covid-19 resources: mclean.org/covid...our own health and the health of the ones we love. •at...

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COVID-19 RESOURCES:mclean.org/COVID

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HELPING THE HELPERS:A BRIEF GUIDE

Blaise Aguirre, MDMedical Director, 3East, McLean HospitalAssistant Professor of Psychiatry, Harvard Medical School

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KEY CONCERN and APPRECIATION

• Just like other historical moments of enduring and persistent stress, the current pandemic will have psychological and health effects that will last beyond its impact on the current generation.

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•We know that our stress response changes gene expression and that these changes are passed on to future generations.

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• Taking care of ourselves today is the most compassionate thing we can do, not only for ourselves but for the well-being of future generations.

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• I want to recognize the relative good fortune that some of us have, and that at this present moment many of our fellow human beings are on the frontline of the current situation. We thank them for their service.

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WE NEED TO FLATTEN THE CURVE

• As mental health professionals, we are anticipating a surge in the wave of people needing help for stress, anxiety, depression, and other mental health conditions.

• By we, the mental health professionals, practicing, modeling and then teaching mental health hygiene today, we can flatten the curve and increase the chance of more effectively dealing with the anticipated surge in mental health care needs.

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FUNDAMENTAL PRINCIPLES

YOU HAVE TO REGULATE YOUR EMOTIONSBEFORE YOU CAN REFLECT ON SOLUTIONS.

YOU HAVE TO CALM YOURSELF DOWN BEFORE YOU CAN CONSIDER A VARIETY OF OPTIONS.

WHEN YOU ARE UNDER EXCESSIVE STRESS YOUR THINKING NARROWS.

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THE AGITATED, IRRITABLE, ANXIOUS MINDCANNOT THINK EFFECTIVELY.

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•We know this better than most. We work with patients who struggle with chronic anxiety and depression, and our goal in therapy is to not only help them reduce their anxiety, but also to teach them better coping mechanisms when worries arise.

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• Our brains are no different. As mental health providers and as caregivers, we too are just as vulnerable to the dysregulating effects of significant anxiety. Some of us don’t always model emotion regulation, particularly when we are overtly stressed.

• However, we can use the very skills we teach our patients!

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WE TOO ARE THEY

Just like our patients, many of us, the mental health professionals, are struggling with the emotional impact of COVID-19.

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WE TOO ARE THEY

•We are anxious, experiencing fear and worry about our own health and the health of the ones we love.

• At home, on email, by text, and in virtual meetings, some of us are increasingly irritable with our colleagues and family members.

Just like our patients, many of us, the mental health professionals, are struggling with the emotional impact of COVID-19:

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WE TOO ARE THEY

• Then, as we become more irritable, we become more judgmental of others.

• Some of us are noticing the experience of unfairness that some people have to be at work while others don’t.

•Many of us are unable to fall asleep, or don’t sleep through the night, or are experiencing nightmares.


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WE TOO ARE THEY

•Many of us are changing our eating patterns: too much, or too little, or switching to junk food.

•We ask ourselves, how can we balance work and home life, especially if we have young children at home—not that teenagers are any easier!


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WE TOO ARE THEY

• For some of us with chronic health conditions, these are worsening under the load of the stress we are feeling.

• Some of us are turning to alcohol and other substance use as a way to cope.


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BRAIN FUNCTIONING 101:THE BRAIN UNDER EXTREME STRESS

The more stress we feel, the more we move to basic survival behavior.

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•We become more self-focused.

•We want our needs met immediately.

•We think less about the needs of other people.

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•We become more reactive.

•We become more difficult to deal with.

•We become less rational. (Do I really need the 20 rolls of toilet paper or 30 cans of tuna fish in my cart?)

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•We become less open to other people’s suggestions.

•Our sense of time collapses, and everything feels urgent.

•Under stress, we act more like younger children whose brains haven’t yet developed reflective capacities.

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ON THE OTHER HAND, WHEN WE ARE CALM

•We can help calm the people around us.

•We can think.

•We can problem solve.

•We can create.

•We can sleep better.

•We can be better therapists, family members, and friends.

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RELATIONSHIPS ARE TRANSACTIONAL

•We are social, emotional, and relational beings.

• The more time you spend with someone, the more likely you are to impact each other.

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RELATIONSHIPS ARE TRANSACTIONAL

• Spending a lot of time with each other makes us more porous to the other’s emotions.

• This makes emotions pretty contagious and situations can quickly turn unpleasant.

•However, although we can co-dysregulate we can also co-regulate.

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SOUNDS GREAT

BUT HOW DO WE GET TO CALM?

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IS THERE A WAY OUT OF THE ASSOCIATED PANDEMIC OF

ANXIETY?

ACT OUT OF WISDOM AND CENTEREDNESS

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A KEY CONCEPT: WISE MIND

In dialectical behavior therapy (DBT), we have a concept known as WISE MIND, and it is the path to a more centered self.

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CENTEREDNESS: Acting From WISE MIND

In dialectical behavior therapy (DBT), we have a concept known as WISE MIND.

•Wise Mind is the state of mind which arises when we are able to observe our full experience in the moment, and then, by integrating the emotional, physical, rational, and spiritual elements of the experience in the moment, act with wisdom, compassion, and effectiveness.

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•We are seeing that the current pandemic is generating extremes of emotional experience and subsequent behavior in so many people—whether they are mental health patients or not.

• And so just like many of our patients who often find themselves swinging between high emotionality to overly rational thinking, we the helpers are experiencing this as well.

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• Functioning from wisdom rather than from strong emotions is certainly the optimal state of being.

•Most of us are typically too involved in the routine of everyday life to consistently act of out of reflective wisdom.

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•Our routine is to mindlessly repeat patterns. This can be very helpful, because it means that we don’t have to do too much thinking and reflecting.

• Although mindless repetition provides structure, it does not help in times of great demand and stress.

•Wise Mind is a way of being that is flexible, adaptive, and holistic.

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CALM CENTEREDNESS

A calm centeredness flows from Wise Mind. It allows us to reduce our reactivity, consider options, and then proceed on to the most effective course of action.

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Sounds like unreachable bliss?

• Attaining Wise Mind is a powerful tool that we teach our patients in DBT, the ones who are struggling with the most painful of experiences even at their baseline. Some of our patients are in chronic states of despair and at times consider suicide.

• Many have found that practicing Wise Mind is the way out of suffering and we too, those who are typically fortunate enough to not have to struggle, can learn to get to and act out of Wise Mind.

• But if you recall from the first few slides, we cannot get to this state until we are regulated.

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THE AUTONOMIC NERVOUS SYSTEM:A BRIEF PRIMER

•The autonomic nervous system is made up of the sympathetic and parasympathetic systems.

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•The sympathetic nervous system increases heart rate and blood pressure, dilates the airways to make it easier to breathe, causes the body to release stored energy, causes palms to sweat, pupils to dilate, and hair to stand on end. These functions are of great importance in times of justified danger, but unhelpful if the brain is pumping out ongoing distress signals when the danger is unjustified.

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•When we are excessively worried and this system is activated, anxiety, panic, fear, and anger arise powerfully and can be magnified beyond the level of threat by our current distress. This prevents us from thinking clearly.

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•The parasympathetic nervous system essentially does the opposite of preparing us for threat. Among other things it functions to conserve energy, slow the heart rate, relax our body, and promote rest.

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There some quick ways to override an excessive stress response or an overresponse of the autonomic nervous system. Our task is to

activate the parasympathetic nervous system.

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RAPIDLY DEALING WITH EXCESS STRESS:The TIPP Skill

T is for TEMPERATURE

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T is for TEMPERATUREFill a bowl with ice-cold water and then add ice to cool the water even further.

Take a deep breath and place your entire face in the water. Keep your face in the water for 30 seconds. Make sure your cheekbones are in the water. This will activate your dive reflex.

You can repeat this a few times, if it helps.

A WORD OF WARNING: DO NOT DO THIS IF YOU HAVEASTHMA OR A HEART CONDITION!

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T is for TEMPERATURERemember: The dive reflex is the body’s physiological response to submersion in cold water and includes selectively shutting down parts of the body in order to conserve energy for survival. When you do this, your heart rate will slow and your emotions will literally cool off!

A WORD OF WARNING: DO NOT DO THIS IF YOU HAVEASTHMA OR A HEART CONDITION!

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I is for Intense Exercise

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I is for Intense ExerciseDo some intense exercise for a short period of time: Sprint, skip, jumping jacks, plank, multiple squats, walk as hard as you can up stairs, do sit ups, push ups, or dance! Some of these you can do in your office or your bedroom.

Do this until you are out of breath. It is impossible to stay in the same state of emotional dysregulation under physically exhausted conditions. You will find that, for instance, you cannot skip and be angry at the same time. Try it!

AGAIN: DO NOT USE INTENSE EXERCISE IF YOU HAVE A HEART OR OTHER PHYSICAL CONDITION THAT PROHIBITS RAISING YOUR HEART

RATE OR ADVERSELY IMPACTS YOUR HEALTH

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PP is for Paced Breathing and Progressive (or Paired) Muscle

Relaxation

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Paced Breathing

Paced breathing will help you regulate intense emotions. The practice is to reduce your breathing rate to 5-6 cycles/minute. Breathe in slowly through your nose for 3-4 seconds, then breathe out even slower through pursed lips for 6-8 seconds. Within minutes you will notice a calming effect.

(If you are congested and can’t breathe through your nose, you can breathe in and out through your mouth. Just make the out breath longer than the in breath.)

PP is for Paced Breathing and Progressive Muscle Relaxation

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Progressive Muscle Relaxation

You can also reach a state of reduced stress by focusing on various muscle groups and then tensing and relaxing each of these muscle groups. Tense for a few seconds then relax for a few seconds.

To magnify the effect of each of these practices, do them together. Tense your muscles as you breathe in and relax your muscles as you breathe out.

PP is for Paced Breathing and Progressive Muscle Relaxation

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TOLERATING DIFFICULT MOMENTS:Use the STOP Skill

ØS: STOP what you are doing when strong urges arise. Do not act on these urges and impulses!

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ØT: Take a breath. Take a step back. Take a 5-minute break.

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ØO: Observe the situation. Assess the facts of the situation as these facts are and not as you imagine them to be.

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Ø S: STOP what you are doing when strong urges arise. Do not act on these urges and impulses!



ØP: Proceed mindfully and ask yourself once you are in Wise Mind, “What do I need to do right now to more effectively manage this situation?” Sometimes the answer is àNOTHING!

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ØP: Proceed mindfully and ask yourself once you are in Wise Mind, “What do I need to do right now to more effectively manage this situation?” Sometimes the answer is àNOTHING!

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ATTAINING WISE MIND: Describe

Describe the observable. Be very deliberate in describing:

1. Your physical state:“I feel tension in my neck, my jaw is clenching.”

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2.Your thoughts as thoughts:“I am noticing the thought that I will make other people sick.”

Thoughts are brain phenomena, they are not always facts. It is important to distinguish between thoughts as thoughts and facts as facts.

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3. Your emotion in the moment as an emotion that will pass:“I am feeling anxious right now.” Stay away from saying, “I AM anxious.”

You and anxiety are NOT equivalent entities. When you look up anxiety in the dictionary, you will not find your photograph.

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By describing your experience in this way, you will distance yourself from being consumed by the emotion.

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WISE MIND: Without Judgment

• Be aware of the judgments that you make.

• Remember that everything is caused, everything has a reason for being as it is.

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• Few of us want to make others upset and yet we might, by our actions, even if not by intention.

• The reason for your crankiness is caused and so is that of your coworker.

• You might be just as irritable as your coworker. They could be making the same judgments of you!

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•When you judge, you remove the possibility of knowing. Judging is the enemy of curiosity.

• If you do make judgments, and we all do, then label these as judgments and then ask yourself if making the judgments helped you get to your desired goal.

• Alternatively ask yourself if being judgmental is making your life easier or harder.

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WISE MIND: Is Effective

• Being effective means doing what works for a specific situation.

• It moves away from questions of right and wrong, what is fair and unfair.

• If your house is on fire you need to put it out! Saying that it is not fair because you did not start the fire is not an effective response.

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WISE MIND: Is Effective

• Ask yourself if you are trying to be “right” at the expense of being effective.

• Are you trying to prove a point at the cost of preserving an important relationship? Sometimes wisdom means letting things go.

• It’s true that you may not have caused all your problems but living in righteousness will not solve them and is not always an effective stance.

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WISE MIND:Focuses on One Thing in the Moment

•We are distracted by the pandemic as well as so many other forces—work, homelife, the need for self-care, our relationships, and so on.

•When you are doing one activity or task, focus on just doing that one thing. When the next task comes along, focus on that one.

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WISE MIND:Focuses on One Thing in the Moment

• The idea of efficient multitasking is a myth. People DO multitask, but research shows that they lose efficiency in doing each of the different tasks at the same time.

• Focusing on a single task at hand is Wise Mind in action, leading to greater mastery of tasks and increased efficiency.

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SOLVING A PROBLEM: SCREW IT!

Imagine that you have the problem of boredom while at home. Or let’s say that you are not sure if

you should go to work.

There are 5 ways you can address any problem you face.

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There are 5 ways you can address a problem you face:

Ø You can SOLVE it.

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Ø You can Change your relationship to the problem.

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Ø You can Radically accept the problem.

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Ø You can Entertain staying miserable.

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Ø You can Worsen the problem by doing things that make the situation even more complicated.

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Ø You can Worsen the problem by doing things that make the situation even more complicated.

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THE HEALING POWER OFRADICAL ACCEPTANCE

•Radical acceptance means the complete acceptance of reality as it is. It is accepting the truth of a situation with your mind, body, and soul. • It means not fighting what is without accepting what is.

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•When we are in emotional pain, we tend to suffer when we insist on not accepting it. We can all bear pain. To this point we have all survived the most difficult and painful moments of our lives!

•Difficult moments only wear us down when we don’t accept that they are difficult. We spend so much energy fighting reality. It’s exhausting.

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• Remember that if you like reality, it is as it is. And if you don’t like reality, it still is as it is. Your opinion does not change reality.

•Once we have accepted reality, we can get down to the task of fixing whatever it is IF it is in our power to change.

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DON’T SUFFER TWICE

•Worrying about something that has not happened makes us suffer twice if it ends up happening. Why is this? Because we spend so much time and energy worrying about what will happen (first suffering), and then we worry again when it does happen (second suffering).

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• If the feared situation doesn’t end up happening, then we have suffered needlessly. If it does end up happening, then suffering will come, so that will be the time to suffer and not before.

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• All good and well but then why bother thinking about the future.

•Use thinking for planning and not for worrying. Make contingency plans for situations that might arise and then know that you have these plans if the situation actually arises.

• Then stay on your course of daily tasks without the worry, because you have your plan in your back pocket.

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• Even in situations when you cannot change the outcome, simply worrying is not typically helpful. You need your best wits about you!

•With an open mind, open hands, open eyes, and an open heart say, “I cannot change this situation, I do not like it, but I will not fight it. I will do all I can, the situation being as it is.”

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ONE MORE IDEA:DECREASE YOUR WORKLOAD

• Many of us are trying to do even more under times of stress. This makes little sense.

• Imagine having to carry a heavy load up a hill. Halfway up, and while you are already exhausted, someone asks you to carry more.

• If instead we started with a lighter load, by the time we were asked to carry more, we would have more energy and more likely be able to help.

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ONE MORE IDEA:DECREASE YOUR WORKLOAD

• The same happens with our brain. Things are going to become more stressful, so reducing the workload now means that you will be more resilient later. What are the things that aren’t essential to do now? Put these aside.

• Self-care will strengthen mind and body. So keep a regular sleep routine so that you can get a good night’s rest, exercise a little every day, and eat three balanced meals a day.

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CONCLUDING THOUGHTS

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CONCLUDING THOUGHTS

•We are all dealing with a strange, new, surreal world.

•We are experiencing many of the same feelings, emotions and thoughts that our patients are feeling.

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CONCLUDING THOUGHTS

• In order to be the best and most effective version of ourselves, we must first take good mental care of ourselves.

•Doing so will ease our state of distress, make us better friends, colleagues, family members, and therapists.

• These skills work well for emotionally dysregulated and self-destructive patients. They can definitely work for us as well.

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CONCLUDING THOUGHTS

As mental health care leaders and providers, managing the level of stress in our lives—

particularly in the current pandemic—will not only help us find centeredness and a greater sense of calm but further model self-care for

those around us.

In so doing we can show that moments of great uncertainty need not

become moments of mental defeat.

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Thank You

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Q & A

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How do I comfort patients and colleagues when I am feeling so uncertain and scared?

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How can I help minimize anxiety at home when my loved ones are worried about me—or I am worried about a loved one’s exposure?

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I’m not a health care worker, but my loved one is. How can I provide support to them in such a worrisome time?

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How can I talk to my social circles about emergency plans without upsetting them?

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Do you have any advice for helping to minimize my workload or setting boundaries around my workday? Now that I’m working from home, it feels like I’m working nonstop, and so are my colleagues.

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McLean is working hard to put together materials to help support mental health during this very trying time. For more

information, check out our website.

mclean.org/COVID

covid-19 resources: mclean.org/covid...our own health and the health of the ones we love. •at...

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