Project ECHO COVID-19
GLOBAL LEARNING COLLABORATIVE
Managing Stress and Burnout during the COVID-19 Pandemic
Monday, November 30, 2020
This series has been created with the generous philanthropic support of the
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Project ECHO COVID-19
GLOBAL LEARNING COLLABORATIVE
Jeff Katzman, MD Professor, University of New Mexico, School of Medicine, Department of Psychiatry
Resilience and Self-Care During the Pandemic and Beyond
Helping ourselves, Peers, Families and Learners
DISCLOSURES
No financial disclosures or conflicts of interest in this presentation
Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.
- Victor Frankl
Common Psychological Responses to Pandemic
DIRECT EXPERIENCE• Exhaustion• Acute Stress Response• Sadness and Grief• Worry• Isolation• Anger/Moral Injury
Pandemic Responses - Responders
• Adjustment Disorder
• PTSD
• Major Depression
• Anxiety Disorders
• Substance Use Disorders
• Brief Reactive Psychosis
• Family Issues
Pandemic Responses
• Compassion Fatigue
• Burnout
• Caution Fatigue
• Complex Grief
Stress Response
• Continued repetition of event in mind with or without reminders, nightmares
• Irritability, hypervigilance, insomnia
• Avoidance of reminders, shut down emotional experiences
• Using potentially harmful strategies to cope (substance use, isolation)
Common Psychological Responses to Pandemic
SHIFT IN LIFESTYLE• Guilt• Detachment and Isolation• Lack of Meaning• Loneliness• Lack of Connection and Spontaneity• Fear
Alexithymia
• Alexithymia • Difficulty identifying feelings in themselves
• Difficulty identifying feelings in others
• Generally externally focused
• Lacking internal fantasy life
Alexithymia
• 21 percent of outpatient clinic of 1500 patients met criteria using Toronto Alexithymia Scale (TAS-20) (Leweke, et al.)
• Prevalence in general population approximately ten percent (Salminen, 1999)
• Risk factor: depression, anxiety, eating disorders, psychosomatic disorders, substance use, hypertension, diabetes mellitus, psoriasis, immune-mediated pathologies, functional digestive disorders (Meza-Concha, 2017)
COVID-19 and detachment
• 3000 Italians during the COVID-19 pandemic, Mazza et.al showed that detachment, among other variables, was a major risk factor for the development of mental health problems (Mazza,2020)
• In a study of 234 Pakistani medical students forced to quarantine as a result of the COVID-19 pandemic, 44 percent described a sense of being “emotionally detached from family, friends, and fellow students”. Twenty-three percent also felt disheartened, and most showed a decrease in overall work performance (Meo, 2020)
• In a study of students and their families in Albania, rates of depression were quite high as a result of quarantine (Mechili, 2020)
The Need to Belong
• Cacciopo and Baumeister
“Loneliness has been associated with objective social isolation, depression, introversion, or poor social skills. However, studies have shown these characterizations are incorrect, and that loneliness is a unique condition in which an individual perceives himself or herself to be socially isolated when among other people.” - John Cacioppo
• Associated with development of heart disease, diabetes, worsening dementia –parallels smoking 15 cigarettes/day (Vivek Murthy, Together: The Healing Power of Human Connection in a Sometimes Lonely World.)
Loneliness and Isolation
• Isolation potentially helpful – need time to be alone to various degrees
• Loneliness may be understood as internal signal to connect inherited through earliest of human lifestyles
• Involves activation of sympathetic system as connected potentially to danger
• If chronic, can result in multiple health care issues
• State of loneliness leads to sense that something is wrong with us, focus on the self, and limits ability to reach out to others- becomes a difficult cycle
• This can lead to state of withdrawal, depression
Circles of Connections
• Inner Circle: Close Friends and Confidantes – Intimate Loneliness
• Middle Circle: Occasional Companions – Relational Loneliness
• Outer Circle: Colleagues and Acquaintances – Collective Loneliness
-Murthy, Vivek, Together: The Healing Power of Human Connection in a Sometimes Lonely World Harper Wave Publishing, 2020.
Meaning and Demoralization
Life meaning altered for many
Job stresses, changes, family relationships, prior passions
Victor Frankl
Stresses on trainees
• Financial pressures in the family• Some directly involved with pandemic, some at home• Balancing life roles – perhaps kids at home• Shift in understanding various residency programs, how they operate, decreased
exposure for medical students• Asked to do difficult tasks out of wheelhouse• Lack of cohort effect• Potential stigma as a health care provider
Building Resilience
• Take all recommended precautions• Structure the Day• Exercise• Diet• Nature and Water• Relaxation – Grounding/Mindfulness, Breathing• Relationships – Opportunities to go well and not so well• Hopelessness and Meaning
Building Resilience
• Calm and transparent conversations – watch yourself
• Honor genuine emotions and find people to validate
• Limit the news
• Limit and separate work hours
• Projects and hobbies if they are helpful
• Find your space
• Identify passivity, fatigue and do something
Building Resilience
• Make a Plan• What will I do if I get virus
• What will I do if family member gets virus
• What if….
• Turn to the plan rather than to the fear
Managing Acute Anxiety
• Alternate nostril breathing involves breathing in and out of one nostril at a time while holding the other nostril closed.
• Alternate mouth/nose breathing
• 4-7-8 Breathing
• Presence – Name 5 things you see, 5 things you hear, 5 sensations of awareness
• Mindfulness meditation encourages focused breathing while guiding your attention to the present moment.
• Visualization focuses your mind on the path and pattern of your natural breathing.
• Guided imagery encourages you to focus on a memory or story that is a resource
• Progressive Muscle Relaxation
• APPS – CALM, Simple Habit
Building Resilience
• Relationships – who are they and can you reach out – time to connect with old friends – make a spreadsheet• Okanawa and moei system
• Parents • Checking in, how can we connect if we’re far away, what is good and
positive in family of origin experience• Children
• Open dialogue, new possibilities, get help if possible
Building Relationships
• Significant others -
• Close quarters, changed lives, fluid emotions
• Collaborative discourse: Avoid but, never and always; Stay with one issue at a time; Repeat state of mind of partner;
• Develop more of what is emerging as potentially positive experience
Building Relationships
• Flexibility:• Open to experiences – good and bad
• Mindfulness of the present moment
• Experiencing thoughts and feelings without obsessions
• Maintaining a broad perspective
• Actively maintain connection with deeper values
• Taking steps toward a goal
(Daks, et al. 2020)
During These Times of Isolation
• We need to find time and ways to connect
• We need to connect to sources of meaning
• We can, as clinicians, find new empathy for our patients who have spent a lifetime experiencing emptiness, disconnection, meaninglessness, and detachment
CONNECTION
…even during these dark moments, we are living, even in the presence of the fear of isolation, we can still rely on our human nature to invest in dyadic reparation by connecting emotionally with significant others with which we can share our experience, co-create coping solutions, match in attuned states of mind, and develop hope and trust in our resources and in the future. By investing in the tiny acts of reparation, we can overcome the fear of isolation and we can build further capacity to be resilient. Each citizen can invest in the power of reparation. (Provezi, 2020)
Attuning to Others
• Team Supports• Where trust is already there
• Peer Supports• Peer Support Systems Highly Impactful
• Battle Buddy program – Dr. Sophia Albott, University of Minnesota• University of Indiana Peer Support Program – Kimble Rihardson, MSW• Arizona State – Amy Athey, PsyD, Arizona State University
Developing Skilled Peer Support Network
• Psychological First Aid-• Good to have some guidelines when faced with disaster just like
physical medicine
• Group of principles to attune to a situation, initiate mitigation strategies, and refer appropriately
• Care management as much as psychological techniques
Psychological First aid: Basic Principles
• Safety• Calmness• Restore self and community efficacy• Connectedness• Hopehttps://learn.nctsn.org/enrol/index.php?id=38 (training course)https://www.nctsn.org/sites/default/files/resources/pfa_field_operations_guide.pdf(field guide)
Psychological First AID: Core Strategies
• Contact and Engagement• Safety and Comfort• Stabilization – Using techniques to manage stress• Information Gathering – form for referral• Practical Assistance – need to restore optimism, confidence and resources, creating an action
plan, identify most immediate needs, and discuss action plans• Connection with Social Supports• Information and Coping• Linkage with Collaborative Services – Up to 3 visits from peers most helpful
Perspective Taking and Curiosity
Golden Rule Revised:
“Treat Others as They Would Like to Be Treated” - Rodney Makes a Friend: A Lesson for Young Children in Building Resilience, George Everly, Gina Brelesky
George Everly, PhDThe Johns Hopkins UniversityAuthor of Stronger: Build the Resilience You Need to Succeed, and The Johns Hopkins Guide to Psychological First Aid
MEANING
Victor Frankl, Man’s Search for Meaning
• To a future sense of relatedness, work efficacy, generativity
Preventing and Working with Moral Injury
• Early support and after care• Factual information about moral dilemmas may face ahead of time
• Avoid false reassurance, frank assessment of reality of situation, or may stimulate anger
• Peer groups to discuss difficult situations
• Avoidance is core response – avoidance of getting help, of feelings involved
• Most difficult when situation involves personal relevance
• Ongoing checking in process for team
Virtual Meetings – Preventing Fatigue
Limit to 25 minute presentations before active engagement
Use Polls and Breakout Rooms
Try to avoid hand raising if group is small enough
Look around the room, stretch, stand up
Get a blue screen for computer
Get a green screen for background variance
Virtual Play, Connection, and Vulnerability
• Question to the Group
• Improvisation• Gift Giving off of your desk
• One word at a time proverbs
• Interview for a movie
• History of…
• Scavenger Hunt
Searching for Experience of “Realness”
"It doesn't happen all at once," said the Skin Horse. "You become. It takes a long time. That's why it doesn't happen often to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in your joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except to people who don't understand. But once you are Real you can't become unreal again. It lasts for always.”
The Velveteen Rabbit
References
1. Albott CS, Wozniak JR, McGlinch BP, Wall MH, Gold BS, Vinogradov S. Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers During the COVID-19 Pandemic. Anesth Analg. 2020 Jul;131(1):43-54. doi: 10.1213/ANE.0000000000004912. PMID: 32345861; PMCID: PMC7199769.
2. Bagby, R. M., Parker, J. D. A. & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale-I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23-32.
3. Baumeister RF; Leary MR, (1995) “The Need to Belong: Desire for Interpersonal Attachments as a Fundamental Human Motivation”. Psychological Bulletin Vol. 117, No. 3, 497-529
4. Bianco, Margery Williams, 1881-1944. (2003). The velveteen rabbit : or how toys become real. Leesburg, VA :GiGi Books,
5. Cacciopo, John T; Cacioppo, Stephanie, (2018) “The Growing Problem of Loneliness.” Lancet 391 (10119): 426
6. Daks, JS, Rogge RD. Examining the correlates of pysychological flexibility in romantic relationships and family dynamics : A meta-analysis. Journal of Contextual Behavioral Science. 2020:18:214-238
7. Everly, George, Brelesky Gina, Everly, Andrea. Rodney Makes a Friend: A Lesson for Young Children in Building Resilience. Bookbaby2018
References
8. Fofana NK, Latif F, Sarfraz S, Bilal, Bashir MF, Komal B. (2020) Fear and agony of the pandemic leading to stress and mental illness: An emerging criss in the novel cornovavirus (COVID-19)) outbreak. Psychiatry Res. 291:113230. doi: 10.1016/j.psychres.2020.113230. Epub 2020 Jun 15.PMID: 32593067
9. Frankl, Victor. Say Yes to Life: - In Spite of Everything. Beacon Press, 2020
10. Frankl, Victor. Man’s Search for Meaning. Beacon Press, 2006.
11. Fromm- Reichmann F. (1959) Loneliness. Psychiatry. 22(1):1-15. doi: 10.1080/00332747. 11023153. PMID: 13634274.
12. Harlowe Harry; Suomi, Stephen,(1971) ‘Social recovery in isolation-reared monkeys.” Proc Natl Acad Sci U S A. 68(7): 1534– 1538.
13. Ingram, I; FP Kelly; Baker AL; Raftery, DK (2018) Loneliness in Treatment-Seeking Substance-Dependent Populations: Validation of the Social and Emotional Loneliness Scale for Adults–Short Version, Journal of Dual Diagnosis, 14:4, 211-219
References
14. Ingram, I; FP Kelly; Peter J. Kelly PF; Baker AL; Dingle GA (2018) “Perceptions of loneliness among people accessing treatment for substance use disorders.” Journal of Dual Diagnosis research and practice in substance abuse comoribidity Vol 14, 2018 - Issue 4 pp 211-219.15. Katzman, JG, Katzman JW (2020) Covid-19 has provided 20/20 Vision Illuminating our Nation’s Health Crisis Pain Med. Online ahead of print doi: 10.1093/pm/pnaa35716. Katzman, Jeff; O’Connor, Dan, Life Unscripted. North Atlantic Books, 2018.17. Leweke, F; Leichsenring F, Kruse, J, Hermes, S (2012) “Is Alexythymia Associated with Specific
Mental Disorders? Psychopathology 45(1):22-8.doi: 10.1159/000325170.18. . Korner, Anthony (2000) Liveliness. Australian and New Zealand Journal of Psychiatry. Liveliness. Vol 34 Issue 5 pp 731- 740.19. Matthews, GA; Tye, KM, (2019) “Neural mechanisms of social homeostasis.” Dec; 1457 (1) 5-25
References
20. Mechili EA; Saliaj A; Kamberi F; Girvalaki C; Peto E; Patelarou AE; Bucaj J; Patelarou E (2020) “Is the mental health of young students and their family members affected during the quarantine period? Evidence from the COVID-19 pandemic in Albania.” Psychiatric and Mental Health Nursing. https://doi.org/10.1111/jpm.12672
21. Meo SA; Abukhalaf, AA; Alomar AA; Sattar K; Klonoff DC (2020) “COVID-19 Pandemic: Impact of Quarantine on Medical Students' Mental Wellbeing and Learning Behaviors” Pak J Med Sci (COVID19-S4):S43-S48. doi: 10.12669/pjms.36.COVID19-S4.2809.
22. Meza-Concha N, Arancibia M, Salas F, Behar R, Salas G, Silva H, Escobar, R (2017) Towards a neurobiologicunderstanding of alexithymia. Medwave 2017 May; 17 (4): e6960 doi: 10.5867 / medwave.2017.04.6960
23. Murthy, Vivek, MD. Together: The Healing Power of Human Connection in a Sometimes Lonely World. Harper Collins Publishers, 2020
24. The National Child Traumatic Stress Network, Trainings and Practices: Psychological First Aid. https://www.nctsn.org/treatments-and- practices
References25. Provezi, Livio, Tronick, Ed. (2020) The Power of Disconnection During the COVID-19 Emergency: From Isolation to
Reparation. Psychological Trauma: Theory, Research, Practice, and Policy American Psychological Association: Trauma Psychology. Vol 12 No. S1. S252-S254
26. Rosenbaum, M; Tinney DM;Tohen M. Collaboration to Reduce Tragedy and Improve Outcomes: Law enforcement, Psychiatry, and People Living with Mental Illness. American Journal of Psychiatry 174, no. 6, (2017)) 513-517
27. Stein, Marray; Rothbaum, B. 175 Years of Progress in PTSD Therapeutics: . Learning from the Past. American Journal of Psychiatry. 2018 06 01; 175(6): 508-516
28. Salminen JK, Saarijärvi S, Aärelä E, Toikka T, Kauhanen J (1999). "Prevalence of alexithymia and its association with sociodemographic variables in the general population of Finland". Journal of Psychosomatic Research. 46 (1): 75–82. doi:10.1016/S0022-3999(98)00053-1
29. Sifneos, PE, Alexithymia: Past and Present (1996) Am J Psychiatry 153 (7 Suppl) 137-142
REFERENCES
30. Stern, Daniel. (2004) The Present Moment In Psychotherapy and Everyday Life New York: W.W. Norton and Company
31. Vandeleur CL; Fassassi S; Castelao E; Glaus J; Strippoli MF; Lasserre AM; Rudaz D; Gebreab S; Pistis G; Aubry JM; Angst J; Preisig M (2017) Prevalence and correlates of DSM-5 major depressive and related disorders in the community. Psychiatry Research (250) 250-258
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