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Therapeutic Presence in the Time of COVID: Podcast with Keri Brenner and Dani Chammas



"It's not about perfection...it's about connection." - Keri Brenner

This week's podcast features a dynamic duo of palliative care psychiatrists, Dr. Keri Brenner from Stanford, and Dr. Dani Chammas from UCSF.  Dani was a huge hit as a guest on one of our earliest podcasts talking about "Formulations in Palliative Care."

This week, Keri and Dani talk about "Therapeutic Presence," an important concept in both psychiatry and palliative care (links to articles about this concept and application here, here, and here).  They describe 3 key ingredients of therapeutic presence, including being deeply attentive, naming (I'd call it complex naming), and creating a safe "holding space" for patients' emotions.

But come on, you might say, we're in the midst of a pandemic.  How can we maintain a therapeutic presence in a zoom meeting with family members you've never met, or with a patient who has a disease that could spread to you and infect not only you but your family.

Keri and Dani speak to the challenge of taking on the strong emotions we're all feeling during this pandemic - anxiety, fear, and the unique vulnerability this disease places on us as health care providers.  They note high rates of depression, anxiety, and other adverse mental health outcomes for healthcare workers in China who dealt with COVID.

In this time, what can we as palliative care providers do? (I'd add geriatricians to that) As Dani says:
I would say it's like we're chefs being asked to cook in an unfamiliar kitchen.  The rules of the game are different, yet at this time in palliative care we need to be mindful and reach for those core ingredients that we know work.   
We as a field have to think deeply about what we want our presence to be in this pandemic.  What do we want to be offering?  We care about protocols, treatments, predictions - we care about all this stuff our colleagues are talking about.  But maybe, just maybe, there is something else that we are uniquely suited to be giving right now that others can't give as well, and that's therapeutic presence.   
Panic is spreading like fire.  We still have to be mindful.  Slow things down.  Be intentional.  Name the core experience.  
To all of our colleagues who might be listening - we hear your anger, your pleas, your fear, your tragic stories - and yes, yes, yes to it all. This is deeply scary.  This is unsettling. This is upsetting.  We have to be the voice naming that in palliative care.   
Keri likes to call us, "Heroes of uncertainty" and I think we are.  We have to be the ones who log into the zoom meeting with family and say, "We can do this.  We can tolerate this uncertainty. We can walk down a path with you where we can't see three feet ahead."  We've been doing this with patients all the time.  Waiting with cancer patients for their scans - they wonder, has their cancer come back?  Has it not come back?  We don't try to guess what their scans show.  We say "yes, this is hard, we don't know." And we walk that path of uncertainty with them.   
When you're putting on your mask to see that patient, we can use use it as a ritualistic cleanse. Put aside myself. Put aside aside whatever craziness in society, so I can be fully present and create a holding space for our patients.  We have to do the same things we've been doing all along, we just have to be more intentional about it, because the rules of the game have changed, and we can't go on autopilot.
This was an awesome podcast.  It was like a therapy session for our collective GeriPal souls.

I hope you enjoy it as much as we did.

To stay up to date on relevant links, check out our new COVID page.

-@AlexSmithMD





  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have two people on the call with us today.

Alex: We have two people joining us. Welcome to the GeriPal Podcast, Keri Brenner, who is a palliative care physician and a psychiatrist at Stanford. Welcome.

Keri: Hi everyone. Thanks for having us.

Alex: And then we have, welcome back to the podcast, Dani Chammas, who was with us in one of our earliest episodes. She's also a palliative care physician and psychiatrist at UCSF. Welcome back, Dani.

Dani: Hi. Thanks for having me back.

Alex: What was that first podcast you did? What was it about?

Dani: It was on therapeutic formulations?

Alex: Formulations. That was a great podcast.

Dani: I like how you're just pretending that you forgot that [laughter].

Eric: And today we're not going to be talking about therapeutic formulations. We're going to be talking about therapeutic presence? Is that right?

Dani: Yeah, that's right.

Eric: And maintaining therapeutic presence in the midst of this Covid pandemic. Before we go into that, we always start off with a song request. Do you have a song request for Alex?

Dani: We do, but before I share our song, I just want to put out there the life lesson, that it is a terrible idea to ask two psychiatrists to analyze together what the right song should be [laughter]. But after like a lot of psychological back and forth, I'm happy to report we landed on the brilliant choice of the theme song from the show "friends".

Alex: Great. Good choice.

Alex: (singing)

Eric: Now we just got to all finish by dancing in a fountain [laughter].

Keri: Exactly.

Eric: And have the biggest apartment in New York city.

Alex: Yeah. Gigantic.

Eric: It's a crazy world where a barista can afford this monster apartment.

Eric: Therapeutic presence. Before we talk about how to maintain it in a pandemic like the one that we're in right now, what the heck is it?

Keri: So therapeutic presence is about the relationships and the connection that we cultivate with patients and their families, that we feel is one of the most fundamental aspects of what we do within palliative care. We know that we actually have a very robust skill set already in our field, the developed way of thinking about things like symptom management and communication techniques. But yet we also know that there's this third element of what we do that has a lot of benefit and value to it and that's therapeutic presence. We feel that the more that we can identify these skills and employ these skills, we can be catalysts of calm catalysts of clarity, catalysts of constellation in this time of distress and anxiety.

Alex: Dani, anything you'd add to that?

Dani: No, I think she really nailed that one. It's interesting because we know within palliative care that there's a lot of research that shows that our presence leads to significant improvements in quality of life and mood. And we also have a lot of research that shows that our involvement helps promote better, more adaptive coping within our patients. And therapeutic presence is something that we think is one of the key features that leads to these beneficial outcomes in our work.

Alex: Now, when I hear the term therapeutic presence, it seems ineffable. Like what is this? I know when I'm working with trainees, some of them have a therapeutic presence. Some of them put on a show, like they are trying to have a therapeutic presence, but it comes off as insincere, not genuine. And patients often consensus it. And other times there are other folks I've worked with who just do not have a therapeutic presence. And it's like, I don't know. And sometimes it has to do with the particular relationship they have with the patient because every dyadic relationship is different. So for some patients who may come across as therapeutic and some not. Could you say a little bit more about like what are the key ingredients of a therapeutic presence?

Eric: I was just thinking back to your take out the trash video, Alex.

Alex: Yes, exactly.

Eric: ... Alex actually is all the palliative care communication mnemonics out there in his discussion with his wife about who should be taking out the trash. It was not therapeutically present for his wife in that cartoon.

Dani: Keri, do you want to start with this one?

Keri: Well, I would say, to be really practical, we could break it down into three sort of core features and active ingredients. And the first one is being deeply attentive. We are present in a way where we have the ability to sit with this and to not be terrified in the face of being with patients who have serious illness. We are attentive in a way that's undistracted, that's nonjudgmental, that's receptive. We're totally present in the moment. We all pay attention to the nuances of what's said. We also are attuned to what's unsaid. We are deep listeners. We allow for silence. We know that slowing things down a bit actually allows us to get there more quickly. And this process of being deeply attentive, it allows us to identify patient's strengths, to bolster their coping skills and to problem-solve with them in a much more personalized way.

Dani: Yeah, Eric, I distinctly remember the very first patient that I saw with you when I was a third year medical student.

Eric: Oh God. You're going to tell me how untherapeutic presently I was? [laughter]

Dani: Something like that. No, no, no. Probably.

Dani: I don't know if you remember, it was a sweet guy who like all he wanted to do was go on an Alaskan cruise with his honey. He always called her his honey. But yeah, I see it in your face, you remember him. But what has actually stuck with me for a decade, what I remember was I like the way that you pulled up a chair and sat down like you were sitting down with a dear friend. Literally like there was nobody else in that world or that hospital except for this guy. And I was floored. It was just a striking contrast to what I had seen as a third year med student so far. I think it might've been when I decided to go into palliative care. You've sort of been stuck with me for like 10 years.

Eric: Wow. I think that was the same case where we actually sat down and we use all the same things that we're supposed to use in palliative care. Like tell me more, what would that look like? And then one day another person came in and told the same story to somebody else and the only word out of that person's mouth was, "Well, that's certainly not going to happen. Let's talk about something that..." Well, that was not therapeutically present.

Dani: That was not, thankfully that other person wasn't you.

Alex: So it sounds like some of those elements are things that we can teach. Like you were talking about we are comfortable with silence, we slow things down and we get there faster actually when we slow things down. So is this something in your palliative care training, in your psychiatry training, where would you say you learned the most about therapeutic presence and was it qualitatively different between a psychiatry and palliative care?

Keri: I think that there our background with... Dani and I have many things in common. We're both psychiatrists and in the space of palliative care. And one part of our training as psychiatrists is that it allows us to have an awareness and to actually bring words to what's happening in the room and in these dynamics with patients and their families. And there's a lot of power in being able to identify that because when I'm in the world of palliative care, I see all these therapeutically present things that people are doing. And so the ability to identify those dimensions of it can be helpful.

Dani: And I'd say actually you guys in this discussion, you guys are hitting on what I would call the second key ingredient to therapeutic presence, Because we talked about being deeply attentive. And yeah, Alex, I do think we can teach that, There's this urgency to do and we can teach people to stop doing. And then Keri, I think you're getting into the second ingredient, which is like we name people's core experiences.

Keri: Yeah. That ability to name the core experience. And by naming I don't mean this superficial naming like, "Oh, that must be hard." I'm talking about real naming where we actually are able to put to words what otherwise is sort of that angst or nameless dread that patients and families might be experienced. Because we know that that ability to name something, to put it to words, to bring it to expression actually allows it to be less awful, where suddenly patients and families are able to feel more accompanied and supported by us, where it's a shared burden. By naming, we courageously go right into it and don't leave people alone with their fears.

Alex: Mm-hmm (affirmative).

Eric: Can I clarify that? Because I see a lot of communication frameworks out there, especially with this Covid pandemic. A lot of people are talking about these different frameworks. All of them have some type of empathize emotions and a lot of the naming is like, "Let's just practice saying that sounds like it's been really hard." You're saying that maybe there's more we should be doing? Can you tell me a little bit more? A little bit more.

Dani: Yeah. I love that psychiatrists line from you. Yeah, Keri and I actually agonized over if we should even call this naming because it's such a distinct thing we are talking about. We're talking -- asterisk, go to my podcast about formulation. We're talking about identifying the core struggle, the core experience that someone's talking to. So you're sitting in a family meeting and there's a million anxious questions. We're not talking about saying, "I can see that you're really anxious right now." We're talking about saying, "It is totally petrifying to think about living in a world without your father." We're talking about taking in everything we notice being attentive, digesting it for them and handing back what we think is the biggest... putting meaning to their experience, putting words to their experience. Two minutes later I might be sitting in a totally different family meeting with a million anxious questions, and again, I'm not going to say, "I can see that you're anxious." With them, I'm going to say, "I can see that it's totally petrifying to have to wonder if these doctors are missing something that actually could be working here."

Dani: Because I've taken in all of this stuff I've gotten in being present and sitting with them and I feel like I've tapped into the biggest struggle, the biggest distress that they have, and that's what I've put words to. And what happens when you do that? You guys have been in a meeting and had that moment when you hit the nail on the dot with what their experience, what happens in the room. I noticed there's usually tremendous relief.

Eric: Yeah. I was going to say relief too.

Alex: Yeah.

Dani: And things slow down and quiet and we're able to get to the deepest struggles and therefore the deepest parts of the solution.

Alex: Yeah. It's often a release of emotion when you get it right, because sometimes you get it wrong.

Eric: What happens when you get it wrong?

Alex: You go out on a limb and you try and put it together and they're like, "No, you don't understand me."

Dani: Yeah.

Keri: Well, and that's a part of why we... We also believe in process. So it's not about perfection. It's about connection. So when we're off a little bit, we get that feedback immediately from patients and families, and that's just more data for us to conduct more authentically and more deeply with them to try again. So it's not about perfection, it's about connection.

Dani: Totally. And if I say the wrong one, then the anxious questions are still coming. You won't feel the shift in energy in the room and you're like, "Got it wrong." And you try another one.

Eric: Are there other words that you use when you get it wrong to try to figure out what is-

Dani: When we get it wrong, I would almost in my mind go back to ingredient number one, being deeply attentive.

Eric: Mm-hmm (affirmative).

Dani: Your job when you get it wrong, and again where it's so hard to split these things apart or a little bit back into our formulation talk. But your job when you get it wrong is to sit and take in more because you've obviously digested a little bit. You haven't actually been attentive enough to understanding what their core struggle is. So go back to ingredient number one and then when it congeals into something else that's new, you put it in out there and you see if you got it right again.

Eric: I got another question. Going to Alex's question is like, is this something that we can learn? Because I certainly have days where I am flustered, I'm running around and I am not therapeutically present. Are there things that I could do in practice to actually get better at this?

Dani: Better at being therapeutically present or better at getting the right core experience?

Eric: No, just better at like just going back to one... And your number one was being present.

Alex: Deeply attentive.

Dani: Deeply, yeah, attentive.

Eric: Deeply attentive. Yeah. See, I got to be more deeply attentive right now. [laughter]

Eric: What can I do to practice being deeply attentive?

Keri: So it's a process of deep listening and so some of it is involved... I have certain things that put me into that space. For example, I have this little portable chair that I carry with me through the hospital on my inpatient consults. And when I carry that chair around and sit right with the patient, that's my signaling device to myself that I'm going into that space, that zone where that patient in front of me is the center and focus of all my attention and energy. And so some of these practices can help us get into that space. Right now we are being flooded with new rituals of hygiene in our life. These cleaning rituals of sanitizing our hands, washing down surfaces, donning and doffing, how can we actually optimize these rituals to put our minds and our emotional energy focus into a different space to be more present with patients?

Eric: Oh that's good.

Dani: And I would say you know like that's super irritating advice when people talk, because we hear a lot about mindfulness and palliative care and meditation and I feel like people are always like, "Just let it go and come back. It doesn't matter if you go a million places, let it go and come back." It's that simple. It's that simple. It's that simple. But when I think about being attentive, it is like that simple. Just try to stop getting anything done. Just try to be there with the person because we all know how to listen. Like I have not met a palliative care provider who doesn't know how to sit and listen and take it in. So just let go of any other agenda process and you'll be fine.

Alex: Well, there's one more thing that we need to forget about that I find is increasingly interrupting. And the trainees I work with get younger every year and I see more and more of this and this is it. This is what happens. Sorry, just one minute. Sorry.

Eric: For those who are listening, Alex is on his phone. [laughter]

Alex: I'm on my phone. Yeah, that's true. That doesn't come across in a podcast.

Eric: It does that.

Alex: Right. A phone is a major interruption. Yeah, even in these meetings.

Dani: I would say that the minute the med student starts third rotation, just be clear. Like if a phone comes out in a meeting, you can't get honors. [laughter]

Keri: We will even try to create this holding space for us to facilitate. I will take the pager or from my trainees and say, "Put your phone on silence. I'm taking the pager because I want you to be able to create this space." That sort of does bring us into the third active ingredient of therapeutic presence, which is creating a holding space. And that's another key ingredient of our work where we actually hold what we are hearing and what we are receiving. We hold this distress in a way where people feel heard and they feel understood and we model how to bear these things while still staying intact, while still staying hold. We model how you can hear and then receive these things without falling apart.

Keri: So in this way we actually become containers of the intense affect and emotional turmoil that might feel uncontainable to the people around us. And a lot of folks have written about this. I know that there was a JPM article called therapeutic holding that came out in February by Lyndon Manual, Vicki Jackson, Leah Rosenberg and myself, where we wrote about this dimension of our work within palliative care, creating a holding space.

Eric: So we'll have a link to that article on our GeriPal Podcast show notes, but what does that actually look like? How do I hold?

Dani: What is the holding thing?

Keri: Go ahead, Dani.

Dani: I will say the holding space is revered. In psychiatry, we love the holding space. You know when in internal medicine, when you guys like when in doubt just gets lupus, it's like in psychiatry, when in doubt, like create a holding space.

Eric: So the whole thing space is, "Oops, sorry, you hour is up". [laughter]

Dani: No, not quite. But, I personally can't think about holding spaces without thinking about parenting. There's totally linked in my mind because I know already that you're both parents, Alex and Eric, I'm going to actually put you on the spot right now with a parenting multiple choice quiz. All right? Are you ready?

Eric: All right.

Dani: You're ready.

Alex: Definitely.

Dani: Here's the question. Your kid has like some activity that they're super excited about, They can't wait to do it. And then something unexpected comes up that you have to deal with. Maybe for example, it's a-

Eric: Pandemic, let's say.

Dani: ... last minute work meeting. Yeah, maybe it's a global pandemic. Exactly. And your kid is super upset. They're pissed. Do you a, fresh it off and say, "Eh, just get over it. Don't be so weak." B, let there overwhelm whereas you're overwhelmed and yell, "You know what, daddy's upset too, kiddo. All right? And your attitude isn't helping. So quit whining."

Eric: Definitely.

Alex: That sounds about right. Sounds good.

Dani: See, you say something like, "Gosh I imagine this is really disappointing and frustrating." It can be a really big let-down sometimes when plans change. Are you sticking with B?

Eric: I think the answer is C but I think I automatically go to B. Although I've been trying to be more mindful lately, especially the last couple of weeks to try see out more-

Dani: To try and see out more.

Eric: ... just to be more mindful for before I go into B. But it's really hard not to.

Dani: Well, in fairness, we've all done all three, right, just depending on our state of mind. But yeah. See, the last one is the only one that creates a holding space. It sends the message, "I see how you feel. I get it. It's okay for you to have this feeling and I'll hold it with you." And Eric, even though you're joking that it can be hard to do this with our kids, you are doing this all the time with patients. When you're watching a cancer patient get some bleak diagnosis, how many times have you said, "Hey, look on the bright side." Never.

Eric: Yeah, never.

Dani: Never.

Keri: I don't think we do that.

Dani: We don't do that. But you probably also, I'm hoping, haven't like started sobbing and getting super upset about it and like the patient has to come and wipe your tears. Instead, you work to make this safe place for their pain and their loss and really like their whatever they're feeling. And you try to carry those feelings with them and that safe place that you've made for them to have the feeling and to have someone on their side holding that feeling, that is the holding space.

Eric: Mm-hmm (affirmative).

Keri: And we knew that patients go through this rollercoaster of emotions with serious illness where I was with a patient just this week who had metastatic pancreatic cancer. We were talking about him going home on hospice one moment and he knew he had weeks to live. And then the next moment he's talking about wanting to see his daughter graduate from college in three years. And we have this ability to hold that, hold all of those hopes, worries, fears, emotions with patients. And we know that these are normal reactions. It's a normal part of the process of integrating serious illness into our lives. And the ability to be present with patients is the holding space that we create with them.

Alex: This is really important. Really, it's I think the most abstract of the three key ingredients, being deeply attentive, naming and the holding space. I like the term holding because it makes me think of like holding your baby or just holding them up, creating a container for their emotion.

Keri: That's exactly what it is, Alex, because I can tell you that in moments of stress, when we're feeling vulnerable, it activates that need for attachment within all of us. The need to feel that connection and physical presence when we're children and it's an emotional connection when we're older. And that brings us a sense of security and constellation to integrate this new reality of serious illness.

Dani: Yeah. You sound like a psychiatrist. I don't know if you want to like go back to residency, but like Freud is somewhere being like, "Yes, yes, he hasn't gotten to the womb yet, but yeah." [laughter]

Alex: That's hilarious.

Eric: So I really like this holding because I got to say that there is part of me and I think for a lot of physicians, we can do the naming and then we want to fix what we just heard in the naming. Like, "Oh, this person's really sad. I got to make them feel better." And I got to say that's not just... We do this with our children. Then like I guess that's another thing that takes some practice to get over is this fix it mentality. I have to... And we even see this with like cancer patients and even how hard it is to talk about this with friends and family because everybody just wants to make them feel better. And I'm getting a sense also this holding I'm not going to try to make them feel better

Keri: Because I think we also know, Eric, that being Polyanna in our approach, that false reassurance gets us nowhere. If only that worked. If only that were helpful. I think we all desire that and we know that there are more effective things that we do within our work that help patients cope. And one of them is actually being able to help them embrace the paradox of living well while acknowledging their mortality and acknowledging the reality of getting sicker and dying and helping them hold that paradox of how do you hold both at the same time, both living well and an awareness of our mortality? And that's a very hard psychological task to do. And a part of our work with them is gradually gaining the ability to integrate that.

Eric: Mm-hmm (affirmative).

Dani: And I would say like, Eric, that urge to do something, I think we to reframe sitting with that moment, sitting with that feeling as doing something. We're showing this patient, we can tolerate this feeling. I can tell you this feeling, you can tolerate this feeling. When I work with trainees, if I could blanketly just give one feedback about that moment when people jump in, it's like just edit out the last line. Everybody always gets there, and you can feel it in the room and it's sad or it's somewhere or it's something and then there's this urgency to like, "But blah, blah, blah." Or, "But we can do blah, blah, blah..." to put something in and it's because it's hard for us to tolerate.

Dani: And so the concrete thing we can do, the concrete thing trainees can do is just take out that last line and tolerate it. Because the patient you're sitting with is going to have to tolerate that feeling long after you leave the room. So you can tolerate it a little bit longer.

Keri: And you're modeling that you can actually take it in without falling apart too. That you can take it in and still remain intact.

Alex: Mm-hmm (affirmative). So I'm hearing echoes of Vicky Jackson who Keri and I trained under in Boston and GH. I remember her saying what is the patient's reaction when you jump to reassurance. When you jump to reassurance, you're showing them, "Well, I'm so stressed out about this, I can't deal with it." And if your doctor is so stressed out about it that they can't deal with it, they have to jump to reassurance, it must be worse than I thought. This must be a horrible situation.

Keri: You're right. Yeah. She is one of my absolute main mentors in this space and she has taught me that you don't flee from the distress, you don't avoid it and you also shouldn't be consumed by it either. And so we walk that fine balance.

Eric: And any other tips before we move on? As far as, again, like Alex had, the holding seems also like, I think the hardest part. Any other tips on how we can do this?

Dani: I guess the one tip that I would want to say is I hear you guys are like... I've worked with you guys are amazing, so you're very humble when you speak. But I would also want to say in palliative care, we're doing it a lot. I see people doing it so much. So in a way I want us all to give ourselves more credit and just be aware of the fact that we're doing it. Because I think the more we can notice like, "Hey, I think I might've been creating a holding space in there for a really long time." The more that we have a language and point it out, the more we're going to see that this is something that we do, that we're able to do, that we can keep cultivating. If that makes any sense.

Keri: And I would say a lot of the communication techniques that we've been trained in are ways that we facilitate this. So when we say that we're hoping for the best and preparing for the worst, we have a plan A and plan B, we use the word and instead of but. Those are all ways that we help model holding the paradox and creating a space for all of the fears, hopes and worries.

Eric: So I was joking earlier about kinda Alex using all our palliative care mnemonics in the take out the trash video. We'll have a link to that too. But do you worry that I have the spikes mnemonic. I have this new mark, I'm going to follow it. Like Alex was saying, it becomes almost robotic and it actually potentially takes away from your therapeutic presence. You're so deeply concerned about what you're going to say next that you're no longer listening.

Dani: I can tell you right now that Keri is probably thinking, "Oh no, Mayday, Mayday. Don't start talking to Dani about this topic," because I feel this so strongly in my resistance towards the presence of mnemonics in the field of palliative care, which don't exist anywhere in the field of psychiatry. Or like you've got a N-U-R-S-E and it's just a deep breath. It's something that I have a resistance towards and I think just for that reason. I think at their core, the mnemonics are well meant and I don't want to throw them under the bus because when we use them they actually help us do these things. But yes, I think there's like a little bit of like you have to go from the N, to the U, to the R, to the S, to the E of a mnemonic that actually takes us out of the present, makes us less attentive.

Eric: I can see you're frustrated.

Dani: I know.

Keri: That was wonderful way to name the core struggle, Eric.

Keri: I would say that this element that we're talking about when we're discussing these active ingredients, it actually gives us the ability to know when to use these communication techniques and in what way to use them and how to use them. So it's a bit of the undercurrent of like what's the core struggle here and it allows us to know the when and the why.

Dani: Yeah. I would almost consider the techniques as like a pantry of ingredients but not as a recipe. And I think that's where we get it wrong. Sometimes we have to teach the techniques, people have to know what they can pull for. But this idea that like you do the sort of in a formula aggressive peed way, I think is somewhat flat.

Alex: Okay. So let's do reality check here. So therapeutic presence, this is all great, I love hearing about this, love learning about this, but... I'm going to say, but instead of and. But we're in the midst of a pandemic here. We're communicating with patients via phone, via video, via iPads to that ICU room across the glass wall-

Eric: Baby monitors, a lot of baby monitors.

Alex: Yeah. With family members who we haven't met in person, who aren't seeing patients in person. What do you see as issues with maintaining therapeutic presence in the midst of this pandemic?

Dani: Yeah, I can see Alex, you wear glasses. So you can feel me when I say if I put on a mask, and it's not fitted right, then my glasses fog up and unfog, fog up and unfog, like dark status in the room. But yeah, there's like a literal and metaphorical six feet between us. I think that is one of the two key things that is very, very different in the setting of this pandemic. We can't practice in the same way that we normally do. We can't connect in the same way that we normally do. What happens when you put those three ingredients that we talked about together? You get connection. You get connection. And connection is so deeply protective of the psyche of a person's mind when they are under stress. And so I think this virus is especially cruel because it says, "Hey, I'm going to make you super vulnerable," and then your necessary response is going to be something that takes away connection. That takes away probably the number one buffer to vulnerability.

Dani: I would say before... I do want to get into the key things, but I want to take a moment to make sure we mentioned, I think the other main thing that is so different right now in a time of pandemic is that we're experiencing vulnerability. There's usually a very clear line in the sand. You're the patient with cancer, you're vulnerable and I'm coming in, not with cancer to help you. Or you're the primary team. You're a struggling with this super-intense really difficult family. And I am the consultant coming in to help you, because you guys are overwhelmed. That's not going on right now. This pandemic is sparing nobody. You could get sick. I could get sick. Our colleague who gets sick, our loved one could get sick. We're all vulnerable to this.

Dani: And then there's this concurrent like pandemic of anxiety that has really spared nobody. It's probably been more contagious than the virus. It's touched us all. We're left with this uncertainty and this fear and all this change and it's in us all. I don't know why I'm thinking about this, but like I'll tell you that against my better judgment, I am in like a bunch of online mom groups. And there is like really nothing in the world or so I thought, that's more addictive and anxiety inducing than being in an online mom groups. Or that's what I thought until I started joining online physician Covid groups. Mom groups are like literally compared to online physician Covid groups. And I think it's true and I think it's really because like people are... It's like panic is spreading like fire, "Can I touch my kids when I get home or should I live in the same place and do I have this and can I test it and do I have masks?" And it's just this like anxious, addictive beat.

Keri: In addition to that, we there's now and we saw the Jam article from the end of March that showed the mental health outcomes of healthcare workers in China where it showed that 45% of them experienced significant anxiety, A third had insomnia, 70% of them had emotional distress. And so there is this sense of vulnerability within all of us.

Eric: I think I had all three of those.

Alex: Pretty much sure for us.

Keri: Yeah, yeah.

Dani: Me too.

Keri: I think that does lead us to... A lot of my colleagues as I've been talking about this in different settings, have asked, how do I keep myself intact? How do I keep myself grounded? How can I first be a therapeutic presence to myself before then being able to give this to others? And Dina and I have tried to think a lot about that piece of it in terms of how do we keep ourselves grounded and we've come up with some practical tips for that too.

Alex: We'd love to practice.

Dani: Yeah. And I do want to say, because I think Alex, you did ask a question that I forgot to answer. So I will answer it before we go there. But I think your question was like how do we give a therapeutic presence when there's a million barriers in the way? And I would say that it's almost like we're chefs being asked to cook in an unfamiliar kitchen. So the rules of the game are different and yeah, at this time in palliative care, we need to be really, really, really mindful about reaching to those core ingredients that we know work. And finding ways to do them. I think we as a field have to think deeply about what we want our presence to be in this pandemic. What do we want to be offering. We care about protocols, we care about treatments, we care about predictions, we care about all this stuff that our colleagues are talking about.

Dani: But maybe, just maybe, there is something else that we are uniquely suited to be giving right now that others can't give quite as well. And that is therapeutic presence. So let's pull up on those things. Deep connection. Panic is spreading like fire. So we still have to be mindful of slowing things down, bringing attention. We can still do that with all these barriers as long as we're intentional about it. It's not going to come as easily, we have to remember. Naming the core experience. I don't know. Like we have to find a way to do it right now in a way that doesn't invalidate it, but also doesn't incite extra panic. So I don't know who's listening right now, but I think all four of us here are going to take a moment to name for you.

Dani: All of our colleagues who might be listening, we have heard you guys. We hear your pleas and we hear your anger and we hear your fear and we hear your tragic stories that you're giving us and yes, yes to it all. This is deeply scary. This is unsettling, this upsetting. We have to be the voice right now saying that in palliative care. I would add, Keri always likes to call us heroes of uncertainty and I think we are. We have to be mindful of being the person who logs into the Zoom meeting or goes into the whatever meeting it is and holding onto the message of, we can do this. We can tolerate this uncertainty. We can walk down a path where we can't see three feet ahead. We've been doing this with patients all the time.

Dani: They're waiting on their scans, has their cancer come back, has their cancer not come back? We're not sitting there and trying to guess the scan, so then we're trying to do this for them. We're trying to say, "Yeah, this is hard. We don't know, but I can walk this path with you where I don't know what's coming three feet ahead." So that was two ingredients. So ingredient number three. And we have to create a holding space. And I think Keri, you started talking earlier about when you put on your masks or when you log into the Zoom meeting or whatever it is, like let that be a ritualistic cleanse. Like put aside myself, put aside whatever craziness is going on in society so that I can be fully present and create a holding space for whoever is needing it right now in this interaction I'm going into. That's a long way of saying, Alex, I think the answer is that we do the same things. We just are forced to be a lot more intentional about it because we can't go on autopilot because the rules of the games are different.

Alex: Yeah. That's beautifully said and an inspiring message for folks in geriatrics and palliative care who are listening to this podcast about our potential to do this work. It's not so different in some ways from what we've been doing all along. Keri, what else would you add in terms of practical tips that our listeners can take away?

Keri: I think that I asked myself a lot, if I'm going to be a container for others, how can I keep my own container from leaking? What can I do to be grounded? What can we do to manage our own anxiety? So there are a few things that stand out. One is process partners. So who is my inner circle of support?

Keri: One of my mentors in this space uses the analogy of about mountain climbing and being on belay. She says if you're climbing a mountain into uncharted territory, it would be utterly absurd to climb a mountain without being on belay, without having somebody supporting you on a rope where if you started to stumble, you wouldn't go and fall too far. And so I often ask myself, who is my belay? Professionally and personally, who can I rely on to vent, to laugh, to worry, to hope, to fear with so I can climb into this uncharted territory when I'm doing my work with patients?

Keri: The second thing that I do is I find it very, very helpful to focus on my immediate spheres of influence. I think that for all of us, we have a lot of altruism that brought us into this work. And using that though to harness our energy to focus on what are the immediate needs before us right now. So for me, I was on my inpatient consult service at Stanford this past week and my immediate sphere of influence was that list of 20 patients and families and the bedside nurses and the referring clinicians and trying to provide a therapeutic presence for them in those moments this week. And then when I met home, when I walk through the door every day, I have this quote from Mother Teresa that says, "If you want to bring happiness to the world, go home and love your family." And they become my immediate sphere of influence. And being able to stay focused in that way can be enormously helpful. And we can talk of... Yeah. And Dani, I know you talk a lot about spheres of influence too in your work.

Dani: Yeah. And I was just thinking because Eric and Alex, you guys sort of set up this cool thing where we can volunteer helping out via video in New York city for these three hour shifts. And I think that the concept of a sphere of influence is just going to be different for all of us. But in those three hours, your whole mind and being is there, and then the minute I turned it off, at least it's with the three kids who are probably waiting at the door for me to come out. But if you think about our colleagues in New York on the front lines right now, it's a very different sphere of influence to be able to focus very attentively on just what's in front of you, I think helps us right now. But Keri, I know you had a third thing. So-

Keri: The third thing is about how do we keep ourselves grounded? Joan Halifax calls it having a balanced diet, a balanced emotional diet in our life. So our work is very emotionally intense. We have moments that are fulfilling and moments that are exhausting. So how do we have an awareness of what brings us consolation in our life and what brings us desolation? And drawing upon actually those moments of consolation to carry us through the tougher times. And we all know what fills our cup. A lot of us use humor, a lot of us use gratitude. There are all sorts of practices that we know brings us consolation, allows us to have a more balanced diet. I know I personally have stopped consuming national and global news beyond about 10 minutes a day because there's enough suffering alone in the work that we do to go around.

Alex: Yeah.

Keri: I'm interested in what you guys do too, that maintains a balanced diet.

Eric: Well, I think one of the feelings that a lot of people have, including myself, we were on a podcast, our last one with Kai Romero from Hospice by the Bay. And there's a sense of survivor's guilt is that we see what's going on in New York and elsewhere, it's not happening here to the extent it is there. We are incredibly lucky because we have the gift of time to get ready. So I think a lot of us are pushing a lot of focus on that preparation, preparation, preparation, meetings, talking about the things that we're going to do if the surge happens. And it's somewhat relieving actually to do that and to focus on that. But what happens is eventually running out of things to do. And all of our energy has been focused on that. And then there's that sense of that relief. Like we're picking and picking and picking and there's nothing left to pick out.

Dani: It sort of reminds me of what you were saying earlier about how when it's hard to tolerate the feeling in the room, you're quick to want to fix it because there is something great about the fixing, right? But I would almost take us back to where we started when you say that and say that really, part of our work is to... Well, we have to do all the fixing and preparing that you're talking about, but part of our work is to ourselves sit with this feeling, this uncomfortable feeling, this guilt, this anticipation, this mix between like gratitude and dread and unknown and then we can tolerate it so well that now we can create a holding space so that all the other people, all the other colleagues that we're working with, all the patients were going to see, so that we can sit with them and help them sit with it. You talked about how it's hard to not add that line on and I'm saying sort of on a really meta level, don't add that line on here.

Keri: I was speaking right now of Fred Rogers and he says, if it's mentionable, it's manageable. And so if we can actually name that feeling of angst that we all have, then instead of it becoming sort of the 500 protocol that we've create, we can actually manage the emotion, if we can name it.

Eric: Yeah. In some ways it's helpful to have that. Part of like our desire to help our colleagues in New York is also part of our desire just to, "I want to help. I want to do something," but you can take it a little bit too far as noted by my constant Zoom meetings every 30 minutes.

Keri: And that's why I think that all truism of us. We know we have a particular skill set where maybe we can be helpful through TeleVisits for New York and so making that as sphere of influence. Okay? I'm going to do these TeleVisits for the next four hours and that's my immediate sphere of influence for this moment of time in my life.

Dani: And in this twisted way, I think it actually, as I hear you talking, Eric, I think it gives us a beautiful insight into what it might be like, not necessarily for patients in the pandemic, but just for the patients that we normally see. Like the rug got pulled out, their life got flipped upside down, nothing is in their control anymore. And we see patients grasping for things that they can do, things that they can hold onto. "Is there a herbal remedy? Let me look into herbal remedies." We see patients in this state of like, "Oh my gosh, the world's flipped upside down. Nothing's in my control. These feelings are hard to tolerate and I need to channel them into something." We see it all the time and now I think we're just getting a taste of it. The lines are blurred. We're all the victim a little bit right now and it might be good for us to be able to taste what it's like because we're sitting with a lot of people who are tasting this feeling constantly.

Alex: Well this has been great. Is there anything, also we're going to make sure we link to that article. We're going to link the take out the trash. We're going to link to the prior podcasts about formulations. Is there anything else that we should discuss today or any other resources out there for our listeners who may be interested in learning more at this challenging time?

Dani: Well, I also think a little bit you play with fire when you ask two psychiatrists if there's anything else that we can discuss today, because Keri and I could be here until tomorrow morning. But Keri, you didn't have a different article, the resource questions that easier. You didn't have a different article you wanted to share. Is that right?

Keri: We'll post some of the articles that are just good resources for thinking about this third element of therapeutic presence, therapeutic holding and creating a holding environment with patients. But I think our main takeaways are within therapeutic presence, us being mindful of that level of attention and also creating the holding space for patients and how we're able to name the experience and those being incredible, valuable assets during this time of distress and anxiety.

Dani: Yeah. And as the rules of the game has changed that we just have to. You guys, we're all doing this at baseline, but right now we have to have to have to be intentional about grabbing for these basic ingredients.

Eric: Well, I want to thank both of you for joining us. Also for being my psychiatrist for the last hour.

Alex: Yeah. Exactly.

Eric: Yeah. I saw some holding going on for me there. Maybe we can end with a little bit more of the Friends song, Alex.

Alex: All right, here we go again.

Eric: It's going to have a different meaning for you this time.

Alex: That's right.

Alex: (singing).

Eric: I get it now. There's some holding going on there.

Dani: Yeah. Friends can hold-

Eric: When the rain's falling, I'm going to be there for you.

Dani: Thank you.

Alex: Who knew that Friends was actually like basic training in psychiatric principles. [laughter]

Eric: Never said I'm going to open my umbrella. [laughter]

Eric: Well, thank you both for joining us. Keri, always, I think we're going to have you back on because that was amazing. And Dani, always great to have you on the GeriPal Podcast.

Keri: Thank you, Eric and Alex. It's really been a pleasure.

Dani: So nice to see your faces.

Eric: And as always, thank you Archstone Foundation for your continued support and all our listeners for joining us every week. Good-bye, everybody.

Alex: Bye, folks



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