Using MASK to Cope With Pandemic-Related Anxiety

Lorenzo Norris, MD; Eliza W. Menninger, MD


January 05, 2021

This transcript has been edited for clarity.

Lorenzo Norris, MD: Hello. This is Dr Lorenzo Norris, editor-in-chief of MDedge Psychiatry. Today we are pleased to have Dr Menninger with us, who's going to talk about the effects of COVID-19; ways in which we can deal with this high level of anxiety, which I'm absolutely sure people are feeling; and how we can think about what kind of resources we internally have and how we can bring them to bear as we deal with all of the stresses related to the COVID-19 pandemic.

Dr Menninger, welcome to the Psychcast.

Eliza W. Menninger, MD: Thank you. I think that the anxiety I've seen is related to many things. People have anxiety as they approach the holidays. What I notice most with people is the fear of the unknown and uncertainty, both of exposure to themselves or potentially exposing somebody else.

There's another aspect of isolation that has come with it. There are many people working from home, so there's stress about feeling more isolated and the sense of feeling trapped in the home. Those are the two big things that I've noticed, with people not only feeling that they can't get out, but also that if they do get out, the worry of a potential exposure both to themselves and to those that they love.

Norris: You gave us a number of different things on which we can focus. I want to go back and get your take on how the anxiety and stress have developed throughout our time and our experience with the pandemic, maybe going back to March. You serve as medical director of the partial hospitalization program, and I'm sure you've seen firsthand in your patients and your staff how, again, the anxiety, while present, is maybe transformed in regard to what are the triggers or the stressors.

Menninger: I think the first thing people noticed was significant uncertainty, and this immediacy of "You're not coming in to work tomorrow, we're closing things down, and suddenly you have to change everything." I think people could really rally around that initially — okay, it's going to change that; we can manage that.

As things adjusted, there was a sense of How long is this going to last? Is this lasting a month or 2 weeks or longer than that? When people thought about longer than that, it was more challenging. I can do this for a day. I can do this for a week. But if you're talking about 6 or 9 months of anxiety, well, what's the end game and what's the plan?

There was uncertainty regarding what's going on, what is this disease, and how to respond, which transformed to how are we going to sustain this so that it could be effective? We decided to do a virtual day program. How are we going to sustain this? How are we going to keep up our census? Will insurance companies continue to pay for virtual? I think that was the next step. Then there was the whole step of, can I keep doing this? Not only that this is getting old, but is this enough for me? Should I be doing more? When is the next wave?

Norris: Let me just go back to that again, that idea of the initial uncertainty and just trying to wrap your arms around that. Maybe you could share with us because this gets into anxiety, but it also gets into practical points. You have to convert your partial program as medical director into virtual, like all of us, overnight.

What are some of the challenges in doing that, particularly with the idea of addressing patient anxiety, and maybe even staff anxiety, in regard to this uncertainty and, as you alluded to, sustainability, and how are we going to navigate it?

Menninger: My recollection was first that people are not used to virtual. I think one of the great things that's come out of this is we realize that telehealth actually works pretty well and that you can connect reasonably well over telehealth. I initially was like, well, we're used to in person; it's not going to be effective. The first was, would this even clinically make sense? The next was, what's the technology to do this? The third is, how do you connect the staff around it so that you make sure you still have the sense of clinical cohesion in treating the patient?

We found that there were many meetings, first in person, and then as there was acknowledgment that you really did have to stay at home, how are we going to make this work technologically? There were so many amazing people who figured out what platforms we'd use and how we would shift the program to continue to have groups in such a way that patients could respond.

Also, I think we rolled it out slowly so that the patients who first started and the staff were more comfortable. We tended to start out with patients who had been in our program and had to take a hiatus, so they knew what the program was. We were in this together because they had stopped suddenly and we had stopped suddenly. They were able to come back and were excited because they knew what the program was. As we rolled it out, we could begin to invite more patients in because everybody was more familiar with the technology.

Norris: Absolutely. Dr Menninger, as the pandemic progressed and you're seeing things in the partial program, we're ramping telehealth up and we are doing what we need to in order to serve our patients. Did you see a change in the anxiety or any way that it transformed as you approached the summer? I'm really curious in regard to what you saw in the patients, or even just your community, in terms of that mental attitude or framework as we entered the summer. For some people, we might have been entering into the lower end of that honeymoon phase of the emotional phase of response to a disaster. I'm just curious about what you saw in regard to the anxiety there.

Menninger: I think it shifted from "How are we going to make this work?" to "How long are we going to have to make this work?" I feel like people shifted from "How am I going to see the next patient?" to "How are we going to sustain this and for how long are we going to sustain this?"

Initially it was sort of like, "Okay, we're going to do whatever we need to do to make this work." And then it's "But we may have to do this for longer than 3 months. How are we going to sustain our morale? How are we going to support the patients?" Suddenly, it is not just a 1-month thing. You're going to probably have to work from home a lot longer. How are we going to support our patients about ways to manage working from home? That's a whole different ball of wax. How do you have a boundary for work? How do you have a boundary for home?

Norris: We're going to get into that. I want to hear your thoughts about that, particularly as it relates to coping and being flexible. I want to go back to what you said during the summer, because as you describe it, you are so correct. I do think that things change. When I think about the change, I go back to what you said earlier about uncertainty, not knowing. I think about the initial stages of the pandemic where there were kids making PPE because practitioners and patients were dying. We didn't have enough PPE.

Once we stabilize a bit, I feel like that fear starts to transform into worry about how can we sustain, again, those two components of anxiety. I think about that fear and how can we sustain.

I'll tell you another thing that I think started to hit me and maybe some of our listeners out there. We are interdisciplinary, so my colleagues in nursing, social work, psychology, psychiatry, and internal medicine, and we even have lawyers, listen to the Psychcast. This is a shout-out to y'all.

What I think about, in addition to that worry that Dr Menninger started to make us think about, is that you start to experience loss. I didn't realize how much loss I experienced until I missed my daughter's eighth grade graduation. At first I was kind of like, oh, well, you know, we're rallying. Then I was like, dude, that kind of sucked. I was looking forward to the eighth grade graduation.

I started to think about everybody who missed those graduations and all of those things. Then, you're like, wait a minute — is everything going to start to be like this? How long can I sustain?

Now, take us into, in terms of how long can you sustain, different things you've seen in regard to what people have been doing to sustain to this point. What type of coping has been there or what has been working from your vantage point in a partial program?

Menninger: I think the biggest piece is kind of accepting that it's different. If you can realize that your daughter was not the only one who had to go through virtual eighth grade graduation, that we're not alone in this. Some of it is acknowledging that it's different and allowing yourself to say so. But if "different" means that next year I'm going to be able to celebrate Thanksgiving with my family as opposed to this year, that's a good thing.

We had trouble when we first had to wear seatbelts. Who wanted to wear a seatbelt? But then you realized, "Hey, if I wear them, I actually might survive a crash." I think part of it is acknowledging that different is different, but if we can be healthy, we'll get to the next year. Part of it is recognizing the resilience.

I have this acronym I came up with called MASK. M stands for make boundaries. When you're at home working from home, make sure work is in one area and home is in another area. If you can have the boundary, then you don't roll out of bed into your workplace and just feel that it's so blurred and that you're kind of always in one place 24/7. You really separate things out, which will help your sense of remembering what it was like to commute to a place and have a separate space for work vs home.

A is avoid the virus. One of the things we've learned is how to avoid the virus; know how to do that. My favorite is for those who used to sing to their kids, "Head, shoulders, knees, and toes, knees and toes." Think about it: Hands, eyes, mouth and nose, mouth and nose. Then you can find a way to realize that we can manage this virus and protect ourselves and those we love.

S is stay connected. We're doing a lot of connecting via the virtual, but it's connected. When you see somebody, you feel like they're present in the room with you and it's not just a virtual thing that you can click off and suddenly they're gone; they actually feel present.

The K is keep the faith. We have a vaccine and we have hope. I think that's one of the things that helps with my patients. You can manage this; we have managed this far. If you've managed since March, you can manage to next March. That looks like when things are going to roll out and we'll be in a better position. Keep the faith, have humor, have hope. We can do this as a team. We are all in this together.

Norris: I'm really loving MASK. I love that. And as a guide, many of the listeners know I'm a big DBT [dialectical behavior therapy] fan; in Marsha Linehan we trust.

I love MASK because the acronym is active. Every time I do it, I can think about it. You need to write a paper or trademark it or something.

Let's go through that a little bit, because I think that this can be very powerful for ourselves as well as our patients. Talking with other folks that have been on the Psychcast, this pandemic is different in so many ways. For me at least, the biggest difference is that we are all going through it. Absolutely, one of the things that I think about is whatever we recommend for our patients, it gosh darn sure better work for us, too.

Let's go through making boundaries. What do you think is a key improvement area or mistake that people make or overlook when they're trying to make boundaries in this pandemic, like something they should avoid?

Menninger: Well, I'm always amused that people focus on the negative; I focus on the positive. I think part of it is being overt about creating them. Rather than just rolling out of bed, you get up, you wash, you pretend as though you're going to go to work, as opposed to just throwing something on and like 5 minutes later turning on your screen. You act the same behavior that you would be doing and also take breaks.

I think the idea of Zoom fatigue is real, so make sure you shut off your screen, get outside. Keeping connected is connected with the world and your people — your friends, your family. When you're in a room with four walls, you just feel so closed in and trapped. People are feeling more trapped, and I think part of the reason is that they've got to get out.

You've got to realize, sure, it's going to be winter, but that doesn't mean you can't still go outside. Yeah, you're going to have to wear a coat, but the world is still out there. Make sure you overtly create times when you get out.

Norris: I think about that in terms of "make boundaries," and I like that you started with how you start. One of those things that I think about in terms of making boundaries actually starts with your own internal sense of boundaries and how you — if I'm hearing you correctly — felt that how you internally say, Wait a minute, the boundary of me getting out of bed and going to work needs to be maintained and I need to do that. That's a very important thing. I think that's hugely important in terms of that internal boundary.

Now with "avoid the virus," I can't top you. I can't sing like that. Can you say the song again?

Menninger: It's "hands, eyes, mouth and nose, mouth and nose." The hands, you wash. The eyes, I really urge people to get some sort of eye protection if they go out in public. It's easy and it does protect you. The mask is mouth and nose, mouth and nose. It just is something you can always remember, have ready in your car. You get in from grocery shopping, you sanitize your hands, and you take off your mask. There's such a pattern and it's doable.

Norris: I'm with you. I like how you did it, but I'm actually going to put a challenge out there to the listeners. If anybody can put that to a pop beat or a hip hop beat or whatnot, I want to hear it. Send it in. Honest to goodness, I will go on a podcast and recite it. Somebody is out there; some artist is out there in the audience who can do this or put it into additional music.

The thing I like is that whatever it is that you do to avoid the virus, it needs to be part of your routine. It has to be something that sticks with you, that grabs.

Now, the S. I have to hear more about this. Not just connect, but "stay connected," which is very different. Let's be honest: We've been dealing with the issue of a whole bunch of connection with no connectedness. As a matter of fact, connection without connectedness, depending on what generation you're in — I think there's no bigger stress of anxiety or worry than anything I've ever seen than debating whether or not 100 or so people like or dislike your most recent post. Go for it — that connection without connectedness.

Menninger: Actually, the beauty of that came from a patient. It was a patient who said that. It's the sense of connectedness between ourselves, between our colleagues, between our family, and I also think between our country. If we can find a way to remind ourselves that we are in this together...

Norris: Let's give a shout-out to our patients. One of the things I always talk about with my residents and my medical students is that the people who teach you are your patients. Make no mistake that everything, whatever textbook you might be reading — shout out to NYU and Kaplan and all those folks — all of that was paid for. Every single piece of knowledge that we have was paid for.

I always say that if I said something smart, I learned it from a patient. If I said something goofy, that was me trying to be cute and too much of an academic.

What can we think of in terms of something that you've heard a patient or a colleague or someone do where they've really transformed "connecting" to "connected"? What's one thing that you've seen somebody do that might stick with folks listening?

Menninger: Truthfully, the thing that always jumps to mind is humor. I feel like if somebody can make you laugh, it feels so visceral and just genuine.

Norris: I love the humor. I think humor, music, exercise, nutrition, sleep — I may have missed a few — are your frontline meds. I say that all the time. I love the humor. I'm going to add to it because it flows into my example.

You really can stay connected with people if you know how to turn your conversations into stories and narratives that people can participate in. When I hear a really good story that makes me laugh and just cry to tears, I feel connected. We can take inspiration from folks in the arts. How does a comedian connect with people? Folks can feel connected. You just have to really work at how you do it.

I do want to go back to something you said that was so very important. I just got off the phone with a colleague who said that they were so incredibly stressed about the political turmoil in this country. Look, we are not getting into politics. We are not taking one political side or another. We are about health.

I do agree with what Dr Menninger said, that one of the biggest issues here is that we are not connected. We are not connected. When I think about that, I'm going to quote one of my colleagues — she may not have said it herself, but she says it all the time and I love it — we have stopped being curious about what other people think.

Menninger: Exactly. I think the more our hope is to understand each other — I have this sign behind me that says, "What people really need is a good listening to." We need to see more of that. You know — just listen. There's a wonderful book called The Art of Hearing Heartbeats. That's what we need to do. We need to hear what other people are feeling.

Norris: I agree with you completely. Hearing, spirit of curiosity, all of those things, if you will, take time and effort. Again, all of this in terms of connectedness lends itself with taking time, mindfulness; it lends itself with any type of psychotherapeutic approach that you want.

Again, going back to what Dr Menninger said, I really like MASK because we're looking for something that can package up a lot of different things that are immediately at our disposal that we can actually use in real time.

Now the final one, my favorite: "Keep the faith." What does that mean?

Menninger: One of the things I have on my mailbox is a heart that says "Hope." We will get through this. It will end. We are a resilient nation. It's just remembering, I think, that it's just one step at a time and just put one foot in front of the other, like the Abominable Snowman did when he learned to walk. The more you say "I have supports, I'm not alone, I have hope" — as my old, gray-haired daddy used to say, "Keep the faith."

Norris: Let me ask you a couple of things in regard to keeping the faith. Can you give me an example when a member of your staff showed you something or demonstrated something in the midst of this pandemic where you're like, wow, that gives me a sense of hope. Can you give me an example?

Menninger: Oh, I think it's the desire to figure out "How do we help address what's happening with this patient? I have some ideas." Working together on rounds to say, "How do we put this all together to help this patient cope better? I have an idea." The desire to collaborate and emphasize that we want to make a difference, and here are some ideas we have.

Norris: Can you give me an example from the partial program, or just even themes or examples where your patients have done some things where you were just like, whoa, that's hope that works. That's keeping the faith.

Menninger: I think their ability to be creative about how they think about their jobs, their lives, their interaction with their family, whether or not they're creative about how to connect with their family, just that willingness to keep trying. I think that's the thing that I'm always impressed by, because everybody feels overwhelmed in terms of "How am I going to do work and how am I going to do treatment, and how am I going to take care of my family?" And the fact that they keep trying, to me, that in and of itself is huge.

Norris: I agree with you. There are so many examples, but one I can think of recently is with one of my patients in a very difficult spot. He said, "Doc, as I start to think about this" —We can say this is reframing, if you will, but we're going to think about the positive — he said, "You know what? I'm going to use this pandemic [positively;] there are many people I shouldn't have been in contact with, so I'm going to use this and not be in contact with them in terms of the substance use."

"I actually remember I used to go to church. Hey, I might as well try it now." "I'm going to be in a homeless shelter. I'm going to be doing things, but I figure if I go to church, I can start to work my way up and I can do some things." I was just like, whoa, that's all right. That's kind of what you're saying — how can I build off of this?

When I think about my colleagues and everybody out there listening, depending on when this drops, unfortunately you're going to be at capacity in your hospital beds; your ICUs are going to be full. You may or may not have had your Thanksgiving plans canceled. You may have had, at this point in time, people, certainly patients, that you know pass from COVID-19, loved ones that you know with COVID-19 or those that haven't passed with COVID-19.

[It's about] the very basic way in which people just keep showing up to work, and they believe in why we are here and what our humanitarian mission is.

Dr Menninger, anybody who knows me knows that I like it short and sweet. You have given me an exceedingly powerful and useful way to think about this. Every time I put on a mask, I'm going to think about what it is that you say. I'm not going to be able to do the song, but I most certainly am going to be able to think about keeping the faith.

Menninger: One last thing I'll say, which is what you have pointed out beautifully with your patient and what you've said, is that people have used this time to be creative. They've taken advantage of this to ask, "What are some things I would have done otherwise that I can now do?", and to really encourage that creativity, just like you did and just like your patient did. That's the beauty of it —to use this time to build on your strengths.

Norris: Well, there we have it. Build on the strengths of creativity. Dr Menninger, thank you so very much for joining us on the Psychcast.

Menninger: This was a real pleasure. You are just a treat to talk with. I really appreciate being involved and helping in any way I can.

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