face that both begged me to say no, making her special, and to say yes, alleviating her fear that she was so unique that there was no help for her.

“Why, yes, I have, many times,” I answered.

She slumped, her body releasing the tension of years of not knowing, of fearing the worst, of thinking that she was beyond help.

“Please, tell me. Tell me. What do I have? What is my diagnosis? What is wrong with me? I just want to know that someone knows what this is called, what my symptoms mean. I want to know. To be clear. To be certain.”

I told her what I thought, while at the same time telling her that not much in the field of mental health is absolutely certain. The brain is a fascinating organ, but when something goes wrong deep inside it, it may neither be as easily diagnosed as a fractured femur, nor as easily repaired.

Many of my patients come to me with anxiety, with fear, with uncertainty. They feel things, they experience things that frighten them and make them feel that their world is out of control. They are hesitant at first to uncover these feelings and thoughts and impulses and changes in mood and thought that they think will label them as crazy or weird or not normal. Can we blame them? Absolutely not. We all want to appear, to feel, and to be normal, at least in the eyes of our family, friends and peers. We crave normality. We crave the usual, the mundane, the predictable. Of things that can be known and explained, we crave certainty.

Now, these past few weeks have been different, wouldn’t you say? We are told to distance ourselves from our loved ones and coworkers. We communicate via FaceTime and Doxy.me and Zoom and Skype. We wear masks. We wash our hands many times per day. We look askance at the person approaching us in the aisle at the grocery store. We have developed an intimate relationship with Netflix. Some of us have lost our jobs, and with that has come a rise in anxiety, insomnia and fear that I have not seen in my patients for quite a long time. All of this is stressful enough, but it is bearable, at least for the short term.

Enter the lack of certainty.

Humans can bear almost anything for a finite period of time. Think of previous pandemics, the fall of empires, the great wars, and natural calamities. We have faced much, and we have survived much. We are able to bear the most painful hurts and atrocities, as long as we know there is an end in sight. As long as we know there is an end to the suffering, the pain and the uncertainty. This is one of the reasons that our current situation, battling the unseen enemy that is the coronavirus that causes the illness COVID-19, is so difficult for us to bear. We simply do not know exactly how and when this is all going to end.

We are told to get out but keep our distance. We are told to go to work. We are told to stay home. We are told that we can work in a modified way, then we are unceremoniously handed a pink slip or a furlough notice. We are told that we must  stay in our homes for six or eight weeks, then we are told that the churches will be gloriously full of people on Easter Sunday.

How do we respond to this? We are anxious. We are stressed. We do not sleep. We hoard things that we think might be in short supply soon. We obsess over how we will pay our bills, care for our children, and check on our elderly relatives. We get depressed. We lose hope, that most precious of commodities that fuels recovery from any disaster. We worry needlessly, because as one of the nation’s top scientists said, we do not make the timeline. The virus makes the timeline. What to do?

How can we protect ourselves? The key is to recognize that we cannot be certain about this virus, this illness or the resolution of this pandemic. Even the medical scientists who know everything there is to know about these things are not in agreement about how this will all play out. We must let that go. What we can be certain about is how we live out our own life in the middle of this event, choosing to be positive and proactive instead of responding to the growing reports of illness and death.

Sleep. Sleep enough and rise and go to bed at the same time each day if possible. Eat healthy foods. Do not overindulge. Exercise. Meditate. Read things other than the news. Journal. Create. Connect with friends and family in any acceptable, non-risky ways you can. We are social organisms, and we do not do well with long term isolation and emotional and physical deprivation. We just don’t. Learn new skills that help you navigate this crisis. Do not expect to do things the same way because “that’s the way it has always been done”. Keep an open mind, learn new techniques and skills, participate and be a part of life as it is today, not as it was three weeks ago.

This pandemic will pass. I don’t know exactly how or exactly when. I just know that I am certain about a few things right now. I can still see my patients from a home office that did not exist until last week. I can get outside and take a walk and eat lunch in the warm sunshine on my front porch. I will go to the river and fish this weekend. I will read and listen to music. I will connect with my family in technological ways that were only vague dreams when I was my grandchildren’s age. This is the life that I can lead right now, and I am going to embrace it with everything I have. Of that, I am certain.

I hope you choose to do the same in your life. Be well and stay safe.

COVIDISMS: Change

I don’t like change. Never have. Never will. That is, big change that impacts me in big ways for long periods of time. Little changes, maybe okay.

That being said, this COVID-19 crisis sucks.

As soon as we knew at work that this was a real disaster, that it would almost certainly affect us locally and all of our coworkers and patients, we began to plan and to act. Almost immediately, we began to scheme how to put at least six feet between us, how to open doors with door stops so that no one would have to repeatedly touch them to go in and out of the various hallways in our buildings. How to sanitize fixtures and other touchable surfaces multiple times each day to keep us safe. The physical cleaning and distancing and separations came almost naturally as a first step to keep us healthy and safe. I dealt with that okay. Wash my hands even more times than usual. Don’t cough or sneeze openly. Use Kleenex, handkerchief, sleeves. Don’t touch stuff and then touch your face. Got it.

Next came how to distance ourselves from each other while all working in the same building, and how to keep patients from coming in and out, potentially cutting down on exposures for all of us. Six feet of distance. No staff meetings. All info exchanged by email, text or other non personal ways. Screening tent set up outside, signs diverting folks coming to the property to that area for the now ubiquitous interrogatory. Injections given outside in the tent by scrubbed, bescarved, masked nursing staff. The first ever, to my knowledge, management team meeting at our place that was completely done by Skype for Business. Most of us were still in the same building, but we were not dropping by to stand in each other’s doorway to chat, we were not doing sidewalk consultations, and we were not having routine meetings in the mornings or any other time. This was a major departure from business as usual for mental health types, who are used to presenting cases, asking questions, getting feedback and working in a team model.

The next step, pressure from the governor’s office to work from home. Not just a few of us. All of us, or as many as practically possible. This meant rapidly, and I mean in a matter of days, prepping everyone to pull up stakes, take everything needed home, learn to connect with a laptop, cell phone or tablet and access all the tools that we use to do our jobs every day, but in a completely different setting with completely different hardware. In addition to that, to speak with patients by video chat or phone (video encouraged) instead of face to face. This changed in less than a week. Hard to describe in words how monumental this is for many of us, who have sat face to face with patients for decades, looking for clues from odors, mannerisms, movements, gait, speech, expressions and other ways of assessing people and their behavioral problems. Suddenly, our world jumped online. Almost totally.

There are still a few of us literally in the building. I am still doing my Telepsychiatry emergency room work at the office since I have all of my technological rig in place there to do high quality video, etc. I am not set up to do that from home. I do, however, have a new laptop that is about halfway set up to do everything I need to do to run my clinic job from home, bolstered by video access that I can get with my MacBook or iPad. I have about sixty patients scheduled for the clinic this week, so I am not sure where the time is going to come from to make these major changes in workflow while work is flowing, but it will come to pass somehow. Soon, I may be asking for permission to share my wife’s art room studio space for a makeshift office in the corner for me, my Dell, my Mac, my iPad, my iPhone and my virtual patients. Major. Major. Major. Change.

Are there changes outside work? Are you kidding me? As I settled in to do my Telepsych shift in the EDs this morning, I got a FaceTime request from my daughter in Denver. Did not have to think twice about answering it immediately. There was my granddaughter, with a smoothie popsicle breakfast in her little hands. She has been in the habit lately, according to her mother, of calling someone that she wants to check on. Today, she wanted to call her Papa. Well, melt me and wipe me up with a Quicker Picker Upper. This is radical. This is heartbreaking. This is fabulous. This makes me laugh hysterically and sob at the same time.

So. Much. Change.

Such a short time to take it all in.

Has this changed my relationship with my wife? Not fundamentally, not in the least. She is my rock, my confidant, my support when I need it most. I try to be hers and return the favor. So are we both stressed? Absolutely. I work in health care. She works in the airline industry. Enough said. Might one of us be exposed to this little particle and infect the other? Of course. Might we get sick? We’re both over sixty. Yep. Might we have to quarantine? Yep. Can she work from home? Nope. We are okay, but we have had conversations. We will have more.

How am I dealing with all of these fundamental and profound changes?

On the negative side, by obsessing way too much (I do that anyway, on a good day!), by updating, organizing, re-reading, trying to concentrate, trying to stay focused on the task at hand and actually finish it in a timely way.

On the positive side? Listening to music, lots of music, uplifting music. Listening to podcasts. Writing. Journaling. Sleeping when I can. Eating good food. Connecting with family by email text, FaceTime and phone calls. Trying my best to be supportive of my friends and my staff at work. Getting advice and help and guidance when I need it. (I still need it.) Making time for my marriage and my relationship with my wife. Noticing that it is indeed a beautiful springtime outside and marveling at the beautiful colorful flowers in our courtyard, my Japanese maple that has miraculously resurrected itself from the winter doldrums to sprout dozens of delicate red feathery leaves, and the azaleas that are shouting at us, “Look! Look! We are gorgeous! It’s spring!” Watching the doves who sit patiently on their nests at the top of the courtyard’s brick wall under a marvelous cascade of tiny yellow roses. Sitting, blinking, soft and beautiful brown-gray and wondering what all the hullabaloo is about.

I do not like change.

I do not like it in my house.

I do not like it for my spouse.

I do not like it at my work.

Out of my routine I am jerked.

I do not like this viral spread.

I do not like the many dead.

I wonder when it all will end.

I wonder if our paths will bend?

I wonder if we all will learn

That viruses our worries spurn.

They set their own trajectory

And care not one small whit for me.

How has your life changed in the last two weeks? How is it likely to change this next month? How will you cope and stay happy and healthy and productive until this pandemic ends?

Stay safe, isolate, wash your hands and we’ll get through this together.

Music Notes and Covidisms

Music is always a good thing, no matter the mood. If I am down, sad, angry, irritable or just flat, music can be the background that either confirms my emotional state or lifts me out of it.

I was pleased to open the music app on my phone yesterday to see that Apple had gifted me with a new curated music list called Get Up! I usually like to play my Favorites Mix, the Chill Mix and sometimes get wild and crazy and listen to the New Music Mix. The Get Up! Mix was especially welcome in light of all the stress I have been feeling in at work this past week. From the opening bars of Drivin’ With Your Eyes Closed by Don Henley (one of my favorite artists) to Elton’s John’s Sleeping With the Past to You Might Think by The Cars, I was immediately transported to a better, more mellow place.

Whether Dan Fogelberg is riffing on democracy or Chicago is making me smile, this music is a throwback and an anchor to times before middle age, viruses and crazy politics. I find myself singing along, tapping my feet, humming, and just letting a tiny bit of the stress flow out of me and back to wherever stress goes when it leaves us.

Like the bands tell me, If my Paper(is)late and I am stressing over deadlines, music can Take It Away. A look to the Western Skyline does Open Soul Surgery on me and, like Tom Petty (may God rest his soul) I Feel A Whole Lot Better. Amen.

What does COVID-19 do to you, even if you’re not infected? Well, from my chair at work, it makes me anxious, it has tripled my workload and it leaves me wondering when this will all end. Any good things, positive things it has done? Yes.

I am concentrating on communicating my needs and the needs of my staff and patients more succinctly. No time for mincing words these days. Formulate the thought, get it out. On to the next thing. It has made me appreciate touching base with my peers. A lot of decisions and plans can be made in a very short amount of time in a crisis situation. I knew this from having worked hurricanes and other natural disasters, but this is different. It is affecting everything from staffing to leave time to employee health to childcare to scheduling to clinic procedures to supervision to patient care to technology to time management. Boom. In a matter of days, the way we did things is no longer the way we DO things. You have to keep up. It’s exhilarating, excruciating and exhausting.

I have had more direct contact with my family members by phone and FaceTime in the last few weeks then in the last year. I checked on my uncle last evening after hearing from my mother that he had sustained an injury in a fall. He sounded the same to me on the phone. A little mischief and humor in his voice, an even tempered assessment of the world, a positive take on what had happened to him and how he was going to deal with it. It made me smile just to hear his voice. Why had I not called him sooner? There is no reason; there is no excuse. Just a loss of routine connection that a tiny virulent particle has prompted a course correction for.

Thanks to Tom Petty for giving me the right thing to say to you, Coronavirus.

I’ll feel a whole lot better when you’re gone.

Productive Anxiety

Mind Matters

Monday, March 23, 2020

Productive Anxiety

“I can’t quite explain what it is,” I told my wife a few days ago. Seems like weeks ago, actually.

“I agree,” she replied. “I can’t put my finger on it either, but something is not quite right.”

We were having what now seems like the first of dozens of conversations about the latest threat to our stability and wellbeing. Of course I am talking about the coronavirus scare that we have all been grappling with over the last few months. The threats posed by COVID-19 have inserted themselves into our vernacular, our school systems, our places of worship, our nursing facilities and our workplaces. We have read newspapers, listened to television reports, made toilet paper and canned goods runs on Costco, and washed our hands more in the last few weeks than ever before. What is it about this latest threat that makes us so uneasy?

Things that we do not fully understand make us anxious. I hear about anxiety virtually every working day from my patients but this is different. None of us know what to expect. Someone told me last week that this is like knowing that the tsunami is coming but not knowing how big it will be and how much damage it will do. All of us, patients and families and caregivers and healthcare providers alike, get anxious about this kind of threat. This is a novel virus. Most of us do not like novelty, change, things that are different and are likely to disrupt our routines. We fight against things that we can see, touch, or manipulate. This is different. This is an invisible threat that will not kill most of us, or even make many of us really sick, but may potentially sicken or kill the most vulnerable among us if we do not act now, and decisively so. This kind of anxiety is normal. Let me repeat that. This kind of anxiety is normal. It helps to make us more attentive, more attuned to the things around us that will help us not only survive, but prosper and move forward. Anxiety can be a catalyst for positive change. It is both a warning and an energizer. It slows us down but propels us to action at the same time.

Now, what happens if we do not stay abreast of the science and the rational warnings being offered by those who know how best to do this, but fall prey to rumors, speculation and frenzy? If that happens, our normal, adaptive, productive anxiety turns to fear. If we touch anything we will get sick. If we do not wear a mask we will breathe in something horrible. If we do not buy up everything in sight, we will run out of something vital. Anxiety turns to fear, which can lead to further speculation which leads to more false information being internalized which leads to more fear and on and on. As you might surmise, this is not adaptive, positive or productive. It makes us circle the wagons, cuts us off from sources of legitimate information, and erodes trust. Anxiety can be motivating. Fear can be paralyzing.

Some of my patients describe going up one more rung of this anxiety ladder, all the way up to panic. If fear is paralyzing, panic is even more isolating and disruptive. Rational attempts to socially distance oneself from large crowds or potentially infected people becomes absolute isolation. Panic makes you feel the most anxious and out of control you have every felt. You feel, literally, as if you might die. Your heart races, your pulse quickens, your palms are sweaty and you feel that you must run out of the room immediately. Panic keeps you from taking in new information, even if it is rational and useful, makes it hard to concentrate and keeps you from making good decisions for yourself or those in your care.

Panicked is not where we need to be at this time of crisis. Afraid is not where we want to be. Anxiety? Now, that is another thing. If I told you I had not been anxious about how COVID-19 was going to affect me, my practice seeing patients in a busy mental health center, my eighty four year old mother or my six grandchildren and their families, I would be lying to you. Of course it makes me anxious. That drives me to seek out good, useful information, make good, safe decisions and take care of myself and those under my care the best way I know how.

How can you keep yourself in a state of productive anxiety, not fear or panic?

Connect with others, but in a healthy way.  Write letters, text and make actual phone calls to those you want to check on. FaceTime with family. Skype with business associates. You do not have to weather these kinds of stresses alone. We are truly all in this together and we are stronger when we support each other through the stressful times.

Educate yourself. Know the facts about COVID-19 and issues related to it. It is very true that knowledge is power, and from my perspective, it is a pretty darn good treatment for anxiety as well. Check out cdc.gov and scdhec.gov for timely and ongoing updates on the state of the virus outbreak and related topics.

Know yourself. Do you have underlying health issues that put you at risk? Are you over age sixty? Do you need to be careful with routine exposure to crowds, avoid sick people, or avoid going out at all unless absolutely necessary? Do you have support from family, friends or neighbors who can run errands or accomplish tasks for you that might be too risky for you right now?

Reframe any mandatory time away from school, church, work or social contacts as time for you. Read. Paint. Put together a puzzle. Take a nap. Watch comedies. We are all guilty of being too busy and never taking enough time for ourselves to just be still, meditate or relax. This is the time to retrain ourselves and understand just how important that time is.

Wash your hands often, use hand sanitizer if you need to in between scrubbings, avoid shaking hands and practice good respiratory hygiene.

Remember, anxiety can be a productive, adaptive, healthy response to stress.

F5s

F5
Incredible tornado.
261-318 mph.
Strong frame houses lifted off foundations and carried considerable distances to disintegrate; automobile sized missiles fly through the air in excess of 100 meters; trees debarked; steel reinforced concrete structures badly damaged.

tornadoproject.com

 

We had a strong storm front come through the southeastern United States last week. Of course, this was not the first time this happened, and it will certainly not be the last. It was fascinating to watch it march inexorably across the country, showing up on my weather app as a ragged green diagonal slash from Gulf to heartland to northeast, moving slowly and relentlessly across the landscape. In the center of the ragged slash was a well defined hard bright yellow-orange-red line of destruction. Pretty on the screen, destructive on the ground. Destroyer of worlds.

Texts began to trickle in from my daughter, who lives in Spartanburg, of an apparent tornado that touched down not five miles from her house and destroyed a shopping center. A coworker who sees patients at the mental health center by telehealth connection also reported frightening noises that drove her to her basement to hunker down until all warnings were lifted later in the day. Both reported the loud, surreal wail of tornado warning sirens, something that I have never heard in real life, but that I am sure must be quite distressing in the midst of gray skies, howling winds,  pouring rain and lightning flashes. Not an F-5, but terrifying nonetheless.

When I hear about such stressful situations and see evidence of the destruction they bring,  I think of my friends, family, acquaintances and patients have who struggled with cancer, financial stress, persecution for various reasons, and other stresses that lead to anxiety, fear and emotional upheaval. My aunt who succumbed to ovarian cancer when I was a boy. My mother, who is a breast cancer survivor. My friend, who tragically committed suicide. My patients, who tell me stories of unbelievable trauma, neglect, abuse and hopelessness. Like an F-5 monster tornado, these life circumstances can drop on any of us unexpectedly from the sky. Pretty colored X-rays and scans reveal the destructive power of the cancer underneath. Sirens go off. The mind screams take cover, take cover! The body sometimes is only grazed, shrapnel cutting but not killing. Other times, the impact is devastating. Nothing looks as it did before the storm. The landscape is flattened and only rubble is left. We return to a place, time or set of circumstances that we expect to be familiar, only to realize that all of our old landmarks are gone, destroyed. We do not know whether to drop to our knees and cry, run headlong into the pile of rubble, or turn and walk away.

Is there anything good about F-5s, cancer, abuse, trauma, and destruction?  What an odd question, I hear you asking me.

These scourges, while leaving city blocks, body parts, and psyches in absolute ruin, are often coldly surgical in their devastation. That is, a few hundred yards away, or a few inches outside the margins, or in some other part of the emotional us, the sun is shining, the tissue is healthy, the coping is reasonably good and life goes on. Friends rush to help. Prayers go up. Communities, wonderful , supportive, dynamic communities form. Support is not only offered but insisted upon. Rebuilding begins immediately in the aftermath of the siren’s wail, the surgeon’s knife, and the abuser’s fist.

When the horror and the shock and the denial and the anger and the tears and all of it subsides, victims become empowered survivors.

Strong!

The chorus goes up.

We will rebuild.

Life will go on.

We’re still here.

The Doctor Is In. Sometimes.

I grew up in a small mill village in northwest Georgia. When things did not go right, someone got sick, or we had an accident, or we needed a sports physical, we would head around the circle to the entrance to the mill complex, just across the grassy field from my house, and see Dr. Harry Dawson. Dr. Dawson was that old omnipresent breed of physician who had a small self-contained office, seemed to me to always be there anytime he was needed, and could treat anything. He got kids through the measles, mumps, chickenpox, broken arms, flu, the common cold and of course that time I dropped the hammer on my brother’s head when we were climbing the tree in the back yard. It was an accident, I swear. He’s fine, thanks.

There are a few Dr. Dawsons left nowadays, but not that many. Same goes for psychiatrists. It is getting harder and harder to simply think, I want to go see my psychiatrist, call for an appointment and actually get one in less than a few weeks if not a few months. There are a few good reasons for this. According to a February 25, 2018 Forbes article Psychiatrist Shortage Escalates as US Mental Health Needs Grow, there are twenty-eight thousand psychiatrists practicing in the US, but three out of five of them are age fifty-five or older. (Here’s looking at me, kid.) As we face more and more angst, shootings and the escalation of completed suicides, the number of psychiatrists who actually see patients face to face and deal with crises individually in their practices, modern-day Dr. Dawsons, are very hard to find. My patients tell me all the time that they don’t want to come in to see a counselor, a nurse, a social worker, but that they want to see their doctor. I understand this, but as you shall soon see, what I and many of my colleagues are doing in 2020 is far different than what we trained to do in the seventies and eighties. If you need mental health care nowadays, you may see any one of a dozen people who are part of a treatment team of health care providers. Your doctor may be in, at least physically, but he or she may not be available to see you personally.

My workflow, and that of my colleagues, has changed dramatically over the last thirty years.

While in medical school and residency training, my schedule of activities was pretty much set for me. I had simply to show up at the appointed time and place and work and learn. Training, classes, meetings, patients, all were set by a scheduler or training director. I had very little input. There was little autonomy during training.

Flash forward to early practice in the late nineteen eighties, when I was a junior faculty member of the Department of Psychiatry and Health Behavior at the Medical College of Georgia. I was an attending physician at the state hospital, in charge of residents barely younger than me, attended faculty meetings, and had a practice life that was still fairly regimented. I still spent a lot of my time working directly with people, around people, talking with people. Psychiatry at that stage of my life was still a people profession, driven by conversations, interactions and face to face meetings.

Go forward still to private practice, which I did for about five years. There were personal interactions with my staff and my patients in the office all day long, visits to inpatients in the hospital, and consults sent for patients on the medical and surgery floors. I was still doing most all of my clinical work myself, making my own decisions, and deciding how often to see patients.

Next came work at the mental health center that started as a part time job in 1991 and then became my primary job in 1993. I loved it, and I have never looked back. Oh, I have done work in crisis units and I have now been doing telepsychiatry for ten years, but my primary mental health center duties are still my most loved ones. The funny thing is, with time, my duties to see patients one to one in the clinic have taken a back seat to myriad other duties, especially since I have been serving as medical director of our center. Individual work (“I want to go see my doctor!”) has morphed into leading a team of other mental health professionals, and even more recently serving as a co-provider in these groups, not even officially leading them anymore. Now in 2020, I supervise a medical staff of thirteen other people, the most we have ever had in my time at mental health. Oddly, though in the past we had as many as five or six psychiatrists working at the center, there are only two of us among these fourteen staff now. I have many very talented advanced practice nurses, nurses, administrative staff and part time, locum tenens and other providers who have helped us take care of patients over the last decade or more.

The thing that I noticed when engaged in a conversation with some of our senior staff last week is that now I do not simply see a limited and finite number of patients, as many as today’s schedule will allow. I do much more indirect and direct supervision, answering dozens of emails each day, talking in real time on Skype, and otherwise making decisions for patients who I am not seeing directly, at least most of the time. I am relying on the eyes, ears and assessment skills of the medical staff as they multiply my ability to hear your stories, assess your symptoms and come up with a reasonable treatment plan that will help you recover. This is both sad and exciting for me. I miss the days of seeing one patient after another, my patient coming in to see their doctor, that most pure of doctor-patient relationships. However, this new paradigm of care allows me to have a much broader reach and treat more people than I ever could alone. That is good. When you need to come in for treatment of mental illness, you may not see the doctor initially, but you will be seen by someone on the team that the doctor is intimately connected with.

What does the future hold? Telepsychiatry is making inroads in hospitals, prisons, jails, schools and even patients’ homes. Mobile crisis teams go out into the community and meet patients where they are, giving care at that point, not relying on visits to a clinic. Traveling RVs staffed with teams of providers scour the backroads for people who need help. More and more, care is becoming collaborative, as mental health workers are embedded with law enforcement and medical clinics, and medical providers set up shop in mental health facilities. Psychiatrists are learning that they can teach, supervise and function very well as part of a larger team, reaching far more souls than they could ever do in their simple solo practices.

I think Dr. Dawson would be proud.

A Milieu of Unfriendliness?

As we had our all agency meeting at work the other day, involving mental health employees from all three of our sites and from all types of job descriptions, I was struck by something that come up as we discussed issues of cultural diversity. We had had a good presentation on diversity and how it was germane to the people that we serve everyday. Then, a few folks made observations that made me understand immediately that they felt misunderstood, unappreciated, and unacknowledged in the positive ways that they obviously felt were important.

How could that be, I thought? I started working for the local mental health center in Aiken part time in 1991 and came on full time in 1993 for the specific reasons that I loved the patients, the clinical environment, and most of all the people that I worked with. I have stayed at the center for almost twenty nine years for those same reasons. Now, I know that we are not perfect, but I do get the sense that the folks I see and work with every day are basically good people, caring people and people who care about my wellbeing as well as their own. For the most part, we cooperate, we commiserate, we collaborate and we celebrate, all important parts of being on a team that pulls in the same direction for positive changes and outcomes. I was a bit saddened to hear that some of my coworkers do not seem to feel respected, genuinely valued or appropriately acknowledged.

How did we get from 1991 to 2020 and this angst? I have a few ideas about what might have changed.

We work in a culture of fear-driven productivity at the expense of much else. Being a part of the management team as medical director, I understand this from a purely operational viewpoint, in that we must do a certain amount of business, bill a certain amount, collect a certain amount of money and constantly push for provision of appropriate services to keep our doors open. Otherwise, we would not be much good or be able to provide services to anyone at all. I get that. But it does seem to me that a lot of our staff feel pressured by the numbers, the spreadsheets and the bottom line, regardless of the emotional toll that this pressure takes on them daily. In this twenty first century world, we have perfected the art of cranking out widgets, but we have sometimes lost our drive to connect in meaningful ways with each other in the bargain.

As a corollary to that, the time that we spend with each other, WITH each other, is minimal.  I have noted, as have others, that sometimes we can pass each other in the hallways and not even acknowledge the other with a smile or a kind word of greeting. Now, there are some of us who are excellent at that kind of connection, bright rays of sunshine in an otherwise clinical gray haze, but I’m afraid many of  us, myself included, can easily fall short at times. We need to connect emotionally and model that behavior that we often try to teach our patients about.

I began to think, we have lots of folks working here, lots of people like me and not like me, with different values and priorities and hopes and dreams and ways to act and dress and walk and talk and interact with others. We preach acknowledging these differences, even elevating and celebrating them in our patients, but are we failing to do the same with those who work in the offices next to us? Based on what I heard at our meeting, I’m afraid that might be the case.

Are we fostering a workplace culture of exclusion? A milieu of unfriendliness?

There is enough stress in the world right now to go around, and then some. There are social, cultural, political and class stresses that make us wonder how we will ever get through some days. In spite of those stresses, we do get through each day.

We need to be consciously  aware at home, at work, at play, wherever we are, that there are those who feel marginalized, unappreciated, unloved, unseen and disconnected.

We must start somewhere.

Smile. Acknowledge. Say hello. Check in. Look up. Make eye contact. Tear down the wall that surrounds the milieu of unfriendliness and build your own bridge to a culture of appreciation and hope.

It starts with me, and with you.