Let's Talk Mental Health

Avril Benoît:

Hi, everyone. Welcome to this special Let's Talk COVID-19 series that we've been doing since the beginning of the pandemic to give you some insights about our work and how it all relates to what we're all experiencing, which is this unprecedented time. So today we're going to be talking about mental health. Mental health care, particularly for our patients, also for the caregivers and for the health care workers, because that's very much the world that we inhabit. So I'm Avril Benoît. I'm the executive director of Doctors Without Borders in the United States. We're known internationally as Médecins Sans Frontières. And that's why you might hear the acronym MSF pop up throughout the conversation. The discussion today will last around 45 minutes. As usual, lots of opportunities for you to ask questions. You can pop in your questions on Zoom in the Q&A box. If you're joining Facebook Live or YouTube live or even Twitch, you can send your questions in the comments or the chat section. We will find them and they will be fed to me.

I'm really excited to be talking about this is not the first time we've actually touched on this subject, because it is so central to the well-being as we get through this awful phase. World Mental Health Day was October 10th, and with the number of COVID cases rising around the world and also the onset of flu season, which is potentially going to make things more complicated, winter right around the corner. And so, an expectation if we haven't already had our second waves arriving, that we will be in it soon. Very stressful time for everyone. As an increasing number of jurisdictions are imposing the kind of quarantines and lockdowns really severing our freedom and our ability to be with the people we love and that the people who can hug us to help us get through it. 26 million cases now have been diagnosed, 863,000 deaths. So, we have some terrific people to help us work through this. It's not a therapy session, but it is going to give us a lot of insights, I think, in terms of how we can look after one another.

We have Athena Viscusi, who's also been with us before on this series. She's a clinical social worker and a psychosocial care specialist working with Doctors Without Borders USA. Welcome, Athena. And maybe you can just pop in as an icebreaker and tell us where you're joining us from and what strange noises we are likely to hear in the background.

Athena Viscusi:

Hi. It's great to be here. I'm calling from my apartment in Brooklyn and you might hear the neighbors.

Avril Benoît:

Some creaky neighbor floors upstairs with me as well. Also joining us, Ebony Lucas, a therapist and wellness support officer who worked with us in a program that we were doing with long term care facilities in Detroit, Michigan. Welcome, Ebony. How are you doing today? And what strange noises are we likely to hear on this call?

Ebony Lucas:

Hello, everyone. I'm very excited to be here. I'm here in Detroit, in my home. And I think the strange noise that you might hear in my home is maybe doors or floors creaking. That's about it.

Avril Benoît:

Same thing. Okay, all right, good. No dogs barking or babies screaming in the background today. Sanne Kaelen is a clinical psychologist with MSF working with us in Belgium. And not only with lots of experience in mental health programs, but she's also researching the impact of these programs in the COVID19 pandemic. Hello, Sanne. How are you doing where you are?

Sanne Kaelen:

Hi, everyone. I'm good. I'm calling in from Brussels, the headquarters here of MSF in Belgium. And normally no animals or baby sounds here, just some colleagues who might be walking around.

Avril Benoît:

Okay, it should be good. It's so good to have all three of you here with us today. And, Ebony, if I can start with you. Tell us about the work that you've been doing in Detroit. What were you specifically working on in the long-term care facilities?

Ebony Lucas:

Thank you. So specifically what we were working on, we came into the nursing homes to provide wellness support. My title was the Wellness Support Officer. So what we did is we came in and we met them where they were as we provided a variety of mental health services so we referred them and linked them to local as well as national resources. We did in services as well as on site therapeutic sessions. We were very open and just kind of multitasking because again we met them where they were at. And so whatever the need was, because each facility had a different need, we try to be flexible in our services to meet that specific need.

Avril Benoît:

And the mental health challenges that the people you were trying to help were facing. Can you give us an overview of what some of those issues were?

Ebony Lucas:

Of course, across the board there was a lot of stress, of course. So I saw lot of compassion fatigue and also a lot of secondary trauma. So a lot of the in services focused on secondary trauma and then aspects of compassion fatigue. But one thing that I found very interesting is that so during this time, we should have seen a focus of seeking the services, going toward the services. But what I saw was people kind of drawn back from mental health services and kind of put the focus more on the physical, which I understand. And it had gotten to a point, from my observation, that the mental health was being ignored. And so we had cases of people chronically stressed out. It was a lot of burnout because these things were essentially being ignored and the staff essentially didn't know what to do. Everyone was confused and here we were increasing their demands, but not providing any services. So that's what we came in to do. We came in to provide them with hands-on services.

We also taught them how to make resource boards where they were able to make this with us, with MSF staff and put on their local resources, resources that they could easily access. And there was also a focus on the DON, so the director of nursing, making sure that they have services, because the issue with them was they were expected to provide the support for the staff. But here they didn't get any support. And so they didn't know what to do. So we had a big job ahead of us, we really did.

Avril Benoît:

We have seen similar kinds of stressors in our projects all around the world. Sanne, maybe you can describe what you've seen in your research as far as that goes.

Sanne Kaelen:

Yes, indeed. We did the same intervention in Belgium, in the nursing home since March. Until now recently, we finished that. And then in May, we started a research specifically on the mental health impact on the residents. Because I know interventions, we were mainly focused on the staff which was very much needed, of course. But then looking deeper into the impact on the residents, we discovered that actually their basic psychological needs were challenged, they were not met. And those basic psychological needs, that's autonomy, having control over your situation, competence, feeling useful in the society and relatedness, connectedness. So this was these IPC measures that were implemented in nursing homes were in fact-

Avril Benoît:

And IPC we should explain is...

Sanne Kaelen:

Sorry. Yeah, it's infection prevention control measures. And these were in fact having harmful consequences on the mental well-being of the residents. And we noticed also that the staff was really suffering with this because they have been all this time, they could not take care of their residents as they were used to take care of them. And that created also some ethical dilemmas for the staff and some moral distress, like we see the harmful effects of these measures. But we are blocked, we can't give them the physical affection that they sometimes want or they had to replace families. Even their families could not enter the nursing home anymore.

Avril Benoît:

We've heard a couple of concepts come up. You talked about moral distress and Ebony, you were talking about secondary trauma. Would you mind, Athena, maybe explaining what those are and how they have come into your work?

Athena Viscusi:

I'm sure my colleagues could, too. But thanks for asking. And what I do in my current work, I work in the field with MSF, in our project running mental health programs. What I do in my current work is counsel our staff. And so secondary or vicarious trauma is when we take on the traumatic reaction of something that hasn't happened to us but has happened to our patient or to a colleague or to... It's something that mental health practitioners in our training, we have to learn how to deal with that or we're toast, right? But it's not in the hands of medical professionals or at least enough. And especially not with the para professional staff that so much works in the nursing home for instance. We know we have to be on alert for that all the time because our job is to listen to distress, right? And help not to take that on and not ourselves wake up with nightmares of something that's happened to somebody else. So that's secondary or vicarious trauma. And what was the other one that you asked me?

Avril Benoît:

Moral distress.

Athena Viscusi:

Oh, moral injury, right.

Avril Benoît:

Moral injury.

Athena Viscusi:

So that's the thing. We learn a lot actually from work that's been done with veterans. We don't like to as caregivers. We don't like to compare ourselves with soldiers. We want to pretend we're very different. But actually, something that came out of veterans were the first people who'd been in combat to talk about the moral distress of when you do something that's against your ethical values. Maybe that's what you had to do in the moment. Maybe it was sanctioned by the organization, maybe you were told to do it. But it still, it goes against your values and then you're left with that inner conflict. In COVID what it was, was not being able to provide the care that people thought was needed and especially the emotional care. I mean, you mentioned Ebony, the staff wanting to hug the patients because they know that normally their family comes in. But you can't because of the infection control and so those dilemmas. Even if intellectually it's the right thing to do, emotionally and ethically it doesn't feel right. Maybe other people want to add something.

Avril Benoît:

Yes. Maybe you first, Sanne, and then we'll come around to you, Ebony.

Sanne Kaelen:

Yes, it is indeed there's dilemma between quantity of life and quality of life that in the beginning of the epidemic, which is also very normal, everyone wanted to shield the elderly off COVID-19, of the infection, after the spread. But in these protective approach, we kind of missed the mental health point. It's something that Ebony also said that mental health went a little bit to the background. And then we saw the detrimental effects of that. So it's now urgent time indeed to put mental health back to the front again and to focus on both infection prevention and mental well-being indeed.

Avril Benoît:

Ebony, can you give us, yes, maybe a concrete example of some situations that you saw for these things?

Ebony Lucas:

Yes. I work with a lot of nursing homes staff that talked about at the beginning of the pandemic when things were... it was still the big unknown. And a lot of people, a lot of the homes didn't have the PPE gear, the safety gear, infection control gear. But they were still expected to perform those services. It's a thing called a level of care. So it's a standard that you as a health profession, you are to provide that standard. But what do you do if you were supposed to provide a standard, but it provided a nonstandard? You're not only putting yourself at risk, but you're putting your family at risk as well, because you can bring those things home.

And so I saw a lot of staff that talked about how they actually had initially quit their jobs, which caused for them a strong moral dilemma because they enjoy what they do. And they understood that now, more than ever before, the residents at the long care facilities really need us. But I feel like I'm putting my life in danger. So how do I reconcile that within myself? How do I go in and provide a service that I know I could not only be putting myself at risk, but my family? And then we have several staff that described for me the fact that they did contract COVID as well as some of their family members. What I found to be very inspirational is those same staffs had came back to work once they had recovered and they came back with a new zest, a new zeal to provide the services. But that's what they talk about. They talk about not having what was needed to provide the services.                         

Then they also talked about wanting to touch the residents who no longer could have their family members touch because founding members were no longer allowed to go into the facilities anymore. So we had workers who were saying basically the residence being almost ignored from a simple touch. They wanted to but they knew the risk was great. So that was another moral dilemma that I saw come up a lot. And a lot of the workers developed strong relationships with the residents. And they described them as family. So for them, it was a chronic thing that kept happening over and over again.

Avril Benoît:

I can imagine that for a caregiver who's usually, the reason they were pulled into that particular career path, that kind of work, is because they really want to give so they give, give, give. And this is the profile often, isn't it? Of people who go into this line of work. Sanne dig into the research a little bit for us to describe what it is that you were trying to unpack, because we've now outlined some of the issues. We're going to talk about more and we welcome your questions through the chat or Q&A function here, they'll be passed on to me. But give us a sense of some of the things that you're trying to unpack here.

Sanne Kaelen:

Yes. So for this research we went to those nursing homes, again, to have interviews with the residents themselves. We wanted to hear their voice of how they experienced these periods of confinement, of lockdown. And we saw impacts in different aspects of their life. A very big one was the loss of freedom that they could no longer go where they wanted to go. They were not allowed anymore to leave the nursing home for summer. I work here now in Brussels for examples, not all those nursing homes have a garden that meant they had to stay inside for months, some even in room isolation. That's a really small room. I can't say it in English terms, in American terms, but very small, yeah, place to stay in. And they said we were becoming crazy. Those are people who experienced the World War. And they said that is not as bad as experiencing this lockdown periods. This is worse to be locked up, to have no more freedom, to not be able to touch anyone indeed. They said it was the most horrible period of their life.

And then very strikingly finding that we found in this research is that all of them said they were not afraid of COVID-19. They were afraid for the second wave that they would be quarantined again in isolation. That was their main fear, to be locked up again. As they said, most of them they are... you have reached an age and you're like, you know you're going to die of something. And they really were like, this is not how I want to live my last days like this in a nursing home. Where no activities took place, before you have some activity, some distraction, stimulation. That was not happening anymore. You could not see the people you wanted to see and even your meals you had to take in your room. They had to take in their room, not together anymore. Most of them could not even see each other anymore. Your neighbor across the hall because they had to stay in their rooms. So these different losses, their loss of freedom, loss of social life, loss of distraction, loss of autonomy had a major impact that made us question okay, what can we do also as MSF to change our intervention also in these nursing homes?

So we worked the past month in nursing homes to help them find the balance again, help them to restart activities in a safe way, help them to open up again the nursing home for visitors and to really improve this mental and social well-being of the people living there. Because in the end, if these care homes are residents homes, it's the place where they live. It's their home. And life needs to continue. We cannot stop life for them. It needs to continue in some way.

Avril Benoît:

I think many of us can relate to that. But in Belgium specifically, I've heard that the rates have gone up so much that you are very clearly now in a phase of a renewed lockdown. Is that right?

Sanne Kaelen:

Yeah. The second wave is hitting us quite hard now. And we are very afraid that all those nursing homes are going back in full lockdown again because it was the biggest fear of those residents. So we are now trying to support them, help them. If you have good infection prevention control measures put in place in your nursing home, you don't need to go back in full lockdown. And you can allow visits and do activities in a safe way just to prevent all these mental health impacts indeed, yeah. But we see if I can just add some one more thing. We feel also now that the staff working in those nursing homes, they are exhausted, they didn't recover yet from what happened in the March, April, May. They had no time to rest, to recover. And it's starting again. And you can feel their despair even. This is not going to end and winter still has to begin. They're very afraid of that.

Avril Benoît:

Yeah, it's a long, long slog ahead. We're getting some great questions here. And I want to encourage you to put them in however you're watching. We have three fantastic guests with us, Athena Viscusi, a clinical social worker, Ebony Lucas, a therapist and wellness support officer and Sanne Kaelen, a clinical psychologist, all working with Doctors Without Borders, with Médecins Sans Frontières. Athena, here's a great question for you. And it's about people being reluctant to ask for help. Stigma when it comes to people asking for psychological psychotherapy, all these kinds of supports with the various techniques is often quite present. Marshall is asking on Zoom are health care workers generally open to reaching out for help with things like secondary trauma? And if so, who treats them?

Athena Viscusi:

Right. Well, yeah. Great question. In MSF, we have a system in place where we proactively reach out to our providers and our projects all over the world. Because, no, it's not in health care providers' DNA to say that they need help. Their helpers. And even in this society, we give very mixed messages. We say thanks for being a hero. Well a hero doesn't need help. I mean, basically, when you're saying you're a hero, you're saying you have some supernatural ability to handle at large. And we don't need to take care of you. Thanks for being a hero.

So we do it proactively and myself. But I think what we need to do is... and I think COVID the vocabulary is changing, but you have to preventatively just say an epidemic causes stress, the disruption of school and work causes stress, working long hours causes stress. Working at home with your children going to school at home, causing stress. Stress untreated causes reactions, physical and emotional reactions. And so we all need, the more stress you are receiving, the more mitigating measures you need to be taking so as not to suffer the effects. Untreated stress leads to affect in everybody, in heroes and in not heroes, in patients and in caregiver. In the general public. In our leadership. That we all are facing stress and we all need, I guess, I'm using these mitigating measures. We all need to take some treatment for the stress.

And so we wear a mask not to get the virus. But what is our emotional PPE? What do we do to protect ourselves from the emotional? And so, in fact, because MSF has so much experience with epidemics and with supporting our staff, our patients, our patients’ families, our staff and our staff's families, through these epidemics. Local health care providers we're reaching out to us for advice on how to handle this during the peak like in New York. And that's why we designed these interventions that Ebony and Sanne bit in the long-term care facilities because we know that.

Avril Benoît:

Yeah, well, emotional PPE is a great way to sell it to convince someone that this is a good idea. It's a protection for yourself, for your well-being. Ebony, so who is doing the treatment for these health care workers? How do you offer it?

Ebony Lucas:

We offer direct service when we're there. And then we also link them or refer them to outside resources. And I say link and refer them because these are services that we know they can benefit from and they can access. So part of that will be vetting the resources out and making sure that it's available and that is easy for them to access. And then we provide the information on how they can access that.

But I really want to tag on to what Athena was saying. I totally agree with that. Heroes or helpers, they see themselves as having some type of supernatural quality where they are not susceptible to the same things that I guess you could say the rest of us are susceptible to. And so what I found when I went into these long term care facilities in my attempts to provide them with the services, they were very resistant initially. I did often hear, well, we're fine. We don't need anything. But I had to be very resilient in my quest provide them with services and I had to be flexible. Again, I had to meet them when they were. So I went in knowing that I would be met with some resistance and so knowing that I knew how to approach it. And a resistance kind of manifested itself not only in them saying that they don't need the help, but even with staff and coworkers joking about the services. And saying, oh, you're in there getting us... you're having a mental health session.

It was really interesting. And even people coming in and not attending sometimes the in services. And so I was creative and I think that's one thing that MSF prepared us for. So I literally would walk around and talk to them, say, hey. I'm having this in service, just come in and sit down for a minute, and I'm sure you will find it very interesting. We always try to make it very interactive so that the word will spread around, hey, this is a fun thing. This is something that we can all benefit from. Just take a little time out your day and no one's saying that, is there anything wrong with you. Because part of the problem, I think, is the whole stigma that comes with mental health. And so we have to kind of work to normalize it and break down that stigma, not only among staff. But, again, also among the supervisory staff. Because we need them to support the staff and seek in this service, we needed them to urge and support the staff in receiving the services. So I think that was a very important thing.

Avril Benoît:

Yeah, it strikes me that this stress that everyone is under in the zones that have been deeply affected by this. And certainly anyone working within a long term care facility would feel it, but also all the cities that have had peaks or even rural areas now we're hearing increasingly across the United States are really under duress. It seems like the norm would be to feel stressed, that it's a signal that you're processing the seriousness of the pandemic to feel stress. And to deny the stress. I mean, look at all the people who watch a sentimental video and they burst into tears now. And they're hugging trees because it's a living being. If you're feeling so isolated, people are resorting to all kinds of ways to self-medicate themselves through this. So it just seems so normal that we should just acknowledge, you know what? We're all cracking under the pressure now and then. And the best thing you can do is protect yourself. I can see Athena you want to comment.

Athena Viscusi:

But what you raised Avril, is that if people don't have positive ways of addressing the stress, they will turn to negative ways. We've had a documented increase in drug abuse during the pandemic because that's a great way not to feel. I mean, this is an adaptive reaction to overwhelming feelings is to try not to feel. And if we don't provide people with techniques to tolerate their feeling, right, or to connect with other people who, at a minimum can commiserate and ideally can actually help them feel better, people will turn to negative. We see a rise in domestic violence during the pandemic, during the isolation when people are cut out. One of the techniques of domestic abusers is to isolate the victim. Well, the pandemic's done a great job of doing that.

And even we're seeing now an increase in gun violence in this country because this is what happens under stress. If we don't give people positive ways to address it, they will default to negative ways, denial. Denial is a negative way of coping with the stress, the overwhelming stress of a pandemic. And we see this is being marketed to people. Deny it and you will feel better, very dangerous. So more and more important that we have this dialogue of you will be affected by this. And here are some positive ways to get through it because if we don't do that, people will default to these negative ways.

Ebony Lucas:

And just to add onto that. Yes, it is a lot of denial that's going on across the board. I experienced a lot of staff that told me I'm not stressed. I don't feel stressed. I'm fine. So sometimes people don't know how to recognize it. And I do think that part of that is a little bit of denial. But just educate people on the symptoms or what you're seeing or you're experiencing these things is a sign that you're pretty stressed out. So for me, just helping people also to recognize what the symptoms will look like and then offering them tips and techniques to deal with it, to cope with it in a positive way. And not in a negative.

Avril Benoît:

Let's jump into some of the techniques, because we're getting a number of good questions around this and some of these techniques I don't know anything about. So I'm very curious to hear. And I don't even know for this specific question from Donald on Zoom, who will know or have a response to this one. But Donald is asking has MSF considered using eye movement desensitization and reprocessing EMDR as a treatment model. Who wants to have a go at that one? Sanne go ahead.

Sanne Kaelen:

Yeah, I am familiar with EMDR indeed, but we haven't, well, at least here in Belgium, we haven't used that in the type of intervention here because we work mostly in groups. We did a group approach because infectious diseases can isolate people very easily. Everyone has their own fear, stress, other sorts of feelings. But by opening this up in group, you can notice that you're not the only one having these emotions. And by sharing them with others, you create again connectedness, relatedness which are all coping ways that can help alleviate the stress. And I think this group approach was used more indeed because in these times we have sometimes a feeling that it's hard to feel connected with other people. So it was a very important one for us.

And the same one is also for the other I mentioned them already, the other basic psychological needs. So this is one of them and the other one is competence, how to make people feel useful again. Okay, creating a buddy system, as Ebony said, learning to recognize stress signals with your colleagues or your friends or your family by talking to each other. Okay, how do you experience stress? How can I see that you're stressed? So that you can warn each other like, I think you're reaching a high stress level now. Maybe it's time to take a break or do whatever works for you, because this is another important message I think.

When you talk about how can we deal with stress, this is really a personal recipe you need to make for yourself. Some people can benefit from meditation or relaxation exercises, while others need to be very active, need to go through running or do some sports. Others want to ventilate, need to ventilate and maybe some other people benefit from a Netflix marathon. So everyone really has their own ways of coping. And you need to find the best recipe for yourself. What helps for you.

Avril Benoît:

A question from Helen on Facebook and a few others just asking about then the techniques. You mentioned Sanne group support. So what is the technical approach to a group counseling session? And I don't know, Athena or Ebony, if you talk about the kind of techniques that you use as therapists, as specialists.

Ebony Lucas:

So during the time of COVID-19 having a type of group support is important because it does, it creates a connectedness. It helps with the isolation. And then it helps for just the overall group dynamics and lends its way for a healthy recovery. Just talking about the different experiences and the different tips of techniques that you apply. One of the things that we always emphasize in our work in the nursing homes when it comes to specific techniques is using a peer support system or using a buddy system with your coworker, learning how to recognize or acknowledge distress. And the either one of you could be experiencing.

But then also being able to admit, talking to a supervisor and say, hey, my buddy or my coworker is feeling stressed today. Is there a way that they can get a longer break, or can they go home early? But then it comes to the supervisor being willing to support that peer connection. Being willing to say, okay, yes, they can go home early. Also, maybe the support person, if they've noticed that the person is feeling stressed or not having a good day, perhaps they can take up some of the slack for that person's work through that day. We really sought to offer practical tips and techniques that they can employ in their day to day life.

And it's important, like she mentioned, to have your own stress recipe. I think that's pressing because each person is an individual. So you have to find what fits for you. For some people, it could be group or some people it could be peer support. Some people could be individual things, walking, meditation, writing. But knowing that you have to put the focus on your mental health, on the stress at this point, I think is the important. Just putting that focus on it and then normalize it throughout the entire facility.

Avril Benoît:

Mohammed is asking on Zoom for some more of those efficient practical tips. You've mentioned a few here, how do you get somebody to see that there is an option, that they do have options to look after themselves? Athena, you have lots of practice working with people who've just returned or are still in very high stress humanitarian crisis zones right in the middle of a stressful situation. So what would you tell Mohammed in terms of how to help somebody figure out what that stress reducing technique would be?

Athena Viscusi:

Well, I mean, we prefer to prevent. So before people go out on assignment, when we do their preparation or pre-departure preparation, we have people... so everybody's been through stress before, right? It's a function of life. Good stress, bad stress, stress. You've taken exams. You've gotten married. You've gotten divorced. You've got people die. If you've gotten this far as to become a professional caregiver, you've been through stress. You know how to... And so you've either adopted some... you probably have lots of positive coping skills in your pocket and probably some negative ones, too, right? And so reflecting on when you've been through stress before, what did it look like? What are your signs? Both Ebony and Sanne have stress, this is individualized. There's not a formula. So what does it look like? Some of us overeat when we're stressed. Some of us stop sleeping. Some of us yell at people, what is the sign that the people around you see when you're stressed?

And telling your buddy, if you have a buddy system, this is what happens to me. Can you tell me if I'm starting to do those things? Because when I'm down that rabbit hole, it's too late. I don't see it anymore. So can you tell me? This is what happens to me, okay. So how have I dealt with it in the past? When I was in that terrible part in my life, when I was going through that terrible thing in my life, how did I get on the other side? What helped me? Who helped me? Who's my best friend who always helps me? Even if I'm in South Sudan on an assignment, can I get in touch with her? Because she's my lifeline. Don't cut myself off of her. Or what's helped me? What's that book that really inspired me? Was it prayer? Was it meditation? Was it running? What was it?

And if I don't have something then I need to find something. I only started doing yoga and I messed up. I hated it before. It turns out it's something you can do when you're confined to a very small room in a war zone where they... And it's awesome. So I didn't have that in my toolbox, I needed to find it. But I had some other things in my toolbox that I kept. But we can't say this is great and then not practice it, we need to practice it. And again, that's where everybody's help us. And that's where, then, supervisors were trained to identify these things saying, you said it's really good for you to run. You haven't been on a run in two weeks. What's that about? So what we do is help people develop a plan before they go out. What are the signs of stress? What are the things that have helped you in the past? And what can you do proactively in this situation, right?

And we even interviewed some of our experienced fieldworkers who had lived under confinement before. What are their top tips for living in a confined space and isolated? And advice that they could give to the general public from what they have learned there. So those are the things and there's a lot of research from like I said, from combat veterans, from Holocaust survivors, from survivors of all kinds of horrible things about what... because you will have 100 people go through the same event. And they will have different reactions, right? So EMDR is something that helps people, that was mentioned before that helps people to integrate traumatic memories and no longer have painful reactions to those traumatic memories. But what makes that some people never even have painful reactions to their traumatic memories?

And we found one is social connection. The people who have strong social connection, are less likely to have post-traumatic stress. They will have stress reactions in the moment but to have them long term post-traumatic. And then Sanne has mentioned so much the sense of competency of mastery. When we have felt completely hopeless. When we were in the situation, when we saw no outcome, we're more likely to have long term effects from that. But people who've been able to see the light at the end of the tunnel, maintain that hope, to remember that they've been through things before. So that sense of connectedness and mastery, some kind of confidence, some kind of not feeling completely overwhelmed and helpless, hopeless and helpless. People who feel hopeless, helpless are more likely to have long term effects. So how can we remind each other that there is a light at the end of the tunnel? And to see the good, to practice... we've talked about gratitude not as a feeling but as a practice. What are the three things that are going well right now? There's a pandemic going on. I'm talking to all these amazing people that are concerned about mental health in a pandemic. How cool is that?

Avril Benoît:

Yeah, I know.

Athena Viscusi:

But do we note those things every day, right?

Avril Benoît:

Yeah. But, Jill on Zoom is asking this question and I'm going to send this over to you Sanne because I see you're trying to jump in here. I'm zoomed out, I miss the social connection, I miss people. And she's asking, how does group support work function? When you're trying to social distance, how can it be as effective if you're the kind of person that actually craves people to sit with and eat with in our nursing home, you just crave that those moments of connection with your family? How does this work when we're socially distancing?

Sanne Kaelen:

That's a very fair question indeed in these social distance times. I prefer also the term physical distance. Hence, so it's not always social distance but physical distance that is needed. And we looked for creative solutions here. For example, meeting each other outside, keeping the one meter and a half distance and interacting in a safe manner like that. That is possible. Sometimes we're very much blocked by all the rules, but it asks a lot of creativity of us. Or for example, I myself I had a hard time reaching out to my support system via telephone only. So we went for a walk, having the mask on and everything, being safe outside just to feel indeed like there was someone physical next to me. But we were interacting in a safe manner.

And I indeed want to intervene on what Athena has said, because it's super interesting to hear her tell about this toolbox, because this is exactly how I was prepared as a psychologist to go to the fields, to go to a Central African Republic, which is in the conflict zone, and which was very an overwhelming experience. But by having this toolbox and I really made that that exercise with the psychologist here in Brussels on paper, you feel prepared, you feel like, okay, I can reach out to something. I have written this before, what is my self care plan? What can help me in this stressful time? Because even though I am a psychologist, I don't always recognize myself when I am stressed. Or I don't always know what helps me. So just if you have this toolbox and try to do this exercise in a moment that you feel calm and then when you have the emotional capacity to sit down and write all these stuff down, it will help you prepare for more difficult times. So this is a tool I really want to sell to everyone, try to do this exercise for yourself indeed.

Avril Benoît:

Yeah. The list of what are the behaviors or things that I do when I'm stressed. And what are the things that make me feel better when I'm stressed, that have worked in the past. Just make the two lists and then be able to refer to it. We're almost out of time here. I suspect that we could go on forever. But Ebony I'd like to finish with you with a question from Bruce on Zoom. He's asking specifically related to this issue of stigma, seeking mental health treatment. Now, people are not so... not sure that they should go there. What can ordinary people, people who are not caregivers, what can we all do to help reduce the stigma? So that caregivers and also the people living in these long-term care facilities and just those who are struggling and suffering is central workers, et cetera, how can we help reduce that stigma so that they do seek the help they need?

Ebony Lucas:

That's an excellent question. And I will have to say so at the individual level, we need to start where we are. So at the individual there are some specific things that I can do to lessen the stigma that is at war with mental health. I can be supportive of someone as a caretaker, someone seeking mental health services. I could work towards prevention. I myself could seek out mental health services while also having resources readily available. For instance, and I think it's always important to have every day technique things that everybody can do. So just starting at the individual level, it would be great to have maybe a magnet on your refrigerator that says if you're feeling down today or having the number to the National Suicide Hotline. And basically, just being open for a conversation around mental health.

And knowing that is something that each of us on different levels have experienced as well. And I think that at the individual level, there are lots of things that we can do. For instance, if you notice someone being a little, what you may call, they seem down or they seem... I'm sorry, let me fix my... They seem stressed, you can advocate for them to seek services. So I think at the individual level, there are lots of things that we can do to lessen that stigma because again it starts from where we are. So I think that it would be a good thing for everyone to have a yearly mental health screening.

I think that if we were to see things like that, that would help to normalize it against the all. And just being supportive and letting people know or understand this something that we all experience. But also it's important to understand that the stigma that relates to mental health, for seeking mental health services is something that is multilevel. So it's cultural, it's societal. So it has a lot of levels to it. But I think if we start at the individual level and doing basic things that we can do every day to support one another, we can go from there.

Avril Benoît:

Sounds like a great place to end. Thank you so much, all of you, for being with us today. That was Ebony Lucas, a therapist and wellness support officer who worked with MSF, with Doctors Without Borders in our long term care facilities program in Detroit, Michigan. Also with us, Athena Viscusi, a clinical social worker and psychosocial care specialist working with MSF, USA in New York City. And Sanne Kaelen, a clinical psychologist with MSF, and she has joined us today from Brussels. Thanks, all of you. And I hope you're doing well. Hang in there. You're doing great work. And thanks for sharing your wisdom with us today.

Apologies if you tuned in and we didn't get to your question, but please stay in touch with us. You can always write to us and we'll try our best to get back to you. Our email address for this series is event.rsvp@newyork.msf.org. And for more information about our mental health work, you can see lots of stories and insights on our website Doctors Without Borders.org and on our international website, MSF.org. You'll also find us on Twitter, on Facebook, on Instagram, the works. And we'll be back in another couple of weeks with another Let's Talk webinar series, this series that we've been running since the beginning of the pandemic. So that's coming up in two weeks time, October 29th. So thanks again for watching. I'm Avril Benoît signing off, take care.