All Shook Up

Oh, well my hand is shaky and my knees are weak

I can’t seem to stand on my own two feet.

Who do you thank when you have such luck

I’m in love, I’m all shook up.

All Shook Up, by Elvis Presley

One year ago, it was still very common for us to walk up to a friend or business associate, put out our right hand in a gesture of friendship, grasp their hand, and pump it a few times enthusiastically. This handshake, though not the way everyone greets others around the world, is one of the most common ways of doing so worldwide.

What is the origin of the handshake? Wikipedia tells us that as early as the 5th century BCE in Greece, handshakes were seen as symbols of peace, and most importantly showed that the parties doing the greeting were not carrying any weapons. The Romans took the lowly handshake a step further grasping the entire forearm, once again to look for hidden knives or other weapons. The knights of medieval Europe did the same thing, shaking the hand and arm of challengers vigorously to loosen anything deadly. Another word for handshake is dexiosis, if you’re into Scrabble. Another bit of trivia for you. Stephen Potter of St. Albans shook 19,550 hands at the St. Albans Carnival in August 1987, breaking the world record. As the famed Guinness Book retired that particular category, the record has since been broken, but Potter holds the European record.

What did a handshake mean to us in the days before March 2020, the pre-pandemic times? I don’t think we were often looking for weapons when we greeted a friend with a good fist pump, but we certainly wanted to convey closeness, warmth, sincerity and greeting. You normally shake hands with someone you trust, or at least can respect. (Remember all those celebrated Middle East peace accords, with two opposing leaders shaking hands on a podium, a beaming United States President standing in the middle?) Handshakes can seal a deal, signify a completed contract, and show that it is okay to move closer. Unfortunately, these days we are doing fewer in person deals, and we have very little reason to want to get within arm’s reach of anyone that has a different last name than we do. Handshakes help us meet and greet, say goodbye, congratulate, and express our gratitude.

Are there other ways to do all those things that do not involve grasping hands? Of course. Again, Wikipedia tells us that The New Zealand Maori touch noses, and Ethiopian men touch shoulders. In the Congo friends touch foreheads. In Asian countries, bowing is an acceptable form of greeting though they will shake hands with Americans and others if they think that is expected.

Why might this be important now, in 2021? Handshakes spread germs. Cold germs. Flu germs. Coronavirus germs. With the 2009 H1N1 flu pandemic, as well as with the pandemic we are now living through, alternative ways of greeting one another have been strongly encouraged. Elbow bumps, head nods, bows, and fist bumps can all be seen across the land. Having traveled to Japan and also having seen how South Korea and other Asian countries approach this dilemma, I am partial to their solutions. Wash your hands, wear a mask anytime you are outside in the public, stay several feet apart, and bow to greet one another. Safe, easy, respectful and not conducive to viral spread. Why do you think that many of us have adopted the elbow bump over other methods of saying hello? Because we crave human contact. We crave touch. We are hardwired that way. This last year has been so very stressful in so very many ways, not the least of which is its toll on our emotional and physical connections with each other, individually and within our social institutions.

Is there a post-pandemic future for the handshake? Some, like Dr. Anthony Fauci, said early on in the pandemic last year that he thought maybe we should never shake hands ever again. I’m not sure how realistic that will turn out to be. However, I know that when the all clear is given, there will be smiling, laughing, tears, hugs and kisses, and I don’t see how a few handshakes can be far behind. In the meantime, think like a Roman or a Medieval knight, assume there are deadly weapons in that outstretched hand, and bow instead.

(Un) Comfortably Numb

“Hello? Is anybody in there?”

“I have become comfortably numb.”

Pink Floyd

We are being bombarded with numbers. Numbingly numerous numbers. Allow me to share some familiar, and maybe not so familiar ones with you.

When I first wrote this piece, there had been one hundred ten million, thirteen thousand eight hundred forty-one cases of COVID-19 across the world. Global deaths were two million, four hundred thirty-two thousand six hundred ninety-five. In the United States, we had twenty-seven million, eight hundred twenty-eight thousand one hundred fifty of these cases, and four hundred ninety thousand, seven hundred eighteen deaths. Of course, the numbers have only grown since that time.

The monster winter storm that engulfed the United States from Texas to the northeast resulted in four million without power in Texas alone, and forty deaths across the land. By Thursday of that week, FEMA had already distributed seven hundred twenty-nine thousand liters of water, fifty thousand cotton blankets and two hundred twenty-five thousand meals.

During the COVID-19 pandemic, forty one percent of adults surveyed in January 2021 had some degree of anxiety and depression, up from 11 per cent in January through June of 2019. Thirty six percent of those questioned related poor sleep, and thirty-two had appetite changes. Up to fifty-six per cent of young adults ages 18-24 had been battling depression and anxiety.

Did you see how I wrote all these numbers out in words? Why? Because it takes you longer to read out each word, to really process what the sheer numbers mean, than if you see another in a long string of mind-blowingly large figures. The numbers do not lie. We see them, day after day after day, but my fear is that we are becoming more and more (un) comfortably numb to them.

It is easy to develop compassion fatigue in times like these. There is so much hurt and fear and pain and need and stress in our world right now that it is easy for us to develop emotional numbness to these massive threats to our daily way of life. Compassion fatigue is that indifference to charitable appeals on behalf of those who are suffering, experienced as a result of the frequency or number of such appeals. It comes in no small part from actually absorbing into ourselves the trauma and emotional stress of others, leading to a vicarious pain and discomfort that become a secondary trauma to the caregiver or helper.

How does it manifest? Physical and emotional exhaustion, depersonalization, irritability (raising my hand here), self-contempt, decreased sleep, weight loss (or gain in some), and headaches are just a few of the signs and symptoms you might find yourself experiencing during these very troubled times.

How might it affect your ability to function at your best daily? You might be trying harder but find yourself helping less. You might give up, feeling that the stresses in the world are so huge right now that there is nothing one person can do. You might find yourself coping by using alcohol, drugs, or food to self soothe. Small, nagging physical symptoms might worsen into actual illness.

How do you decrease emotional numbness?

Reconnect with the world, with your world. Find a way to reach out and connect locally, nationally or internationally as you feel might be most helpful.

Practice good self-care. This is not the time to back off good pandemic hygiene, good patterns of eating and sleeping, or your usual exercise routine. It is time to double down on these things that make us healthy and keep us happy. I have recently started meditating, having never done it and knowing absolutely nothing about it. I have been amazed at how a brief ten-to-twenty-minute meditation practice session can put me back in the game. Learn something new. I recently listened to a chapter in Dr. Sanjay Gupta’s book Keep Sharp that talked about learning a new language or something equally as challenging. I was heartened to hear him say that it is not impossible to learn these difficult new things as we age, though it might take a little longer than when we were younger. Give yourself the grace to try, to do, and to succeed. We are making history just by surviving in this one-hundred-year pandemic!

Take time with family and friends when you can do so safely and practically. We need social interaction, as discussed here before. We just need to realize that continued vigilance is necessary until we can see the true end of the pandemic approaching.

Write in a journal. As you know if you have been reading my columns and blog posts for long, I love to write. I write in small notebooks, large notebooks, software programs, on Post-It notes, and on the back of envelopes. Our thoughts jotted down on paper or converted to ones and zeros in an app somewhere will be the primary sources for someone who one day writes the definitive history of this pandemic. Think about that and contribute.

I’ve borrowed from Mother Teresa before, and I will do it again to close these thoughts for the week.

“We cannot all do great things. But we can do small things with great love.”

Pandemic Pitfalls

I read a good article on the physical effects of the coronavirus pandemic on our physical health recently. Yes, the Pandemic Is Ruining Your Body was written by Amanda Mull and published on January 14, 2021 in the Atlantic. In it, she addressed many of the ways that living in the middle of the worst worldwide health crisis in a century affect us as human beings who are struggling to be brave, squash fear, stay productive, and thrive, all without the help of our usual social institutions and personal interactions.

She acknowledges that for some of us, myself included, sitting at home virtually all the time, even when working hard, is a situation of relative comfort and incredible luck. We have jobs that allow us to use computers, faxes, cell phones, scanners, email, and videoconferencing to meet, greet, schmooze and therapize to our hearts’ content, just not in person. But at what cost? She says that in her own experience of working from home, she began to experience decreased hip mobility, low grade headaches, sore shoulders, a stiff neck, and dry skin. At first, she and her ailments felt isolated, because she was isolated. She could not see that her coworkers were doing the same things, stretching the same tired muscles and “gobbling up ibuprofen” as she was. Many have been sickened or even died from COVID-19. Those who have avoided those fates, says Mull,  are living through an extended disaster that at the least is painful, but at its worst can be catastrophic.

What are doctors and others seeing? Aches and pains come up for seemingly no reason and then stick around. People who work from home found themselves setting up what they thought would be a temporary home workstation that they might need to use for a few weeks at best, a few months at worst. I did this myself. Over the last year, as pandemic reality set in, I have changed my equipment configuration, furniture and workflow more times than I can even remember. Sitting in front of a too short table, shoulders hunched, laptop screen too low, keyboard at the wrong height, and normal implements not easily reached, makes work tough. This, as Mull says, “all while sitting in a chair meant to support a human for the duration of a meal, not a workday”.

We are also working longer hours. How can that be, I asked myself after I read this in multiple articles for the fifth or sixth time. If you must get up, get ready, drive to your workplace and then leave at a prescribed time once you are done, there is an eight or nine hour rhythm to your day. If you subtract some of the prep time and all of the commute time, you find yourself (and again, I can attest to this) working an extra hour or even two. As I wrote this, I finished a “normal” ten hour workday that was jam packed with patients, emails, consults, and reviews. It simply feels that work has been busier, more packed with tasks and with much less down time or break time then pre-pandemic. Let’s be honest. Everyone feels just a little twinge of guilt when they work from home. And Mull says, “expectations of productivity have increased” because you are there. Granted, some may be able to outfit a spare bedroom or home office with nicer and more usable equipment, but “for those living in cramped housing with kids who go to Zoom school and other family members who also need space to work, building a personal mini office simply isn’t an option”.

Does any of this bleed over into our emotional wellbeing and ability to cope with the social and mental stresses that this pandemic has caused? Of course it does. In the past year, many months of which I have worked predominantly at home, there has not been a workday that goes by without me hearing about folks who are anxious and can’t sleep. Not a single day. Much like Amanda Mull discussed in her article about the physical stresses that can lead to physical problems, I have seen the psychological toll that the coronavirus has had on our normal psychological and emotional worlds. While staying home, we have lost out physical connection to others. There is no chatter around the coffee pot or in the parking lot before or after work. We have been forced to use different “equipment” to connect with each other. As my rector opined at a recent annual church business meeting, “Well, Zoom gets the job done I guess, but it’s not the same, is it?” Screens are now our “windows on the soul”. Why? Because any time we are face to face with most people we know outside our immediate family, we are wearing masks. Unless you are extremely close to someone, it is hard to read real emotion from just raised eyebrows or crinkling crows feet. Why is this important?

Because stress, anxiety, depression, loneliness, and hopelessness kill. They are not dangerous in themselves just for the misery they cause, and the potential for catastrophic consequences like suicide. As Mull states in her article, depression and anxiety “are enormous risk factors for heart problems, especially among people over 50. Quarantine itself is also a risk factor. Loneliness and social isolation increase the risk of myocardial infarction and stroke by up to 30 per cent”.

What can you do now, today? Connect with others, however you can, however awkward. Call. Zoom. FaceTime. Text. Reach out to the elderly who have little social support. Spend some non-screen time with a child. Cook dinner, and then leave part of it in a basket for the neighbors next door. I know I keep saying this, but it’s true. This pandemic will end. We will get through this together. We just need to make sure that we come out of this ordeal as physically and mentally healthy as we possibly can.

What Kind of Stress?

Over the last pandemic year, I have heard countless stories of people who have lost their jobs, had to move, lost a loved one to COVID-19, or just felt that their entire world had been upended by the restrictions and lockdown that this time in the world has foisted on all of us. These folks are invariably stressed, sometimes to their breaking points. They are not functioning well. They are irritable and depressed and anxious. They can’t eat and they barely sleep. They have little desire to do anything and have lost the joy they used to feel for almost everything. They come to see me, tell me their stories, and then tell me what they think the problem is and what I need to treat them for.

“I have PTSD,” they tell me, sure that this is the diagnosis that this pandemic has saddled them with, and equally sure that a medication or two will fix things and get them on the fast road to recovery and mental health again. But wait, is it really PTSD, or is that simply the diagnosis that most people know is associated with trauma, therefore must be the one they are suffering from?

I would like to talk to you this week about two kinds of stress reactions that are very easily confused. Most of the information that I am about to share with you can be found in UpToDate, a medical resource that pulls together the latest research and knowledge on a wide variety of topics and illnesses.

The first disorder is ASD, or Acute Stress Disorder. ASD is an acute stress reaction that occurs within one month of the traumatic event that causes it. Prevalence for this disorder is between 5-20%. What kinds of trauma can lead to ASD? Thirteen per cent of those who have severe motor vehicle accidents will have it, as will 16% of assault victims and, most horribly notable for all of us over the last month or two, 33% of those who witness mass shootings. Risk factors for developing ASD include being female, having various pre-existing mental health or physical illnesses, having a history of a previous trauma, and being exposed to a more severe trauma in the first place. The trauma experienced by someone may lead to a very transient reaction and no ASD, with a very swift return to normal. On the other hand, it may lead to ASD, then within a month also return to normal, pre-trauma life. One group, however, may go on to develop PTSD, or Post Traumatic Stress Disorder. As we shall see shortly, these folks may suffer long term effects that are life changing.

What are the symptoms of ASD? Re-experiencing the traumatic event is common, as is anxiety. Nightmares and vivid dreams may affect sleep. Recurring thoughts and increasing feelings of fear may arise. There is sometimes hypervigilance guarding against further threats. One might avoid people, places or things that remind of the trauma, and emotional numbing with flat features sets in. Dissociation from others, isolation and social avoidance complete the picture of someone who is feeling terrible but has an extremely hard time communicating this or sharing it with others, even those they are the closest to.

The good news? Most people who experience traumatic events of various kinds will have a brief period of symptoms and adjustment, and then will adapt and go back to their previous level of functioning within days to weeks. In some studies, it has been shown that 40-80% of people with ASD will go on to develop PTSD. The bright side of that is of course that almost half will not.

How is the diagnosis of ASD made? Quite simply, one must have several necessary symptoms. The first is exposure to the trauma, either directly, as a witness, or being told of the danger or injury to a loved one, for example. Intrusive symptoms can include dreams, memories and flashbacks. Mood becomes negative. There may be dissociative episodes. Avoidance tries to prevent recurrent trauma. Finally, arousal leads to decreased sleep, irritability, and an increased startle reflex. ASD may begin immediately after a trauma, but is usually best diagnosed three days or more afterwards.

What about PTSD? How is it different? It is diagnosed after four weeks of symptoms following the traumatic event. Two of the most likely types of events to lead to PTSD include sexual trauma at 33% (which may include childhood sexual abuse, rape, or domestic violence) and interpersonal traumatic 30% (which might include the death of your spouse or the serious illness of a child). Lifetime prevalence of PTSD may be as high as 6-9%. In one sample of 5692 adults in the United States, 83% had been exposed to severe traumatic events, but only 8.3% had developed lifetime symptoms of PTSD. Some very specific groups like native Americans and refugees from other countries with endemic abuse and stress are at higher risk for PTSD. Gender, age, educational level, history of previous abuse and poor social support may also lead to a higher risk of developing PTSD. Women are four times more likely to suffer from PTSD than men. A higher severity of symptoms at one month seems to be predictive of more serious PTSD symptoms at six months and onward.

Diagnosis of PTSD is similar to ASD, in that exposure to a traumatic event is necessary, intrusive symptoms such as re-experiencing and flashbacks are often present, and avoidance is present. Depression, decreased interest in activities, guilt, and disconnection from others are often seen. People feel on edge, reckless and irritable, and they tend to engage in risky behavior or make poor decisions. There may more serious depersonalization or derealization, or even amnesia for parts of the traumatic event.

PTSD tends to be a chronic disorder in many. One third recover at one year follow up, but another one third might still have symptoms ten years after the trauma. Some studies have shown that those with PTSD have poor social supports, increasing disability and inability to complete higher educational goals,

Now, what does all of this mean for the dozens if not hundreds of patients who have told me that they have “PTSD” because they feel traumatized and anxious due to pandemic? The very good news is that the vast majority of us will have initial anxiety when traumatized in this way, but most of us will recover in a very short time. We anticipate getting back to our pre-COVID lives one day, and we very much look forward to that. Those who go on to develop more serious anxiety symptoms and the other associated symptoms of PTSD should of course seek treatment as needed for what can turn into a chronic and debilitating illness.

Peekaboo, the ER Sees You!

Peekaboo, I see you!

Any of you who have children have played this game over and over with your young ones. At a certain age, they love to pull a blanket over their heads, or better yet, to have you hide behind that same blanket, and then squeal with joy when you emerge. It’s always as if you went far, far away and then miraculously returned to be with them again, much to their delight. The repetitive interaction teaches your child that you are always there, that if you appear to be gone that you will return and that you are a constant in their lives. They learn that you are there for them, and that you will keep them safe.

In mental health, we try to see and evaluate children in many contexts. We see them for who they are in a family unit, in their school environment, with their friends and in other social settings. In pre-COVID-19 times, we might have seen a child in the office, with input by a therapist, nurse and child psychiatrist. We might have had a school based therapist see the child in his or her natural environment in the classroom, the lunchroom, or the playground. We most likely would have wanted to get collateral information from other family members, several teachers, court systems, pediatricians, probation officers, or anyone else who might know something about that particular child and their presenting problem.

Since the pandemic began and lockdowns of various types began to be commonplace last spring, a lot of this normal information gathering has been curtailed. Clinics are closed and onsite, face to face interaction with mental health professionals is severely curtailed. School based therapists have been deprived of their most fertile diagnostic and therapeutic ground, the school itself, because so many children have been placed in virtual learning environments, often from home. If mental health providers cannot see the kids, they cannot do an adequate assessment and provide timely treatment. The result is the very real possibility that more depression, academic failure, physical, mental, or sexual abuse or neglect may be happening but never seen. Where do children and their parents turn when care is needed, but normal avenues of assistance are cut off?

The CDC tells us in their Morbidity and Mortality Weekly Report (MMWR) for the week of November 13, 2020, that emergency departments are often the first point of care for children’s mental health emergencies. As a community telepsychiatrist who has seen folks in the emergency rooms of South Carolina for the last ten years, I can attest to the truth of that statement. An interesting point here: during the first few months of the pandemic last spring, ER visits for all sorts of problems for adults and children actually went down, not up, at least at first. Why? Everyone was so afraid that they would contract COVID-19 at the ER that they stayed away, even if they had legitimate emergency health issues that needed to be attended to right away. Starting in April 2020, the CDC tells us, the proportion of children’s mental health related visits among all pediatric ER visits increased and remained high through October. Compared with 2019, the proportion of mental health related visits for children aged 5-11 and 12-17 years increased 24% and 31%, respectively.

We know that the coronavirus pandemic has had a negative effect on the mental health of children. If other services as outlined above are not available, children end up in ERs. These resources are invaluable when the going gets tough and there is no other option, but by virtue of their very nature, rapid assessment and evaluation of the sickest among us and triage to admission or discharge to further outpatient assessment, it is impossible for ER staffs to do a really thorough assessment of a child with serious mental health needs, even with telemedicine and other services there to assist.

Monitoring indicators of children’s mental health, the CDC tells us, promoting coping and resilience, and expanding access to services to support children’s mental health are absolutely critical during the COVID-19 pandemic. With the launch of vaccinations and continued use of masks, handwashing and physical distancing, we will get through this pandemic and back to some semblance of normal. In the meantime, we must not let even one child who needs us slip through the cracks and suffer from mental illness that can be assessed, diagnosed and treated.

Peekaboo, we see you.

Diamonds in the Rough

According to the Smithsonian Magazine, diamonds are formed deep within the earth, about one hundred miles down in the upper mantle. As you might imagine, it is quite hot in that part of the planet, and there is a tremendous amount of pressure bearing down in that location. The brutal combination of pressure and heat is what it takes to form diamond crystals. Now, we can’t actually travel there or even adequately sample the earth at that depth, so how did the diamonds that we mine today get brought to the surface? The Smithsonian tells us that huge, violent volcanic eruptions, like none we have seen in our lifetimes, carried the newly formed diamonds upwards in channels that made cooled lava formations called Kimberlites, and that these conduits ran at twenty to thirty miles per hour. Why is that important? Because if they had transported the diamonds any more slowly to the earth’s surface, once they got here and the eruption cooled, all that would have been left was lumps of graphite. The diamonds had to be rushed from the fiery pits of hell to the coolness of the surface rapidly, and the changes that they endured created some of the loveliest crystals that man has ever seen. Formation may have taken forever, but transformation, ah, that happened very quickly. By moving quickly, these diamonds got locked into their crystalline structure, and there was simply not enough energy available at their destination to ever turn them back into graphite. Diamonds are made of carbon atoms that bind to each other extremely strongly, each carbon atom joined to four others. Once they have made the turn and become the diamonds that we know, there is no turning back.

I have heard many stories over the last ten months. I have heard the lamentations of those who feel downtrodden, alone, forgotten, with moods as dull gray as the graphite one hundred miles below the surface of the earth. I have heard the stories of the white-hot heat of grief as a loved one is lost to COVID-19 or another illness. I have heard the stories of the volcanic eruption that occurs with the loss of a job, the loss of income, the loss of a home. I have listened as someone describes the tectonic shift of being displaced, turned out, evicted, down sized. I have heard and witnessed the rapidity with which one can be faced with the loss of a business that took decades to grow. The people of our planet have been forced to deal with rapid, forceful, painful, monumental change in the short space of ten months. Ten months. We did not even know exactly what COVID-19 was this time last year.

Like diamonds, the most marginalized and ostracized and forgotten among us have been thrust upwards on a hot wave of change that threatens, if it goes on too slowly and too long, to reduce us to nothing but gray ash. The upside of the pandemic? We have been forced to change the way we see our world, our work and our worth as we think outside the box, learning to be teachers, learning to conduct meetings online, learning to find new income streams by learning new skills. We have been forced to change so rapidly that we have found new bonds, strong bonds, that no virus can break. We have been transformed into shining examples of resiliency. We have lived and loved and mentored and supported each other.

Some of you may even now think of yourselves as gray, sad, and worthless. No. As you have been carried along by this 2020 volcanic wave of change, you have been made stronger than you think. Those four bonds, six bonds, a dozen bonds that you have nurtured this past year have transformed you into something bright, shining and capable of surviving anything that COVID can throw at you. Use those bonds. Be strong for yourself and for those around you. Polish yourself any way you can so that when this ends, and it will end, you will no longer be a diamond in the rough. You will be clear eyed, look toward the future and know that you have survived the fastest and most challenging medical threat in a hundred years, and that you have emerged with a clarity that nothing can ever take away again.

It’s a Pandemic Life

I have had more than one patient tell me that although they have no specific plans to kill
themselves, they sometimes just wish that they had never been born. They are so depressed
and hopeless and have so little regard for themselves that they feel that anyone who lives with
them or loves them would be much better off without them. In this time of the coronavirus
pandemic, these feelings have been intensified. Losses mount for some. Loved ones grow ill and
die. Jobs disappear, and with them the ability to pay for food, clothing, rent and even gifts for
the children at Christmas. Think of it. The people who count on you for their very lives and
support are the ones who you think might be better off if you had never existed. Ironically, it is
the strong attachment to those people, especially young children, that often saves us from
ourselves and pulls us back from the brink of an irreversible act of self-destruction.
Have you seen the movie It’s a Wonderful Life? I highly recommend this 1946 film starring
Jimmy Stewart and Donna Reed. George Bailey, played by Stewart, has spent his whole life
giving of himself to the people of his hometown, Bedford Falls. On Christmas Eve, George’s
Uncle Billy loses an $8000 deposit from the Building and Loan that George runs, which is found
by the town’s villain, Mr. Potter. When Potter hides the money, George is in very real danger of
being arrested for bank fraud if an examiner discovers that the money is missing. Thinking that
his wife, his young children and others who love him will be better off without him, he
contemplates suicide. After crashing his car into a tree, he walks to a bridge and is planning to
throw himself off. The prayers of all those people reach heaven and an angel named Clarence is
sent to earth to help George, promised that he will earn his wings if he is successful. Clarence is
able to show George what the world would have been like if he indeed never had existed, and it
opens his eyes. He is able to see all the blessings that are his, the people who care for him and
the fact that love and togetherness and a mutual respect for each other can conquer any
problem.
No doubt, there are many people who are hurting this holiday season. There are those who
cannot take care of their families, who do not have a job, and who feel that life would be better
for those they love if they had never been born. Like George Bailey, they may be thinking of
suicide. But also like George, many of these people may have a Clarence just begging to help
show them that they matter. We sometimes feel that we can do little to change the course of
history or the arc of misery that the world seems to be on. Think about this holiday season and
how you can play the part of Clarence, Angel Second Class, for someone you love. Can you tell a
story and share a memory of a good deed done? Can you offer a smile? Can you send a note
thanking them for the influence they had on your life? Can you drop off a meal or Christmas
cookies or a small bag of toys for the children at the front door? Can you give a card and more
of those cookies to the postman who brings your mail every day?
Especially in this time of pandemic, in this holy season, it is important to count our blessings
and use our time and talents to help those who need it most. Who knows, if you are successful
in making the holidays bright for just one desperate person, you might just earn your wings.

Empathy

I have always tried to understand what my patients are feeling. Why are they depressed? Why are they anxious or afraid? What keeps them from getting out in the world and working or traveling or visiting with families or going to church? It is very hard to put yourself into someone else’s body or mind, or to walk a mile in their shoes, but the practice of mental health treatment almost demands this thing called empathy. Since March of this year, our mental health center has been sorely tested, forced to rearrange schedules, send people home to work, see patients for injections outside under a tent in the open air, and really think outside the box to continue to provide socially distanced, medically safe, efficacious treatment to those who suffer from mental illness in Aiken and Barnwell counties.

So what is empathy? The ability to understand and share the feelings of another. I alluded to the first part of the definition in the first paragraph, but did you catch the second part? To share the feelings of another. Now, I would argue that understanding and sharing the feelings of someone who is hurt, ashamed, fearful, depressed, angry, or suicidal would normally, at least in my field, be a voluntary action. It would be something that I would choose to do, as I care about my patients and what they are feeling and want to figure out how best to help. I would go so far as to set up regular appointments, ask questions, learn about family history and listen to the hopes and dreams of the person, all in the service of understanding and trying to feel just a little of what they feel.

The coronavirus pandemic has forced us all into an involuntary state of misery. The CDC tells us that stress during an infectious disease outbreak can sometimes cause the following:

  • Fear and worry about your own health and the health of your loved ones, your financial situation or job, or loss of support services you rely on.
  • Changes in sleep or eating patterns.
  • Difficulty sleeping or concentrating.
  • Worsening of chronic health problems.
  • Worsening of mental health conditions.
  • Increased use of tobacco, alcohol, or other substances.  

We stay isolated from each other, but we try our best to connect through Zoom, Teams, FaceTime, and Skype. We communicate in real time but we cannot hug or touch or shake hands. We work together as teams, but do so virtually, knowing each other only from the neck up. It is very hard to be empathic if you sit in a locked office, maybe somewhere out of state, talking to a person who is hurting as they walk around their back yard swinging an iPhone that gives you an intermittent view of first their face, then the ground, then the sky.

One would think that this pandemic era would be extremely hard on anyone with preexisting mental health issues, and as plenty of evidence has shown, you would be right. However, I was amazed to learn something new from one of my patients a few weeks ago that made me rethink how empathic I had really been over the last few months. I had asked him how the pandemic had affected his life and if he was more depressed or upset because of it.

“No, Doc, not at all. And you want to know why?”

I did.

“Because now everyone else knows how I feel every single day.”

You see, this man had felt loneliness, social isolation, anxiety about being in close proximity to crowds in stores, fear about getting ill or dying, worry about being able to find and hold a job and pay his bills, lack of transportation, and most of all, the stigma that is associated with an illness that is completely out of his control. He had been living with these very difficult issues for many years. We had just been dealing with them for a few months at most.

“You know, Doc, staying at home, playing with my dog, playing a game on my phone, watching TV, listening to music, it’s not so bad really. It relaxes me.”

Profound words from one of the folks who teach me more than any expensive textbook I ever bought. We have all been forced by the coronavirus to feel what some of our most vulnerable feel and live with every day. We have experienced the social isolation. We are anxious about our health, or jobs, keeping our homes and putting food on our tables. Maybe one positive effect of this pandemic is that we will learn to be just a little more empathic towards our fellows, knowing that only in staying together even as we are apart is the only way we will survive this.

Masks

Masks are the talk of the town lately, are they not? To wear them or not to wear them. Cotton or synthetic. Single layer or multilayer. Inserts or not. Mainstream or rebellious. Republican or Democrat. Individualistic or conformist. Surgical or fashionable. How did a little piece of fabric with ear loops rise to the level of cultural totem for the various groups that see it as medical savior or condemn it as heresy in 2020?

According to Wikipedia, a mask is an object normally worn on the face that may be used for protection, disguise, performance or entertainment. Masks have been used for various purposes since antiquity. The word “mask” appeared in English in the 1530s, from the middle French masque “covering to hide or guard the face”. How have masks been used throughout history? Well, there are funeral masks, life masks, death masks, ceremonial masks, performance masks, ritual masks, religious masks, healing masks, and political masks. Masks may be used in festivals, carnivals, burials, plays, and stories.

Now, all of these are similar, but they differ a bit from the functional masks that have as their purpose the protection of the wearer. We are a bit more familiar with these in the year 2020. There are oxygen masks, surgical masks (including the N95 that has been in the news off and on since March of this year), face shields, and even pocket masks that can be used by a good Samaritan who happens upon someone who needs CPR. Protective masks filter the outside air in some fashion to make it safe for the breather. Other functional masks might include the kind worn by robbers and thieves to keep their identity safe from their victims or security cameras that might capture them as they go about their dastardly deeds. Plague doctors in Europe wore beaked masks that contained herbs in the beak to attempt to ward off the Black Death.

Do you get the point here? Masks have been around for literally thousands of years and have served every purpose from identifying the wearer to hiding his identity to celebrating his life to commemorating his death to punishing him to keeping him healthy. According to Stephen E. Nash writing in Sapiens Anthropology Magazine, the earliest well documented masks came from the arid Judean Desert in the Middle East about 9000 years ago. They may not have been the earliest ones, but they were certainly among the earliest preserved ones. Masks have been important cultural phenomena for thousands of years.

How about the medical aspect of mask wearing, which confronts us now in 2020? A bit of history is informative here as well. A July 27, 2020 piece in The Conversation said that during the 1918 flu pandemic, cities around the world passed mandatory masking orders. In the United States, the American public at that time embraced mask wearing as “an emblem of public spiritedness and discipline”. Mask wearing was widely unpopular in Canada during that time, but was embraced by the public in Japan. To the Japanese, mask wearing symbolized “modernity”. The Japanese continued to wear masks to protect themselves from the flu, and later against SARS and avian influenza. In a country that takes etiquette very seriously, wearing masks has become a form of politeness. Controversies over mask wearing continue in the United States and other countries as well as the coronavirus pandemic rages on. To some, masks represent control, are uncomfortable, unnecessary, and possibly even harmful to their own health. To others, seeing people wearing masks is a tangible reminder that the pandemic is real, and is frightening to them. Some have an “optimism bias” and believe that the coronavirus will not affect them.

The latest advice from the CDC and other groups maintains that the Three W’s (watch your distance, wash your hands and wear a mask when not able to social distance) are still the best way that individuals can protect themselves and others from infection with coronavirus.  Masks have been around for millennia, and they still appear to be one of the easiest and best ways to protect ourselves as we navigate this pandemic. Educate yourself, practice good social hygiene and stay safe out there.

Fake It Until You Make It

I have been talking with friends, family members, and patients over the last several months about our lives in 2020. We continue to try to describe what it feels like for each of us to live in the middle of the biggest pandemic in the last hundred years. We talk about the things that we have all been feeling: the sense of loss, grief over the changes in our normal lives, the lack of social interactions with others, the inability to participate in things that used to give us joy, and the lack of certainty that pervades every aspect of our lives. We talk about how these stressors have changed the way we work, play and interact with others. We talk of the longing for things to get back to the normal, the predictable, and the reassuring. Almost everyone I know feels less confident, less powerful and less able to influence his environment since the start of this pandemic. We have been shrinking into ourselves, staying at home more and shunning the very social interactions that make us fully human.

There is a phrase that I am sure you’ve heard before. Fake it until you make it. This idea probably goes back to at least Alfred Adler in the 1920s. According to Wikipedia, Adler developed a therapeutic technique that he called “acting as if”, which allowed his clients to practice alternative behaviors that would help them to change dysfunctional patterns. You may know this technique by its more modern name still used today, “role play”.  Fake it until you make it leads us to imitate confidence, competence and a positive optimistic mindset until we can actually achieve these things in our real lives.

Wikipedia offers another way to look at this, attributed to William James:

“Action seems to follow feeling, but really action and feeling go together; and by regulating the action, which is under the more direct control of the will, we can indirectly regulate the feeling, which is not.

Thus the sovereign voluntary path to cheerfulness, if our spontaneous cheerfulness be lost, is to sit up cheerfully, to look round cheerfully, and to act and speak as if cheerfulness were already there. If such conduct does not make you soon feel cheerful, nothing else on that occasion can. So to feel brave, act as if we were brave, use all our will to that end, and a courage-fit will very likely replace the fit of fear.”

— William James, “The Gospel of Relaxation”, On Vital Reserves (1922)

Another place that I have recently found reference to this ability to fake it until we make it is in the 2016 TED talk given by Amy Cuddy. In it, she describes how body language visually telegraphs our mood and state of confidence, and how our nonvisuals impact not only those around us, but ourselves as well.

One of her main points in her talk is that we can fake it until we become it, until we can tell ourselves, “I’m really doing this!” Tiny tweaks in our behaviors can lead to big changes in our lives.

We are living in very stressful times. We are dealing on a daily basis with social upheaval, political unrest and the possibility that we might contract a deadly illness. Even without being told, we have felt ourselves shrink from daily encounters with others, decrease our normal social interactions, and forfeit many activities that give us joy. We may not feel overtly afraid, depressed and defeated, but our body language and our actions may telegraph otherwise, both to others and to ourselves.

Can we fake it until we all make it? Yes, I believe we can. Listen to and act on the recommendations by the CDC. Wash your hands. Wear a mask when you leave your home. Observe social distancing recommendations. Be smart about how and when you interact with others both indoors and out. This pandemic is fueled by the spread of a tiny virus that will stop spreading when it is deprived of new hosts. Our behaviors, coupled with the eventual development of viable, effective, safe and reliable vaccines that we all choose to receive, will stop it in its tracks, and this medical nightmare will finally be history. Until then, even if you feel deprived, depressed and distanced from the people and things that make life worth living, fake it until you make it.