Emotional Well-Being and Coping During COVID-19

Hands being washed with soap over a sink.
In this section:

These are unprecedented times. We need to work extra hard to manage our emotions well. Expect to have a lot of mixed feelings. Naturally we feel anxiety, and maybe waves of panic, particularly when seeing new headlines. An article by stress scientist and Vice Chair of Adult Psychology Elissa Epel, PhD, outlines the psychology behind the COVID-19 panic response and how we can try to make the best of this situation. Her tips can be found below.

Our anxiety is helping us cope, bond together from a physical distance, and slow the spread of the virus. So our anxiety - while uncomfortable - is a good thing right now, especially if we manage it well. At the same time, we must effortfully prevent panic contagion and create periods when we can be screen-free and calm, engaging our attention in normal daily activities. Seize opportunities to share lightness and humor. Laughter right now is a relief for all of us!

You can also find moments of hope and resilience all around us despite the uncertainty. For example, a project created by UCSF postdoctoral scholar Nouf Al-Rashid shares stories of resilience and hope in response to the pandemic from individuals all over the world.

It may be helpful for you to make a list of what you can and cannot control right now. In this guide, we suggest radical acceptance of the situations we cannot control, and focus on what we can do.

Graphic

Tips for everyone

Stay physically safe from the virus

In this case, the biggest safety behaviors (physical distancing and hand washing) which decrease transmission of the COVID-19 virus, are also an integral part of anxiety management. Stay home when you can. When outside the home, wash your hands thoroughly and frequently.

To help us make the thorough hand-washing a new habit, try this: “Wash as if you just chopped up a jalapeno pepper (without gloves) and you now have to put in your contact lenses.” Don't forget the sides of each and every finger, the back of hands, palms, the creases and nail beds, and the back of nails. Wash for at least 20 seconds - as long as it takes you to silently hum the Alphabet Song, Happy Birthday, or recite the Loving Kindness Prayer. If you are a speedy hummer, say it twice.

Limit media to reduce anxiety

By now you have heard this recommendation many times and there is research behind it: Watching or scrolling through the media makes us even more anxious. An excess of news and visual images about a traumatic event can create symptoms of post-traumatic stress disorder and poor health years later, according to research by UC Irvine's Roxy Silver, PhD, and others.

Try to limit COVID-19 media exposure to no more than twice a day (e.g., checking for updates in the morning and before dinner) and try to avoid reading about COVID-19 before bedtime. Take a vow to not forward (and thus propagate) alarming headlines to friends and family.

The media often creates an exaggerated impression of global panic. The reality emerging from research data in Seattle, an epicenter of the outbreak in the U.S., is that most people are dealing with this very well and rising up to help others.

Get and provide warm, comforting, social support by video, phone, or text

This is critical! Taking time to share your feelings and to listen and support others will go a long way. Talking with others who have our best interests at heart makes us feel safe. Use phone, video, text, or email. Fortunately these new highways of social contact are unlimited resources. More than just providing social support about the current crisis, it is a good idea to use these connections to talk about the things you normally would - host your book club online, for example - which can create feelings of connectedness. (See 8 Free Apps to Help You Stay Connected During Coronavirus). Host a dinner using FaceTime or Zoom so you can talk while you eat (and talk about some positive things, not just this crisis). Loving and caring for our pets can be phenomenal stress reduction for us too!

“Social Distancing” is actually a misnomer, it is actually physical distancing while we work hard to stay socially connected. Let’s switch to that phrase!

Find ways of expressing kindness, patience, and compassion

Be extra kind to yourself. This is a hard time for everyone. Humans across the world are sharing this experience with you. We are all in this together and we may all emerge with a renewed appreciation for our interconnectedness. Helping others in need is both critical to get through this well, and also creates more purpose to our days and well-being.

Here are general tips and ways to help others right now:

If you are physically well, there is another important way you can help: The American Red Cross faces a severe blood shortage due to an unprecedented number of blood drive cancellations during this coronavirus outbreak. Eligible and healthy donors are strongly urged to make an appointment to donate and help ensure that lifesaving blood products are available for patients.

Create new routines and keep practicing health behaviors

Routine and ritual are restorative to us. Our brain wants predictable activity so we can relax our vigilant nervous system. Go to bed early and go outside each day to be active. (More information about sleep and activity is available below.) Remember that our activities, thoughts, and mood are closely linked. If you want to change your mood, change your activities and/or your thoughts.

Eat well

Good nutrition helps our mood. Stress makes us seek comfort foods, and in turn high carbs and sugars impact our mood. Many population-based studies show that a Mediterranean diet has been linked to better mental health and stress resilience, whereas a junk food western diet is linked to depression and anxiety. Try to fill your home with fresh produce, frozen vegetables, and whole foods when possible.

If you or a family member is struggling with an eating disorder, please see the toolkit of resources provided by the UCSF Eating Disorders Program.

Work well enough from home

Working from home may be new to you and can have its own challenges, especially in a small home with children. Don't expect to have the same type of productivity as usual. We are all distracted and needing to cope with a different daily life now, while helping others. Reduce your goals for typical work that is not urgent, if possible. Here are some recommendations on how to stay focused and productive during work hours:

Dealing with isolation and quarantine

The psychological stress of sheltering in place when living alone or being in quarantine once infected can be severe. Here are some resources:


Cognitive and somatic coping

Our thoughts shape our physiological stress responses

Acute, short-term stress is not necessarily bad, and, in fact, can be good. We can approach stressors with a positive mental view that we can cope well, that we have the resources. We can also view the physical stress response as one that helps us perform better, such as increasing oxygen to the brain. These are both types of “cognitive reappraisal.” UCSF professor Wendy Mendes, PhD, has shown that teaching students a positive way to view acute stress led to better performance on tests.

Be realistic and fact-based. Since the COVID-19 pandemic will likely go on for months, we need to make sure we are creating breaks and coping well with the stressful events that arise each day. It’s easy to think about the worst outcomes, which are catastrophic, but that creates unnecessary stress arousal and suffering. It can be helpful to think of worst case, and then best case scenarios, and settle on something in between, according to University of Pennsylvania psychologist Martin E.P. Seligman, PhD.

Creating short-term stress in the body, that we recover quickly from, can even be good. It creates a calming effect afterward, stimulating the counter-regulatory stress response. Exercise is one example. A protocol of physical acute stress developed by Dutch extreme athlete Wim Hof has become very popular in many countries. Preliminary studies suggest it is helpful for improving our immune response, and Elissa Epel, PhD, and Wendy Mendes, PhD, are currently studying how it improves autonomic and emotional stress responses and mental health at UCSF. It consists of a carefully guided protocol of hyperventilation and breath retention and cold exposure. Wim Hof is offering the online course free now. If you want to try it, it is important to read his safety tips. One can download the Wim Hof Method app to guide you through the breathing.

The acute effects of deep breathing and cognitive reappraisal are important to use throughout the day. See the breathing techniques described below.

The UCSF Department of Psychiatry and Behavioral Sciences has created videos of strategies you can use immediately to reduce acute stress in the middle of your day. These are often considered trauma-informed strategies. Here are four different strategies for you to try:

Reducing stress arousal through breath practices

Practices that manage stress reactions in the moment are critical, particularly for front line providers. Taking time out during the day, frequently, to self regulate, can be very helpful. Find a breathing technique that works for calming you.

The most basic thing to know is that taking a longer exhale than inhale can help calm your body. Easy techniques include slow diaphragmatic belly breathing (vs. chest breathing), a 2:1 ratio for the exhale (i.e., inhale to the count of 4, exhale to the count of 8); 4-7-8 count breathing, and a common yogic alternate nostril breathing (pranayama). UCSF clinical professor Daphne Miller, MD, has used these techniques to help her and her patients in the hospital or even through Zoom.
 


Trauma, moral injury, and grief

What we are facing now in the midst of this pandemic is acute traumatic stress. In other words, COVID-19 is a direct threat to our life or the lives of others we know. We are all either vicariously witnessing trauma, through media or through supporting others, or directly experiencing trauma, by becoming ill, isolated, or experiencing the plight of close others. We all know, in some vague way, that “normal” has changed and the world will never be the same.

Even more, frontline providers are at risk of developing traumatic stress symptoms. These acute stress reactions are natural, but it is important to promote self-care, social support, and sleep, in order to prevent prolonged psychological consequences such as post-traumatic stress disorder and depression. These serious reactions are more likely to occur in people with a history of trauma, especially childhood trauma, but we can take steps to protect ourselves and minimize the negative consequences. Resilience and healing from trauma is something that happens best in the context of supportive relationships.

We may also be experiencing a communal sense of grief at the loss of how things were, and anticipatory grief at the threat of loss of life. Another common feeling is moral distress and outrage, expressions of anger at witnessing injustice and poor management of our national crisis. This is natural and commonly expressed now online, but can lead to shaming and blaming, and not necessarily helpful to the person suffering. Also, some providers may be experiencing ‘moral injury’ by witnessing (anticipating) or being forced to take part in moral dilemmas created by trying to save people with limited resources. These intense states when we feel our integrity is violated are described well by the humanitarian Joan Halifax (who also has tips for coping with moral distress). In this section, we have asked several acclaimed experts in these sensitive and critical issues to share helpful education and tips.

For coping with all of these issues, we emphasize ‘trauma informed” strategies:

  • Use strategies to reduce stress throughout the day, including statements that support a resilient mindset (radical acceptance, self compassion, positive challenge appraisals), as well as mind-body exercises that reduce stress reactions such as breathing exercises, meditation, physical activities (with social distancing), and social support.
  • Recognize and reduce traumatic reactions. During a past webinar, UCSF's Alica Lieberman, PhD, and Edward Machtinger, MD, described traumatic stress—including how it is different from typical life stress, how it can lead to avoidance and emotional numbness and shame, and how to manage it. It is important to help patients, providers, and staff feel safe. Encouraging the early seeking of care is crucial.
  • Understand organizational and community perspectives. It is helpful to realize that in response to large scale disasters and traumatic events, solutions must be communal and not just individual (like one-on-one therapy). As noted by Jack Saul, PhD, communal perspective provides outlets such as community peer support groups, ritual, art expression, and safe environments. Trauma-informed practices and principles help make people feel safe and thus more regulated. It includes prioritizing relationships (as social support and connection can buffer stress responses), creating physical safety (a safe environment decreases the stress response and ensures rational thinking, judgement and attentional control can occur), and emotional safety (to help staff understand what to expect).

Moral injury from the COVID-19 crisis

Moral injury is a new term to most. It is defined as the psychosocial and spiritual burden caused by an act that goes against one’s own or shared morals and values. UCSF professor Shira Maguen, PhD, is an expert in moral injury in war veterans, who has shared the following to help us think about its role in our mental health.

Moral injury is an important framework to help understand the mental health impact associated with the current coronavirus pandemic. Moral injury has most frequently been studied in combat veterans following deployment to war. For example, killing or feeling responsible for the death of another in war has important downstream effects on mental health, functioning, and well-being. Health care workers on the front lines also may feel responsible for the death of others during a pandemic where impossible choices need to be made about distribution of life-sustaining equipment. Given the shortage of ventilators for those who need them, health care workers are left to bear the burden of these decisions while simultaneously putting their own lives at risk.

We can learn from medics who go to war. They have taught us what it is like to make impossible choices, to not be able to save everyone needing help, to hold a dying patient in their arms while being shot at during a battle, and to suffer from moral injury when the war is over and they have to live with the memories of those they could not save as a constant reminder.

Some of the identifiable symptoms of moral injury include demoralization, inability to self-forgive, guilt, shame, and self-punishing behaviors. Health care workers may struggle with feeling like their morals and values conflict with the choices they have to make during this pandemic; terrible thoughts and images may continue to haunt them.

Others can suffer from moral injury from COVID-19 as well. Many individuals have had to make difficult choices that contrast with their morals and values during this pandemic. Some may have made decisions that they regret, resulting in another high risk-person being infected with coronavirus and becoming seriously ill or dying. Others may have ongoing guilt because they needed to make decisions that resulted in others losing their jobs when they had families to support.

Moral injury can happen both from actions and inaction. For example, not being able to be at a loved one’s bedside when they fall ill from the virus can cause distress. Witnessing upsetting situations and not being able to help may also result in moral injury (e.g., witnessing loved ones get sick and not being able to intervene with love or support due to risk of contagion; being a patient in a hospital and feeling helpless while hearing others around you in distress).

The bottom line is that health care workers and others can experience moral injury when they are not able to act in ways that are in line with their core values due to the pandemic. It is important to watch for symptoms of moral injury in our current climate and reach out for support during this challenging time if you or someone you care about is experiencing some of these symptoms.

Recognize moral injury and associated grief. Importantly, this pandemic will not only take a physical toll, but a tremendous psychological toll. Even when it seems impossible to tend to our psychological well-being due to exhaustion or isolation, it is crucial. Starting with your family, make sure that each individual is tending not only to their physical health but also their mental health. If some family members are in isolation, try to communicate in safe ways (phone or online), offer support, and check in about mental well-being.

What to expect when experiencing loss and grief during the COVID-19 crisis

The pandemic has caused loss of everything we are familiar with, including our daily structure, for some jobs, and social contacts. It had led to serious financial despair, illness, and death. There are thus a range of emotional responses including grief, loss, and mourning. UCSF distinguished professor of psychiatry and author of "Grieving as Well as Possible" Mardi Horowitz, MD, has shared here the process of grief.

You may find that you grapple with all kinds of emotions. These are all within the normal range of experiences and not under anyone’s full conscious control. It is not a matter of will power to prevent your mind from clouding with unwanted emotions, or to force a cleansing bout of weeping at a funeral service. Rather, as with grief in general, it is a matter of courage and stamina to endure what must be tolerated, and to make easier those difficulties that can be made a bit more manageable without too much emotional cost to others.

The grief period after a loss can be lightened, but not eliminated. Each individual’s personal experiences differ, even in the same household. Each person must negotiate their own darkened passage with the help of their community supports. For a time after a loss, you may experience feelings of apathy, insomnia, poor or increased appetite, anxiety, irritability and weight loss or gain. These symptoms are often associated with feeling deeply sad and having severe worries. But do not be surprised if there is a stage of feeling numb and a bit unreal or not yourself. There are stages of reaction and not all affected parties to a loss of loved one go through the phases at the same time.

Take pride in taking care of yourself and others. Pay attention to feelings and keep up with social activities as much as you can. If you have suicidal impulses or cannot function, you are probably suffering from a complicated grief reaction and/or a clinical depression, and you should promptly seek professional help.

Grief in the time of the COVID-19 crisis

UCSF palliative care physicians B.J. Miller, MD, and Mike Rabow, MD, share guidance for those of you suffering from grief below, including a chapter on grief from Miller's 2019 book "The Beginners Guide to the End." Words are not enough—they never are—but particularly in this pandemic of loss. Still, here are a few thoughts to help us find a way through the terrible pain of grief in the time of COVID-19.

Grief is the pain of loss: Our losses are multiple, nearly overwhelming, and being experienced right now by everyone on this planet. We all know the ache of being at odds with our own lives. We all know vulnerability. We all know loss. The current pandemic is bringing us loss—and grief, the human response to loss-—at scale. Many losses are of people: our family, our lovers, our friends, our neighbors, people across the world we have never known. But our losses are of other important things too: school, work, connection, the prom, sports, certainty, predictability, blissful ignorance, weddings, funerals, normalcy. Some losses are life delayed (for who knows how long), some are life canceled and gone forever. Each person’s grief is personal, and true, and incomparable to another’s. There is no ranking of loss, just what it means to each of us to go without, to miss, to be separated, to be disappointed, to feel alone and bereft.

Grief has to be, because we love: Grief is normal. We grieve the loss of what we care about. If you are hoping to avoid grief, then you’d have to avoid love. Noting this connection can help soften the sting of these hard feelings. In this way, grief is something of value and is worth protecting. Hence, many cultures and societies have long ritualized the mourning period. Our funerals must now be online and in our hearts. But ritual reminds us that we have lost what we love and points us to the comfort of community, honor, and meaning.

Grief is how loss heals: Grief is necessary. Grief is a powerful, painful, and deep experience of how we deal with loss. Understanding what you’re feeling is itself therapeutic, even though it means sitting with the discomfort and pain we all inevitably feel. There is no right way to grieve, there is just the process that each of us must go through to integrate our losses into our lives. Grief is the human process of metabolizing and accommodating loss.

There are a few things to know about grief:

First, grief is an amalgam of emotions. Grief can feel like impossible sadness, but it can also be expressed as anger, numbness, or discombobulation. Even odd giddiness can be grief “talking.” Grief rarely presents itself as any single emotion for very long.

Second, grief is dynamic. That means that grief comes and it also goes. It’s important to note that whatever you are feeling will not last forever in the same way or at the same intensity. Furthermore, a hallmark of emotion is that it cannot be easily controlled. We’ve met many mourners ashamed of unwanted feelings (guilt, anger, relief, indifference), even though such feelings are normal. Our advice is to ride grief’s waves rather than try to command them. It can be helpful to cultivate positive states during this time as well.

Third, there is no particular timing to grief. In fact, grief can begin even in anticipation of loss (anticipatory grief), or it might be delayed for some time. When taking into account how grief shifts shape over time, it is important to recognize that we are never “done” with it, just as we are not done with whomever or whatever we have lost.

Even so, grief can trip into depression. We tend to distinguish the two based on severity and time since the loss was incurred. We strongly recommend you seek professional counseling if you simply want help or are struggling for long periods of time. There is nothing pathological about wanting help, and therapy—whether individual or group sessions, online or from six feet away—can be helpful along the way.

Finally, even the words of a great poet pale in the profound pain and the fundamental diminishment of our losses. But, perhaps, simple words can offer some small solace in our new lives.

Resources for dealing with grief

From author and UCSF grief counselor Claire Bidwell Smith, MS

Online support

Podcasts

Books

Movies

Coping with loss and virtual funerals

Invisible losses: Secondary trauma, survivor guilt, and moving through the COVID-19 crisis

From Michael W. Rabow, MD, and David Bullard, PhD

The world is suffering deep losses in the COVID-19 pandemic. Already, millions are infected, hundreds of thousands killed, a global economic disaster ,and all the suffering that accompanies it. And even if you yourself are not infected with this virus, even if you haven’t lost your business or your job, even if no one in your family is sick or has died, we all are affected.

For almost everyone, there is anxiety, fear, and, at least some of the time, a sense of helplessness and hopelessness. In charts and tables, in town halls and zoom meetings, in videos and photographs, our news and social media document real losses in painful and visible detail. And, for almost everyone, there also are invisible losses.

This is the “Both/And” virus. It is true both that many have already died, and that the majority will not. It is true both that some have lost everything, and that some will only know the greatest suffering second-hand. Many of us are being hurt by what is happening in our world, and also by what has not happened. Indeed, there is pain and loss even in what we escape.

We are professional caregivers, usually drawn to this calling from a deep sense of responsibility for others, often taking oaths and making deeply personal and celebrated public promises to care for the ill. Even when uninfected ourselves, we know the names of the overwhelm for which we are at risk. Numbing and compassion fatigue are when emotional and physical exhaustion sap our ability to empathize or to feel compassion. Compassion fatigue can be the unwanted, uninvited cost of caring. Repeatedly now in the time of COVID-19, we are advised (appropriately so) by a series of platitudes that are, nonetheless, absolutely true: “put on our oxygen mask first,” “prioritize on self-care,” especially as we reckon with the fact that “this is a marathon, not a sprint.” We must sustain for the long haul, or at least refuel for the next wave.

We can be hurt by what we bear witness to in others. In caring for our patients, we can experience secondary trauma. Repeatedly seeing and hearing about, working to ameliorate or treat the traumatic losses experienced by others, we are at risk of being traumatized ourselves, going beyond just empathy for another’s pain to an actual vicarious experience of suffering and trauma.

Here in the San Francisco Bay Area, with our flattened curve and our comparison to New York City, some of us are developing survivor guilt, an unfounded sense that we have done something wrong by not being infected or even by surviving an infection with COVID-19. We are hurt by what has not hurt us. This feeling can be both rational and irrational, conscious and unconscious. Literally and figuratively, our brothers and sisters, our spouses and life-partners, our grandparents, parents and children, at home, across the street, the country, and the globe, are dying of what we have escaped. And, sitting in a quiet room in front of our computers and smartphones, many of us feel guilty about not doing enough. For some, there is guilt about not using the “time off” in the lockdown productively to learn to bake bread, speak Spanish, or be a better parent. Professional caregivers, in particular, can feel guilt and even shame about not being on the front lines of the pandemic, rolling up our sleeves and “doing our part” alongside our colleagues, the real heroes out there being exhausted, pushed to the brink, even dying for the cause.

We can even experience another invisible but well-documented emotional response—unconscious survivor guilt—whose outward manifestations are thoughts that act as tools for self-punishment, a common response to the perception that we have fallen short of our natural and even hyper sense of responsibility for the lives of others. Rumination and worry are exaggerations of thoughtful self-reflection, and contribute to feelings of unease and depression, distorting the natural sadness and grieving that are inherent in our humanity, and robbing us of joy and delight in our own present moments of precious living.

And here again, the advice is repeated. Though it has become commonplace, even cliché, it remains true: recognize your feelings are normal (and common); realize you are not exempt and there will be time still for us all to feel losses that we might deem big enough; and, if you can, pay it forward. If you have had good fortune, you can dedicate yourself to having your life and work be an honor to those who have not had such luck. Let yourself find moments of peace, connection, joy and love; they can be valuable treatments for the wide world of pain and suffering.

Ultimately, be gentle with yourself. Be compassionate to yourself for the losses that anyone might see in your life, for the invisible suffering only you can feel, and for your place in the misery of what has befallen us all in a million inexplicable ways.

Whether on the frontlines or the sidelines, kindness and taking care of yourself allow you to be compassionate with and to provide deep help to others. Kindness and self-care, most of all, allow us to see the sacrifices and contributions that we and so many are making and to feel our connection to all humankind.

A poem about what we can and cannot do

On March 17, as sheltering-in-place was starting, poet Jane Hirshfield wrote a poem, “Today, When I Could Do Nothing.”

For UCSF employees who are looking for help

The UCSF Department of Psychiatry, in partnership with UCSF Human Resources and the Center for Digital Health Innovation, has launched a new program specifically for UCSF faculty, staff, and trainees to provide additional mental health assessment, treatment, and referral resources to our valued colleagues who are experiencing distress related to the COVID-19 pandemic. These services are available to all UCSF employees, regardless of their personal health insurance carrier or status.

The UCSF Employee Coping and Resiliency Program uses a simple and confidential online screening tool to connect UCSF employees with a wide array of emotional support services. Employees requesting assessment and ongoing care through the Cope Program will have the option to be treated by UCSF Psychiatry clinicians or, if they prefer, to be connected with their existing health provider.

In addition, employees seeking help with substance use issues will be connected with Bright Heart Health, a telehealth treatment program not affiliated with UCSF. (Please note that this a referral only; UCSF does not control costs or ensure insurance coverage for services provided by Bright Health Health.)

To utilize the program, UCSF faculty, staff, and trainees should visit tiny.ucsf.edu/cope or text COPE to 83973. 


Dealing with stigma (COVID, mental health, or other)

This expertise is provided by Michael Trujillo, PhD; Elissa Epel, PhD; Margo Pumar, MD; Elena Fromer; and Stephen Hinshaw, PhD.

Stigma can be a powerful and toxic force affecting people’s lives and opportunities. There is unfortunately a lot of stigma arising during this period — stigma of race, ethnicity, political beliefs, and even contracting COVID-19. Stigma is an ancient and ugly term, originally signifying the marks or brands burned into the skin of social outcasts in ancient Greece and Rome. Today it signifies the devalued status placed on individuals including racial/ethnic, religious, or sexual minorities — as well as people with serious health challenges, mental disorders, or substance abuse. Some formerly stigmatized groups (for example, left-handers, adoptees, HIV-positive individuals) today experience less (or hardly any) stigma, signaling that as social norms change and as political action occurs, acceptance can carry the day. Particularly in the case of HIV, effective treatments also make a huge difference.

Stigma associated with mental health

Despite far greater public knowledge of mental disorders than 50-60 years ago, public attitudes have been slow to budge. Depression continues to be a leading cause of disability worldwide. Still, a growing surge of openness, disclosure, and "parity" for mental health care coverage is combining to usher in a new era. We can no longer tolerate silence and discrimination. Given the sheer number of people experiencing mental disorders, everyone loses if fear, shame, and silence continue.

UCSF and UC Berkeley professor Stephen Hinshaw, PhD, is an expert on stigma and mental health who has written extensively about the field of mental health stigma and strategies to overcome it.

Do we have stigma about mental health issues at UCSF? We do, and we need to fight that together. During COVID-19, the CDC reports that 40% of U.S. adults reported struggling with mental health or substance use. These statistics include a rise in those who have considered suicide, most prominently among respondents who are ages 18-24 (25.5%) and essential health workers (21.7%), but people think they are the only ones and are fearful or ashamed of sharing their struggles. This also leads to barriers to seeking help.

The seriousness of this issue is brought to light by the tragic story of Lorna Breen, MD, head of the emergency department at New York-Presbyterian Allen Hospital, who died by suicide on April 26, 2020. After a few short weeks working around the clock treating incredibly sick COVID-19 patients, watching many die, and contracting the virus herself, this exemplary physician with no prior history of mental illness experienced a mental health crisis. Her sister wrote, “And when she became so overworked and despondent that she was unable to move, her biggest fear? Her job.”

Many in health care worry that they will be seen as weak, ostracized or put their careers at stake if they break the silence. However, with the ongoing uncertainty, isolation and exhaustion associated with this pandemic the rise of mental illness and substance use disorders can no longer be a quiet epidemic, and we must learn to speak out for ourselves and others.

Stigma associated with COVID-19

The COVID-19 pandemic has placed fear of literal contagion front and center, leading to the stigma of those who test positive for COVID-19. In fact, a reason why stigma exists is to keep people “away” such as avoiding disease. The level of stigma associated with COVID-19 is due in part to:

  1. Ambiguity: COVID-19 still has many unknowns. (e.g., Can I contract COVID-19 again once I’ve had it?)
  2. We fear the unknown
  3. It is a natural human tendency to associate that fear with ‘others’—to blame others, to fear others, when we are fearful ourselves.
     

This can lead to prejudice and discrimination, in part to exert a sense of control over a situation that feels very uncertain. As described in a July 2020 Lancet article, there has been social ostracism, violence, and attacks on both health care workers and COVID-19 patients.

In spite of this, we can and will endure this pandemic. But in the meantime, following safety protocols, and undergoing quarantine if one contracts the virus can help with controlling the immediate environment. Also, realizing that most people are encountering stress, anxiety, and even depression associated with this pandemic can remind us that we are all in this together.

There has been xenophobia towards people of Asian descent, because of some attaching a location and/or ethnicity to COVID-19. This act of prejudice has led to hate crimes and other acts of discrimination against those perceived to be Asian. To help combat this phenomenon, UCSF's Thu T. Nguyen, ScD, MSPH, has created a video detailing how being sensitive to the language we use can reduce prejudice and discrimination.

Stigma experienced by health care workers

Being exposed to COVID-19 has led health care workers to be more isolated. In public, they may be denied access to certain spaces for fear of higher risk of transmission. Friends and coworkers may avoid them for fear of exposure. In their homes, they may not be able to easily hug or show affection for their families or in some cases, even live with their loved ones. For many working with COVID-19 patients, it has been a time of stress without the usual social support.

UCSF’s Robert Rodriguez, MD, has documented the specific stressors, such as social isolation, in emergency room physicians nationally. Contracting COVID-19 has led to stigma at work — where coworkers tend to avoid the person who recovered from COVID-19. Now that we have more resources to safeguard against contracting COVID-19, we must also attend to reducing the burden associated with this stigma.

Tips for preventing and reducing COVID-19 stigma

COVID-19 is a worldwide phenomenon which affects everyone, and in that way, we can all play a part to reduce its impact. Below are some things we can do to reduce stigma, based on suggestions from the Mayo Clinic. A downloadable guide to dealing with stigma is also available from WHO/UNICEF.

  • Fight the ‘infodemic’ of false information. Facts, not fear, will stop the pandemic: Getting the facts about COVID-19 from reputable sources such as the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). Share them with your family and friends.
  • Speak up if you hear or see inaccurate statements about COVID-19 and certain people or groups. Share sympathetic narratives.
  • Reach out to people who may feel stigmatized. Ask how you can help. Listen to them and show that you understand and support them.
  • Show support for health care workers and others who are caring for people with COVID-19. Thank them for their work and share positive messages on social media.
  • Show support for essential workers. Share extra gratitude and kindness with those who continue their essential jobs to help you and your community, such as police officers, bus drivers, grocery store clerks, food bank workers, and delivery people.
     

Maintaining good sleep

This expertise is provided by Aric A. Prather, PhD.

White bedding

Sleep is a pillar of health. Getting enough sleep keeps your immune system strong. It is also crucial for helping you mentally cope during this uncertain time. That said, it is completely natural to experience more disturbed sleep during this pandemic - including difficulties falling asleep, staying asleep, or waking earlier than you are used to in the morning. You may also find yourself feeling more fatigued than usual. Below are some tips to help your sleep in this challenging time.

Create a “COVID-19 free” wind down

Before going to bed, it is important to unplug and ready yourself for a restful night. The first thing to do is to say goodbye to all COVID-19-related news. We suggest:

  • 1-2 hours prior to bed, unplug from email, news, and anything else that creates a busy mind and begin focusing on creating a calm, relaxing environment. Say goodbye to COVID news; trust that it will be there in the morning.
  • Turn down the lights and do things that are relaxing. Relaxing activities vary by person, but often include reading, listening to music, or a meditation audio.
  • Avoid alcohol close to bedtime and discontinue caffeine after noon.
     

Keep a regular sleep schedule

Maintain a regular wake up time. If possible, also try to get some direct sunlight in the morning. Together, these will help regulate your circadian rhythm.

Don’t toss and turn in bed

If you are unable to fall asleep or wake up and can’t fall back to sleep, don’t toss and turn in bed for longer than 15-20 minutes. Get out of bed and do something relaxing until you feel sleepy and then go back to bed.

Make your bedroom a shrine to sleep

Be sure to keep your bedroom dark, quiet, and cool.

Mind your day to protect your night

What you do during the day can have a big effect on your night. Working from home affords convenience, but also may lead to more sedentary behavior and napping. Napping can eat away at your sleep drive, making it harder to fall asleep at night. Inactivity can similarly lead to lighter sleep and less feelings of restoration in the morning after a night of slumber.

Good sleep habits for children


Dealing with pandemic fatigue and avoiding COVID burnout

This expertise is provided by Elissa Epel, PhD, and Elena Fromer.

You are not alone. We are in the marathon stretch of the pandemic after over half a year of coping with social distancing and isolation, uncertainty, financial stressors, and changes in every walk of life.

Why do I feel tired all the time? You may not be getting enough sleep, working longer hours, or not having food work boundaries now that work may be at home. You may be exhausted from two jobs, caregiving, home schooling, and your day job. Or you may have no identifiable reason for new fatigue, but it’s there. Just simply living in the pandemic is new. Our mind, even unconsciously, is taking on the mental work of living with uncertainty and that is exhausting. It requires a certain amount of our attention and vigilance, all the time. There are many possible sources for your fatigue (attentional overload, insufficient quality sleep, emotional stress/burnout, or a psychological disorder). Identifying the sources for you allows you to address them directly. Many of these causes are interrelated.

Pandemic fatigue from stress or depression may be associated with elevated levels of inflammation. Chronic stress can create sickness behavior response, triggering innate immune response, inflammation, and fatigue symptoms. These symptoms are common during chronic stress, but reversible. That said, pandemic fatigue is not to be confused with the fatigue that accompanies serious medical issues, such as myalgic encephalomyelitis (chronic fatigue syndrome), Lyme disease, thyroid issues, autoimmune conditions, or anemia. These come with symptoms other than fatigue, and need a medical work up to identify or rule out causes.

Do I have attentional overload? There are new demands on our attention. Many of us have a habit of checking the news frequently. It is understandable — there is always new news, but it is no doubt a habit you can no longer afford as it can increase stress. We recommend limiting your exposure to once a day and not near bedtime. We know from research on disasters that more media time is related to prolonged post-trauma anxiety symptoms and worse health.

Remote work can contribute to fatigue and burnout. We used to transition from home to work, and we often had protected focus time while at work. Working at home while managing the needs of others, such as pets and small children, diminishes our ability to focus on one thing for a prolonged period. This type of multi-tasking and distractions also take their toll on our energy and well-being.

Mental Zoom fatigue is partly due to this demand on our attention. We are used to interacting with people in person, where we get strong signals from them — from body language, voice, and emotional expressions. On Zoom, all we get are weak signals. We need to strain harder to read the situation, context and content, all at the same time. Plus we may be dealing with a Brady Bunch box of 10 faces at one time!

Part of the problem with Zoom is that we are used to “synchrony” — the range of precisely timed vocalizations, gestures, and movements to communicate, and rely on precise responses from others to determine if we are being understood. A delay of even a few milliseconds causes our brains extra work to overcome the desynchrony. We recommend limiting Zoom meetings to 50 minutes instead of the full hour to give yourself a break. You could also consider making phone calls instead.


Maintaining physical activity

Woman and child doing yoga

Find ways to exercise. More than ever before we know that our physical health affects our mental health, and exercise can reduce stress reactivity and even ameliorate moderate depression.

Although it may be tough to exercise indoors, engaging in regular physical activity will help reduce your anxiety and stress. The online applications below have guided exercise routines. Each day, more teachers put their classes online. We will highlight good ones here each week.

Consider that live classes for exercise and meditation give us a group experience which we otherwise now lack and structure to our day, and we may be more likely to show up for them.

  • Planet Fitness live streams classes everyday at 4pm PST, 7pm EST: https://www.facebook.com/planetfitness/
  • J&J Official 7-Minute Workout is a free workout library containing 22 preset workouts, varying in intensity and duration. Workouts are designed to fit your schedule and range from 7 to 32 minutes in length.
  • Wakeout comes with hundreds of exercises you can do right at your desk, such as yoga, chair exercises, and hand health exercises to stay productive, energized, and healthy.
  • YogaWorks offers around 80 live streaming, high quality free classes each day.
  • Do Yoga With Me and Yoga with Adrienne offer free yoga videos for everyone.
  • Down Dog Yoga is free to all until May 1. If you are a student or teacher, Down Dog is free until July 1 when you register with your school’s domain.
  • Core Power Yoga offers free classes online.
  • Zumba dance concert videos offer great workouts.
  • A vigorous 30-minute Vinyasa yoga class with master teacher Janet Stone
  • Peloton is offering a 90-day trial of their digital membership, which offers streams of live/recorded group classes from a closed set. (It doesn’t require their bike to access classes on cycling, strength training, yoga, and meditation.)
  • The Workout.Today is a daily email newsletter with a free workout that you can do at home. They are also offering live yoga and live workouts during this time.
  • UCSF Fitness Center is offering over 115 daily live classes for the entire UCSF community. No membership required.
     

Most of us still have opportunities to go outside for exercise while maintaining physical distancing! Research shows fresh air, and seeing greenery, reduces somatic stress in our body, and clears our mind. Here are some specific to Bay Area:

  • Due to the high volume of visitors looking for relief in the various parks in the Bay Area, many locations have made the decision to close in order to help enforce physical distancing policies.
    • If possible, take walks and enjoy nature in your immediate neighborhood.
    • A regularly updated list of Bay Area park closures is available online.
       

Online stress reduction resources

Different people like different types of stress reduction practices. On this website, we have pointed you to social support (at a distance!), exercise, and sleeping well - all of which build your stress resilience. It also helps tremendously to adopt a daily mind-body practice, like yoga, qi gong, or meditation. Even if it’s only for five or 10 minutes a day, that practice makes a difference. Set a time of day you block out for this on your calendar; if possible, right after waking is a great time for practice. We have highlighted free apps, but there are an abundance of longer practices on the web to do at home for deeper restoration.

Here are a variety of practices to reduce mental and somatic stress that can be done online. Explore these and see what you love! This is a great time to join a live group online. We will update this section regularly, including live events.

Emotional Well-Being During the COVID-19 Crisis for Health Care Providers webinar series: Focus on psychological first aid

View videos

We know this is a difficult time for everyone, especially those of you who are serving patients. Please view our webinar series featuring mental health and emotional wellness experts showing how health care providers can reduce personal stress during the COVID-19 outbreak and climate disasters.

Meditation

AM live events (times are PDT)

PM live events (times are PDT)

  • 12:30–1:00 p.m.: UCSF’s Amy Hepner has weekly meditation sessions on Wednesday via Zoom. (Meeting ID: 514 447 417, or call in at the phone number: (669) 900-6833).
  • 7:15-9:15 p.m.: Monday night meditation group from Spirit Rock Meditation center in Marin with Jack Kornfield and other excellent teachers
  • Various times: The East Meditation Center offers meditation self-care groups online (some specific to POC, LGBT, those with disability, and others).
     

Online

Mind-body movement for restoration and relaxation