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Kaz Nelson: How to identify and respond to four common mental-health responses to crisis

Psychiatrist and educator Kaz Nelson discusses four common mental health reactions during the coronavirus crisis: psychological stress, grief, isolation/loneliness and panic.

Kaz Nelson
Kaz Nelson: "If all of this had happened just five years ago, I don’t think that this attention to our collective mental health would have been part of the story."
University of Minnesota Medical School

Like many people around the world, my feelings of stress have been ramped up by the news about COVID-19. I’ve been thinking about ways to approach this topic in my writing, and the truth is I’ve been reluctant — mostly because I don’t want to go down a rabbit hole of worry and have a hard time climbing back out.

But I know that I need to address these issues and write about how they are impacting Minnesotans’ mental and chemical health.

Looking for a way to put COVID-19 in a mental-health context, I reached out to Kaz Nelson, associate professor and vice chair of education at the University of Minnesota’s Department of Psychiatry and Behavioral Sciences. Nelson, who, with her brother George Joyer, created the podcast, “The Mind Deconstructed” as a way to talk to talk about mental health in the context of current events, seemed like the perfect person to talk to for my first COVID-focused article. If I was going to put my toes in the water, I figured it’d best to start with her.

Nelson, as one might expect, had plenty to say about the mental health impact of COVID-19. She’s been observing different people’s responses to this crisis as she virtually moves around the world. The latest episode of her podcast digs deeper into this topic, offering observations and advice about how to understand — and cope — with a range of pandemic-triggered mental health responses.

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I talked to Nelson from her home office, where she’s preparing to teach online courses to her medical students and psychiatry residents.

MinnPost: These days, COVID-19 is the only thing that people are talking about. That has to be taking a toll on our collective mental health. As a mental health professional, what are you seeing? Does it seem like people’s stress levels are running higher than normal?

Kaz Nelson: I’ve been heartened that even though there’s been all this talk about physical health and not getting infected, there has also been a more prominent sliver of reporting that acknowledges, “This is affecting our mental health, too.”

If all of this had happened just five years ago, I don’t think that this attention to our collective mental health would  have been part of the story. Even just five years ago we weren’t having those kinds of conversations. But now there has been a little bit more willingness to acknowledge this toll that it’s taking, for people to talk openly about their mental health. For media outlets to be reflecting on this is really different.

MP: So recently you’ve really seen a significant change in the way people are discussing the mental health impact of serious world events?

KN: Even with all the mass shootings we’ve been experiencing over the last five years, even then people weren’t talking about the mental health impact. Of course, the usual little pockets here and there were speaking out on that subject — NAMI was talking about it, of course — but this is something else. There is a clear drumbeat through all of this that is really different.

I think we’re experiencing a real shift here. People are acknowledging, “This is real. It is really happening. It is really impacting our mental health. We are willing to talk about this.”

MP: How are you monitoring this new, more mental-health-aware response to COVID?

KN: Just like everybody else, I’ve been glued into different social media sources like Facebook and Twitter. There’s a lot of noise out there, but one thing that I’ve noticed is that people’s responses to this crisis are tending to fall into four different categories.

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Last week, before I went out to record my podcast, I sketched out the four common mental health reactions that I’ve been observing and sorted them into four buckets.

MP: Interesting. Tell me more about these.

KN: Sure. They are:

  • Psychological stress
  • Grief
  • Isolation/loneliness
  • Panic

It’s important to note that some people might be having all four of these responses right now. Some might have just one of them. And some might not have any. I want to emphasize that however people are feeling right now that is just how they feel — there is no right or wrong reaction.

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MP: People experience these specific mental health reactions in other situations, right? This information isn’t just applicable to COVID-19.

KN: Yes. All of these things come up for people outside of this current circumstance in different ways. I just happen to be recognizing these reactions all the time right now. I’m informed as a psychiatrist and these observations are based on my years of practice recognizing these patterns in my patients. Right now, in talking with people and taking in a lot of content and conversations, I’m seeing all of these reactions surface.

These are universal patterns that human beings experience in different contexts. This is the type of context, because of the high stakes and the uncertainty we’re living through now, that would trigger all four responses. It is very serious and it is occupying so much of our time and attention.

MP: So why don’t we talk about these different mental health reactions and how to recognize them?

KN: Sounds good. Common mental health response No. 1 is psychological stress. What’s going on in the world right now is incredibly stressful: There is this sense of impending threat. There is a lot of uncertainty. Are we going to end up like Italy or like Singapore? What will this look like? And then there’s all this changing of routines: Is school canceled or not? What is happening with my work? With my income? Will I get evicted because I can’t pay the rent? All of this creates stress that leads to anxiety or a whole range of feelings.

MP: I’m guessing that psychological stress must be one of the most common reactions to COVID-19.

KN: Right now, the needs of this situation exceed our resources, which is the definition of stress. It is naturally very stressful. Everyone is being overwhelmed with all these things that they need to attend to and we’re not prepared to do that. This is unprecedented and scary, so it is only natural that people are going to be experiencing stress.

MP: So what response goes in your second bucket?

KN: Mental health response No. 2 is grief, which is different from stress.

Right now, people are experiencing grief from all of the graduations that are being canceled, the vacations that they’ve been saving for that are canceled. They’re experiencing grief from losing money, losing contact with loved ones, from funerals and weddings being postponed.

Superimposed on the stress that we all are experiencing is a very substantial sense of loss. And then if you actually know someone who has died from COVID, then you’d be dealing with actual bereavement from a death. This is a different sort of bereavement, the experience that people are typically talking about when they use the word “grief.”

Whatever kind of grief people are experiencing, it helps to say, “We see you. We see there is this grief in addition to this.” It can feel good for people to have their feelings and reactions recognized.

MP: What’s the third common mental health response that you’re observing these days?

KN: The third common mental health response is feelings of isolation and loneliness, particularly for the people who are not off-the-charts introverts.

There are a lot of people who feel morally compelled to engage in physical distancing and staying home from work and staying in. For some of us that can be incredibly isolating. In this situation, people can start to feel really lonely.

I live with five other people. So I never feel lonely. But that’s not universal by any means. There is a lot of isolation and loneliness out there right now. It can be a risk for suicide. That is something we have to pay attention to and not minimize.

MP: And what’s the fourth mental health response?

KN: The fourth mental health response I’m seeing lately is actual panic. This is a sort of anxiety or fear that builds to a point where it is completely overwhelming, where the intensity of the fear response makes you lose your capacity to think clearly or do problem-solving.

If you are experiencing panic, you might have an elevated heart rate or be sweating or have this impending, overwhelming sensation of doom. That’s the definition of panic.

MP: Are people more inclined to panic in times of crisis if they don’t feel confident in the actions that their government is taking?

KN: I have observed that many people report experiencing a deep sense of unease because they have a generalized lack of trust or attunement with the people who are in charge of the ship, so to speak.

MP: Why don’t we talk about some helpful ways to respond to these mental health reactions?

KN: That’s a good idea. Some of this is going to seem like common-sense advice, but I still think it bears repeating.

MP: So how do you help a person who is experiencing panic?

KN: For a panic response, there is a very specific reflex that people can trigger to bring down their panic, their heart rate, their breathing and the stress hormones that are exacerbating their panic. It’s practical advice, and it works.

In cases of panic, we instruct people to stimulate their vagus nerve by putting ice or ice water on their faces. That action physically stimulates the vagus nerve, which terminates a panic response.

This works even better when paired with a breathing technique called “paced breathing,” where you breathe out for longer than you’re breathing in. Try breathing out for eight counts and then breathing in for four. This can really help reduce the feelings of panic. It is a very specific ratio of breath out to breath in. It is important to breathe out longer than you breathe in.

MP: I like this advice. It feels really immediate, practical and helpful, like something anyone can do to calm things down right in the moment.

KN: It is helpful. It will go a long way in reducing your sense of panic from a 10 out of 10 to an eight out of 10, which is helpful.

Everyone is saying, “Don’t panic,” but I believe that if people could stop panicking, they would. Nobody is choosing to panic. The message that we’re hearing may be, “Stop panicking,” but it should be, ”Of course you are feeling that way. You aren’t alone. How can I help you move closer to regaining a sense of peace and safety? How can I help you not feel so overwhelmed?”

MP: I think social distancing means that these days a lot of people, especially those who live on their own, are feeling lonely and isolated. What sort of practical steps can a person take to ease that response?

KN: For the loneliness and isolation response, you really want to find creative ways to connect with others. This can be done over the phone or online. It helps to be deliberate about it, to even schedule interactions. When times get tough, it can be easy to just isolate, but it is important to keep your social connections strong. Making phone calls, sending texts, even old-fashioned letter writing can help you feel connected to others.

Maybe now is the time to dip into social media — unless exposure to social media is creating mental health problems for you. If it works for you, you can develop connections with known people or reach out to new friends through different online groups. There has also been a lot of talk recently about interactive video gaming. This is a way to connect with other people in a virtual space. For a lot of people, that can be meaningful.

Another way to curb feelings of loneliness and isolation would be going outside and walking with someone while avoiding close physical contact.

MP: Humans really are social creatures, aren’t they? There’s been so much said lately about how our automated modern lives already create distance between individuals, but this experience is showing us just how important our social connections are for our mental health.

KN: This might be a good spot to mention that social distancing can be confusing. We are trying to encourage socialization while being physically distant. It’s important to do your best to maintain social relationships however you can while also being physically distant. Words and conversation can go a long way to build connection. And connection is really important right now.

MP: Are you still seeing patients in person? What do you think that people who really need to see their therapists for mental health support during this time should do?

KN: We’re trying our best to move to telehealth for everyone’s safety right now. If you do go in for a face-to-face appointment with your therapist, bring disinfecting wipes and sit on the other side of the room.

MP: In other words, don’t share the couch.

KN: (laughs) Even in normal times, a therapist sharing the couch with a patient isn’t best practice.

MP: What are your tips for helping to ease the grief response to COVID?

KN: With a grief response, my advice for coping is going to be similar to the advice I’d give for coping with psychological stress. The important thing with grief is letting yourself or your loved one grieve, identifying that what you are feeling is grief and reminding yourself or your loved one that it is OK to have those feelings and they are natural. It’s self-validating.

Sometimes just sitting with the grief and observing it allows it to pass productively. The idea is to not minimize it or say, “That’s not important,” or, “Of course we have to cancel things. Otherwise people will die.” It may be logically understandable that these things need to be canceled, but it is still important to acknowledge that here is a loss and feel it and sit with that loss. It legitimizes the feelings and eventually helps people heal.

MP: What are your support tips for the psychological stress response?

KN: Most people have a broad toolkit they like to use for emotional regulation, self-care stuff like exercise, nutrition, limiting the reading of upsetting news stories or reducing social media use. It can help to employ some of those tools. You can employ an ensemble of strategies for self-care and emotional regulation. Even something like binge-watching a pleasant TV show can be effective for bringing down the intensity of psychological stress. Be really careful about using alcohol or other substances as the primary strategy to mitigate stress. That can backfire really quickly.

Another helpful strategy for reducing psychological stress is to find ways to pitch in and help others. Providing assistance to others, even in little ways, can channel internal stress.

MP: I know that young people are experiencing a lot of psychological stress right now. What’s the best way to respond to a child or a young person when they’re talking about their stress and anxiety around COVID?

KN: A good response is to take what they’re saying seriously. Be proactive and not minimize what they are saying. People tend to tell kids to minimize things. They don’t always think that their responses are valid. And when young people hear messages like, “You should just get over it,” they tend to suffer even more.

Recognize that these are all legitimate responses that people will experience in this time of crisis. It is our job with our loved ones to validate first, to say, “Of course you are feeling this way. It is natural and a lot of people are also feeling this way.”

The ultimate message is more, “How do we work together to solve this problem?” vs. “Don’t feel this way.”

MP: It can be hard to avoid the impulse to try to “fix” feelings of grief, stress, isolation or panic for others, especially for people you love.

KN: A great way to deal with that is to use the “yes, and” technique instead of the “but” technique. Using “yes, and,” acknowledges that both things are true, rather than negating one for the other. It helps to validate a person’s response. When your feelings are invalidated, when someone responds to your concerns with “but,” it is jarring and confusing. It doesn’t allow us to move toward recovery.

MP: So you’re saying that the emblematic British World War II saying, “Keep calm and carry on” is an oversimplified response to stress, isolation, grief and panic.

KN: I think “keep calm and carry on” is the affirmation, but what comes before that? There needs to be further affirmation of these mental health responses, an acknowledgement that they are all normal and appropriate.

These kinds of messages are likely circulating around the state. “Keep calm and carry on” is emblematic of British reserve, but that stiff upper lip is a very Scandinavian thing, too. It only works when it works. It’s pretty culturally specific, and we might want to be looking at other cultures for other ways to respond to what’s happening right now in our world. We need to treat ourselves and others with care.