Alone Together in Our Fear: Perspectives From the Early Days of Lockdown Due to COVID-19ation by articles

EDITORIAL

Alone Together in Our Fear Perspectives From the Early Days of Lockdown Due to COVID-19 Jenifer A. Nields, MD

e work in strange times. Isolated in our quarantined spaces, alone or among family members, many psychiatrists and psychotherapists now see patients on screens, and listen to them over telephone lines. Accustomed to attending to subtle cues—a shift in posture, a gesture, a new cologne or a whiff of fear—we are deprived of such input. Forced into physical separateness, we are united by a common trauma, a common fear, and the upended circumstances of our lives. Patients ask “How are you?” not as a formality, but out of a need to know whether or not we are indeed ok, whether or not we can be there for them. Some of us are terrified for our own safety, or that of our loved ones. Some are overwhelmed by the flood of conflicting information—all vital, all potentially false—that comes via newsfeeds and e-mail listservs. The same is true for our patients. Some are grief-stricken and alone, and some have lost their jobs. It is easy for us, in these circumstances, to abandon our therapeutic stance, to listen as fellow citizens rather than as therapists. We may be tempted to offer medical advice, and sometimes it is in the patient's best interest that we do so. However, sometimes the talk about COVID-19 serves as a deflection and draws us away from the job we need to be doing. Here is an example. A patient was suffering from loss of appetite, followed by a persistent dry cough and marked fatigue. She had wondered if the cough were due to gastric reflux, a reflection of her anxiety, or the early symptoms of COVID-19. Her therapist asked some pointed questions, as she had been experiencing some of the same symptoms herself. Initially, the patient was happy to have her health concerns taken seriously, but subsequently, she felt a loss of holding: the therapist's questions probed for factual information rather than seeking clarification of the patient's concerns and a deepening of therapeutic understanding. The therapist's own unprocessed fears contributed to an empathic failure. We are suffering not only from the spread of the virus, but also a contagion of fear. During a townhall style Zoom meeting of local psychiatrists, the discussion centered on statistics, and questions like “When will we experience the surge?” “Who is at risk?” “Who will die unnecessarily?” “Who will die alone?” “What are we to do as psychiatrists, those of us who have not been repurposed for medical functions?” A feeling of helplessness prevailed. Finally, someone said, “We can listen.” At once, the conversation shifted, and stories poured forth. Here is some of what I've been hearing from patients, my own and those of colleagues. Clinicians at our local VA remarked that patients with PTSD seemed among those best able to cope and wondered why that might be. Others remarked that their patients with bipolar illness, accustomed to chaos in their inner lives, were doing better than expected. I was reminded of a night I spent as a trainee at a long-term inpatient psychiatric facility for patients with refractory depressions, psychoses, and personality disorders. Not on call, I was forced to stay overnight because a tornado had hit our location, downed trees, loosed torrential rains, and blocked and flooded the parking lot so that staff and inpatients alike were stranded there. The winds and rain lashed the windows, and branches crashed against the roof and walls. Normally, there were multiple daily and nightly outbursts of violence among the patients, but that evening, there was an eerie calm. It was as if all the patients’ psychic torment were being amply expressed, as it were externalized and detoxified. No one was left alone with their fear, and no one was exempt from the common threat. During the current pandemic, a patient with OCD with prominent hand-washing rituals said, “It is as if everyone now is living how I live every day. It's comical, in a way. For me, nothing much has changed. I am no more worried now than I was a few weeks ago, and I feel a lot less crazy, because now at least there is a real thing out there to be worried about.” My patients with social anxiety, too, are feeling less marginalized. Now everyone is afraid to leave their home, and social interaction seems fraught with peril. In a way, the world has become more Yale University School of Medicine, New Haven, Connecticut. Send reprint requests to Jenifer A. Nields, MD, Yale University School of Medicine, New Haven, CT. E‐mail: jenifernields@gmail.com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/20/20806–0441 DOI: 10.1097/NMD.0000000000001202

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The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020

accessible to my anxious patients. For some, it is not so frightening to have eye contact over FaceTime or any of a variety of telehealth platforms we have rapidly learned how to use as it is to encounter people in the flesh. One patient tellingly said, “I no longer feel ashamed of my isolation.” What a remarkable statement. Patients need no longer feel ashamed of their isolation, their fear, the sense that, although they need others, they also feel threatened by others, and need to navigate a way to feel nurtured and safe. A colleague, also a psychiatrist, did a podcast on anxiety in the age of coronavirus. “We need anxiety. Anxiety is what will enable us to do what we need to do, to wash our hands, to social distance…. This is what anxiety was made for. It is nothing to be ashamed of.” One elderly patient said, “My greatest fear has always been that I might die alone. In this pandemic, I may indeed die alone. And that is terrifying. But... I will know I am not the only one who is dying alone. And I feel oddly comforted by that thought.” Part of our role as psychiatrists is, and will always be, to bear witness. To bear witness to the unique way that each individual faces, this pandemic is to have a window into the human condition, into aspects of it from which we habitually shield ourselves. Life and death. Hope and dread. Agency and helplessness. A friend who was listed as “next of kin” had to make the difficult decision to decline a ventilator for her elderly mentor with COVID-19,

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renal failure, and heart disease. Unable to visit him, she wept, grateful for the care and attention of the medical staff. In every conversation, she thanked them profusely for the work they were doing. When her mentor passed away 3 days later, the ER doctor, seeing the name on the morning's roster of those who had died in the night, phoned my friend to tell her. A gesture of kindness and humanity that brought her once again to tears. The doctor, too, wept, saying, “It is so seldom that someone tells us thank you at this time of relentless bad news.” I hope we can keep listening, learning, and honoring one another's fear and one another's strength. Sometimes, it is all we can do. ACKNOWLEDGMENT The author is grateful to the members of the Group for the Advancement of Psychiatry and Religion Committee for their review and helpful suggestions regarding this article. DISCLOSURE The author is an Assistant Clinical Professor of Psychiatry at the Yale University School of Medicine and a member of the Psychiatry and Religion Committee of the Group for the Advancement of Psychiatry, which has approved submission of this article as a Group for the Advancement of Psychiatry product. The author declares no conflict of interest.