So Much Is In The Doing

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

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

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

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

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

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

Taking One for the Team

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

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

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

The path that Simone Biles chose was self care.

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

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

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

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

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

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

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

Mercy

“Woah, ah, mercy, mercy me

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reentry

Reentry

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Happy reentry!

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.

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.