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On July 23, Drexel University held a virtual presentation for faculty and professional staff to learn ways to manage anxieties related to the COVID-19 pandemic and, as fall term comes nearer, returning to campus. About 500 Dragons tuned in to watch College of Medicine Vice Chair for Education and Professor of psychiatry Donna Sudak, MD, give a presentation on this topic and answer questions from the audience.
Here is a lightly abbreviated transcript of the event:
President John Fry: Good afternoon everyone and thank you for joining us.
Before we begin, I would like to thank you for your continued support. I truly appreciate the extraordinary efforts that our faculty and professional staff have made to pivot and readjust to better serve our students during this unprecedented time in American higher education.
As you know, Drexel will be implementing a hybrid teaching approach this fall which requires both adaptability and agility from all of us in order to meet the needs of our students as well as uphold the academic commitments we, as a University, have come to expect from ourselves.
Many of us are deeply concerned about the rising number of COVID-19 cases in other states as well as an uptick in parts of Pennsylvania. And we have the federal government pushing to fully reopen schools, businesses, and a host of other services. So naturally we're all thinking about how these developments might impact our plans to return to campus in the fall.
I think we’re still in a strong position. First, because we have nearly two months until the September 21 start of our fall quarter. But primarily, it is because we are being extremely careful in everything we do to ensure that we responsibly reduce the risk of COVID-19 transmission and infection.
You’ll hear a lot more detail in the coming weeks about our plans. Please know that we’re going to be flexible and be ready to recalibrate our approach based on the best public health advice available.
Today’s presentation could not have come at a better time as “uncertainty” seems to be the watchword when it comes to COVID-19.
We are not immune to the anxiety that comes with this environment. And that's why I'm so grateful for today's presentation as I hope that it will provide some additional context — if not comfort — and help all of us more effectively support each other in the weeks and months ahead.
I want to thank our presenter, Dr. Donna Sudak, for helping us explore some of the issues surrounding anxiety about returning to campus during this pandemic.
I'd like to turn now to Professor Eric Zillmer who will say more about Dr. Sudak and explain how we’ll conduct this presentation. Dr. Zillmer is Carl R. Pacifico Professor of Neuropsychology as well as Drexel's athletic director. Eric?
Carl R. Pacifico Professor of Neuropsychology and Director of Athletics Eric Zillmer, PsyD: Thank you President Fry and good afternoon Dragons.
I've been looking at this pandemic through the lens of a clinical psychologist, and it's obvious to me that this medical crisis is also spreading fear and anxiety. In fact, in my opinion, the mental health fallout is a public health crisis in and of itself. Why do we feel so exhausted all the time? Why do people feel so concerned about wearing masks, about returning to work? How many of us have taken the time to check in with ourselves and ask ourselves the following question: “Am I okay?”
We are all in this crisis together — each one of us. It's not your fault, but it is our problem. Normal anxiety can motivate us. It's manageable, even welcomed, but excessive and prolonged anxiety is cumulative and can lead to negative consequences that stick around long after it should. What you resist persists.
So today's presentation, “When Pandemic Becomes Endemic: Managing Distress While Living With COVID-19,” is spot on and like President Fry said, the timing could not be better. After the presentation, we will have time for questions that have been submitted earlier online; there will be no live questions.
I would like to now introduce you to Dr. Donna Sudak, today's presenter. Dr. Sudak is a professor, the vice chair for education and the director of residency and psychotherapy training in the Department of Psychiatry at Tower Health, Drexel University College of Medicine.
Dr. Sudak is a clinician educator with a wealth of experience in teaching and patient care. In addition, Dr. Sudak is an adjunct faculty member at the world-renowned Beck Institute and the past president of the Academy of Cognitive Therapy. And, most importantly, she is a Dragon.
Professor and Vice Chair for Education Donna Sudak, MD: Thank you Eric for that gracious introduction. So this talk actually started by a presentation that I did for folks who are individuals working in medicine — folks who were caring for COVID patients and managing the distress of working in hospitals with COVID patients. And what's become apparent to me, as Eric alluded to, is that we are all now living with the considerable stress of this pandemic, and rather than a quick resolution, we now are facing living with the virus in our midst for the foreseeable future.
In the Northeast, as we've been able to institute measures that have gotten the virus under better control, folks are beginning to try and navigate managing with the virus alongside some of more normal daily life because in fact there are medical and psychological risks incurred with continuing the isolation and lockdown of our society. We have to figure out what we can do to navigate our stress with living with the virus and how to assess and manage the uncertainty about what will be safe for us.
What this isn't going to be about is whether it's safe or not safe to open society or the campus, but it's going to be about managing your own reaction and your fears to help you to more carefully decide what risks are reasonable for you; how to stay more physically and emotionally safe; and the importance of feedback and reaching out to others.
I don't know about you, but when the pandemic struck I was already juggling more balls in the air than almost I could manage and it threw in another five or six of them. And for most people we really felt pushed to our limits in trying to navigate just the lockdown itself and the stresses of COVID, and now we have another challenge in navigating what is it going to mean to live with the virus. We need to take a breath, manage the juggle a little bit, take some time for self-care and think about how our emotions are affecting us in our judgment in order to more carefully attend to the kinds of demands that exist when it comes to keeping our own personal and emotional safety.
Some of us already have things that make us more vulnerable to the stress of COVID. We might be caring for kids or older relatives or a spouse, and that would increase our own sense of personal threat about the possibility of being infected or infecting someone in our own personal lives. The personal meanings that COVID has for us and our own personal tolerance of uncertainty also will affect how we manage with the virus.
A slide from the presentation of Donna Sudak, MD.
COVID has some unique things about it that make it more difficult for us to manage psychologically. We can't see the virus and one of the things we know now about things that threaten us that we can't see is that they automatically become something that seems more dangerous. That's why in scary movies, they don't show you the alien until the very end because as long as they aren't letting you in, it's even scarier yet. Our imagined sense of whether or not this person is infected or this groceries cart is dangerous is inflated, because we just don't know.
This has gone on a long time and many of us are tired. That fatigue is dangerous to us. It makes us frequently make decisions that are not with the whole picture in mind. Witness people, once things were reopened, behaving in some ways that might have accelerated problems. We need to be to be cognizant of the need to care for ourselves so that we're making good decisions.
Moral injury has incurred. By that I mean that for many of us, we have a sense that some institutions have betrayed the public trust in a way that feels injurious to us. That inculcates a sense of more suspicion and distrust which can be problematic.
Normal mourning has been impossible for those who have lost folks to COVID or even to non-COVID related situations over the last months. It's meant that we can't be together with our loved ones and spend time in the way that helps us to heal and to grieve.
And finally, and a very important thing, is that we've been extraordinarily lucky. Over the last 50 years or so we have lost our experience in navigating infectious diseases in most places. And except for certain circumstances, like HIV and Ebola, we have not had significant numbers of individuals with infectious diseases. We have done so well that that’s made a real difference in our ability to live life without the sense that those things are out there.
Now with this psychological challenge that's posed by COVID, we need to remember what that's done to our fear system. Now normally fear is a gift to us. We have it in our hard drive because it's protective. It helps us to avoid danger.
However, that fear system was really built to be triggered and then an action taken and then the red alert to be deactivated. Our brains were not wired to over and over and over, for months at a time, be built to be triggered and afraid. And the more emotion we experience in that way, the less accurate our thinking is. One of the things that happens is that our brains have already been designed to overestimate risk and underestimate resources so that if I'm giving a fear stimulus, I'm programmed to think this is something that could really hurt me until I can take a second look and make sure that this is something that's dangerous to me.
The more anxious we are the, more overestimation of risk occurs. We have to really control the volume of our distress signals. We need to do that to be more accurate in our estimation of risk and we also need that to protect our nervous system. It's not designed to be constantly thinking “there is a threat to me right around the corner” and be triggered in this particular way. Hopefully I can give you some strategies to help you to do that.
A slide from the presentation of Donna Sudak, MD.
I want to take a pause for something I call “annoying human tendencies,” because often we will disregard as humans reasonable solutions and not take paths that might benefit us because we think that something isn't fair or because they don't look big enough to potentially solve a problem entirely. So sometimes when we are uncomfortable or unhappy about a situation that is not of our own making, we will often not do things that could potentially help us. Sometimes that leads us to a situation where we might be right that it's not fair but we're not any happier.
In addition, we discard things that seem like small things that we can do that might benefit us in the short term because they don't solve the whole big problem. I might suggest to a beleaguered colleague that getting out and sitting outside in the sun while they're having lunch might help them to feel a whole lot better. When we’re feeling particularly beleaguered, we might say, “That's just so silly. How could be being out in the sun make a difference to this whole big picture, even though it might make enough of a difference to help me think more clearly?” There are some annoying human tendencies that are fallacies in thinking that also affect us in terms of COVID and will need to watch those as a community.
So with that as preamble, what I'm planning to do is to discuss ways to manage our emotions or thoughts and the way that we're acting so that we can preserve our own beings as community members and preserve our ability to care for others during this pandemic.
The first step is to reduce our vulnerability to excess emotion and by this I mean putting our own oxygen mask on first. There are certain things that everyone needs in order to be less vulnerable to excess emotion. I have to really allow my nervous system to have the things it needs to face the world in the most objective way. Alcoholics Anonymous has an acronym: HALT. Don't get “hungry, angry, lonely or tired,” because that makes you more vulnerable to be impulsive. Those are things that we want to be watching out for: getting enough sleep, eating good food, watching for mood altering-substances, taking sufficient time for exercising, getting in contact with someone or something meaningful that allows you to feel comforted and close and connected, and identifying short-term solutions even if this is a long-haul problem. Those are things that are going to reduce your vulnerability to your emotional state so that you can think more clearly, because the thinking parts of our brains are what we're going to need here.
Another thing that reduces vulnerability is support. We need to reach out to the people that we care for, to our community, to help us manage difficulties that need to be tolerated right now. We also need to connect and communicate effectively the concerns that we have, the ideas that we have, as we navigate living with COVID in our midst. We need to be available listeners to one another and hear divergent points of view as well as hear what it is that people are struggling with. Just having an empathic listener, someone who's able to say, “I'm so glad you told me that,” is really something that can both decrease our distress and help us to share ideas and be more connected in the midst of this pandemic.
We often want negative emotions to go away instead of understanding and managing them. It is perfectly normal to be afraid and sad in this circumstance when it won’t be normal. That life that we had before COVID is not here now and it may not be here for quite some time. With uncertainty as the order of the day, we are not 100 percent certain how to manage that situation.
We need to be able to manage our fear so that we have fear at a level that protects us and doesn't damage us.
A slide from the presentation of Donna Sudak, MD.
Nevertheless, COVID-19 will pass. Humankind will survive. Almost all of us will be alive in its aftermath. Humans have lived through many such tragedies. Almost everyone who has had COVID-19 or large numbers of people who have had it have survived and are alive in its aftermath.
Step two is to solve what can be solved and accept what cannot. This is very tough. Most of us are problem solvers and we want to do something. We have to remember that we can't control everything and it's very important to keep that in the front of our mind.
Part of this involves accepting some things that are not in our control — accepting the existence of COVID involves tolerating uncertainty and that is very difficult for us. Our brains are programmed to not like uncertainty. Our brains are also programmed to think that what is uncertain is dangerous and many people have a different set of tolerances. For uncertainty, some people don't mind it at all and some people are very intolerant of it. There are some folks who don't get on an airplane without feeling uncomfortable and we have other folks will go skydiving.
The second piece about this is that living life involves living with the risk of dying every single day, even before COVID. Quarantine actually incurred risks: some people died during quarantine because they were so afraid of going to the hospital that they didn't go when they had chest pain and then died of a heart attack. If we look at this in a tongue-in-cheek way, being healthy is just dying more slowly. The bus can come for us anytime, but having COVID in our midst has brought that existential anxiety to the fore. So the question is, when there's no way to be 100 percent certain, how are we going to live our lives? How to live with the fact that this is out there? We have to develop for ourselves an acceptable level of risk and tolerate that without being 100 certain and having a full and meaningful life.
However, besides the existential anxiety and our need for personally understanding for ourselves what is going to be acceptable, we should also reduce manufactured fear. This is a concept I teach a lot in addition to the existential reality: we have to watch out that we're not magnifying the risks in our own mind. We want to be fearful enough to take reasonable precautions. We need to keep fear as a gift and assess our risk accurately. That doesn't mean that it isn't important to keep in mind that this is a very dangerous virus and we need to be careful about it, but it means we need to be clear about the actual danger to ourselves personally.
A slide from the presentation of Donna Sudak, MD.
One way to do this is to keep that threat level down by limiting the news; being able to, for example, use a news source that is dispassionate, like Johns Hopkins. Maybe don't spend more than an hour a day on it and use guidelines that are based in science rather than in social media.
We also need to consider worry. Now, worry for me is repetitive verbal behavior and there are two different buckets for me. One is productive worry: I get in the shower, I feel a lump, it says to me this isn't right. I get it checked out, I find out whether it's something I need to deal with directly and that's really productive worry. Unproductive worry is after I've checked it out and I find out that it's okay, I worry about having another lump and maybe this next time it could be cancer. So part of this is dealing with your tolerance for uncertainty and whether uncertainty is always dangerous. We might use something called “worry time,” which is really wrangling your worry monster by giving it a certain 10-minute time period during the day during which you will worry. But you need to anticipate when you're worrying because when you do, you're telling yourself a story about something that hasn't happened. You're writing a script for yourself about bad events in the future. We need to wrangle the worry monster by remembering that not all the stories you tell yourself in your worries are really accurate or based in reality.
You can decrease manufactured fear by testing your thinking. Don't rely on your wiring; your initial response to a fearful stimulus is potentially going to be inaccurate. You have to apply the scientific method to your thinking. Most of us, in many of our circumstances, will potentially have a thought that is inaccurate and then at second glance we get a different perspective. We need to do that when our emotions are high. We can ask ourselves, “What was the thought that I just had? What was I predicting? What does this situation mean?”
It helps to write down our thoughts. The thoughts in my mind seem more real and more true and I'm more dispassionate and able to be scientific about them when they're on paper. We don't always know in advance if our thoughts are true and people believe things that are untrue all the time, so we need to be able to test them out.
There are some great questions that we can use to test out our thinking. We can look for evidence — is this evidence that holds up in court, not just because I feel it's true? — and look for alternative ways to look at things. What would I tell a friend or a family member if they had this particular thought about this situation? Is there something I should do about this problem if I change my way of thinking, what would that do to how I feel?
If we're anxious, we can really ask ourselves questions about our risk. What's the worst thing that could happen here? Could I cope if it did? What's the best thing? What's the most likely thing? What are my odds here with our accurate ways of predicting this? If my friend thought this, what would I tell them? And finally, after you ask yourself all of these questions, is there a more accurate way to think about this situation? And if I thought this, would I feel better in this circumstance?
The important thing is, don't believe everything you think. Our minds aren't designed to always give us the most accurate picture when we look at a situation. When we’re emotional and concerned and fearful, we are less likely to get the whole picture.
A slide from the presentation of Donna Sudak, MD.
Another thing that we need to do is to promote positive emotions. When we're anxious over long periods of time, we do get tired and often can feel helpless and despairing. In addition to the anxiety fueling that, we have lost a number of normal life pursuits that we normally do to cope. There are some things that people have done to be incredibly creative to cope. Plan things that are enjoyable and important to you, but it's important to also try and verify what we're doing. Find things creatively to reclaim what you've been missing and be connected to others.
It's really important to also give yourself credit for staying healthy. You're giving up things that are really important to your life so you can stay healthy, and so your community can stay healthy. It’s important to manage your expectations. Sometimes doing a good enough job is good enough. We need to give ourselves a break in terms of how we manage this, particularly when we're comparing ourselves to others.
We have to validate the fact that we all feel frustrated and that much of this, COVID for sure, is not fair. But being miserable about that is not helpful to us. We need to use that to fuel action, to create meaning, to find some ways to solve these problems.
I'm going to just point to three tools to manage extreme emotion that you may just want to practice on your own. These are really quite validated tools and they work to manage extreme emotion and to quell anxiety but you need to practice them when you're feeling calm. There’s nothing worse than trying to put up a tent for the first time in a hurricane.
One of the things that I would advocate is if you have a fair amount of anxiety or you're struggling with insomnia, that you turn to YouTube and find a good example that you like where you can practice some of these techniques.
The first is called “controlled breathing,” which has to do with slowing your breathing down. Belly breathing is a variation of this, but for people who have trouble with breathing too quickly, sometimes that can be a problem.
A slide from the presentation of Donna Sudak, MD.
Some people find that positive image imagery and mindfulness is helpful to them. Some people are allergic to it. You’re only going to know if you try it out.
Last but not least is something called “progressive muscle relaxation,” which is a terrific thing to help you feel calmer and more relaxed and then able to think more clearly. I don't think any of these are a panacea by themselves, but I like having lots of tools in my toolbox for circumstances like this and for times where one of my tools in my toolbox isn't working so well.
Eric Zillmer, PsyD: Donna, thank you so much for your thoughtful presentation. We have some time for questions. Let me put one question for you which was submitted online: Please speak about how faculty can be sensitive towards students in the fall during their first face-to-face classes. What do we need to understand about our students during this time of crisis?
Donna Sudak, MD: Every person will have their own background and individual experiences and risk tolerance. It's important to very sensitively understand that students may have different needs around this. They may have incurred personal losses, for example, that make them more sensitive to the risks involved. They may have their own health conditions that make them more concerned about the risks to them. Our students will also have very different access to tech or facilities with tech and we need to be sensitive to their different abilities around that.
In terms of navigating their class work, on the other hand, many students will have come into school having a lot of pent-up demand and a sense of loss, particularly those who are coming straight into freshman year. They've missed the prom, they've missed graduation, they've missed being with their classmates. They may have missed a lot of time in terms of getting ready for the transition to college and students will be at varying levels of readiness in terms of managing their own impulsivity. We’re going to need to sort of track and reinforce for them that they're being MVPs in being safe and what they're doing with the community to allow all of us to be together and work and learn together in more than the virtual space.
Eric Zillmer, PsyD: So it's fair to say, Donna, that it's not business as usual. And it is appropriate to turn to our students, really anybody that we work with, and say, like, “How are you doing?” Is that a fair assessment?
Donna Sudak, MD: I think that all of these things certainly bring us to the place where checking with people how they're doing as the start of the conversation makes the most sense. If somebody's beset with upset and anxiety they're not going to be learning very well either and so it helps to diffuse and have that to be a part of the conversation before we start in on where we are with our educational pursuits.
Eric Zillmer, PsyD: I have a question for you personally before we move on to another one. You mentioned journaling, which is interesting because in all my life I've never used a journal, but during my “Happiness” seminar that I was teaching last quarter, I asked every student to also keep a journal. Why is it important to write things down? And your idea that this is also an opportunity to really have a meaningful life to learn and grow through this crisis really resonates with me. Can you speak to that please?
Donna Sudak, MD: Eric, I'm glad that you brought that up. First of all, when I was talking about writing down thoughts, I really wasn't talking about journaling per se. The reason for writing down thoughts just in that moment where you have a high level of negative emotion is really to get your thoughts on paper and have them be something that you examine for logic which is really quite different than the journaling people do as a way of sort of promoting mindfulness or promoting gratitude.
I do think that for some people journaling is quite useful and gratitude journaling has been shown to promote positive emotions and certainly when those are in short supply, it's a good thing to be able to look at those things.
I think that cultivating a sense of community and purpose really does make for meaningful life and that every person is going to need to determine what it is that does that for them. Many of us find that meaning in our life is somewhat determined by work and the chance to be able to work with students and be able to be in the presence of learner for me provides a lot of juice. That's what I do. And so I think having the chance to navigate that provides for me a sense of meaning and everybody’s going to have to think that through as we manage this pandemic.
Eric Zillmer, PsyD: Thank you. Okay here's another question; it’s a work question: How do you deal with a coworker who is so anxious and worried that it bothered everyone around them? I mean, to paraphrase, it really is, “How do we manage other people’s emotions?”
Donna Sudak, MD: I'm not sure that we can manage the emotions of other people. I think that one of the things that's very helpful is to validate the fact that this is a scary time for everyone. Nobody is 100 percent certain. This is a really hard time and to find out what the central concerns of the person might be and potentially looking at ways the person could help feel calmer and safer in that environment — what things actually exist that are precautions, for example, that are being taken — might be useful.
I think that the most important thing that we all have to remember is that uncertainty is going to be out there through managing with COVID. Everyone will have a different level of tolerance for that and I think being able to help our coworkers who are really beset with a lot of distress around that might be quite important as we navigate coming together again.
Eric Zillmer, PsyD: The next question is something I've been wondering about: When we return to work we will have certain directives about mask-wearing behavior, which has been really complicated in our society. I mean we have almost 100 percent seatbelt compliance, right? But what is your cognitive behavioral take on why people have difficulty complying with masks?
Donna Sudak, MD: I'm not sure it’s a cognitive behavioral take, but I'll give you my take. One is that they're uncomfortable. They’re hot. In some ways it's very difficult to not be able to see expressions behind people’s masks. And we're just not accustomed to it as a society, although in other societies and cultures this is seen as normal behavior.
I think that the important part is that just like with seatbelts, just like with smoking, it needs to become unacceptable to not wear a mask. We need to remind people in our midst to continue wearing the mask. We need to ourselves model wearing masks at times when we’re with others in order for it to become what is socially desirable to be doing. And we need to find comfortable ways to do that make it easy for people to do the right thing.