This is Democracy – Episode 91: Mental Health in a Pandemic

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Dr. Jeremi Suri: Welcome to our new episode of This is Democracy. Today, we’re going to discuss one of the most difficult and probably most important issues that we confront during this pandemic, and that’s the question of mental health. How do people preserve their mental health during periods of quarantine and stress? How do we understand mental health, and how do we address mental health concerns for citizens and particularly for health care workers and others on the front lines?

We have with us the person who I think is probably one of the very best people in the world to talk to about this. He’s also a great friend and an award-winning teacher. This is Dr. Stephen Sonnenberg. He’s a Professor of Psychiatry at the Dell Medical School. He’s a Professor of Instruction at the Steve Hicks School of Social Work here at UT and the School of Undergraduate Studies. He’s also the director of a really exciting program that I’ve had the opportunity to sit in on a few times, a program in the Humanities, Health Care, and Advocacy, which is part of an interdisciplinary set of courses that Steve has put together. He’s a Fellow of the Frank M. and Dorothy H. Conklin Endowment for Medical Ethics, and I could go on and on. He’s basically involved in everything important that’s happening at the intersection between health and society today. Steve, thanks for joining us again.

Dr. Stephen Sonnenberg: My pleasure.

Dr. Jeremi Suri: Before we turn to Dr. Steve, we have Mr. Zachary Suri here, of course and he has written a scene poem for us today. What is the title of your poem, Zachary.

Zachary Suri: For the Healers.

Dr. Jeremi Suri: Let’s hear it.

Zachary Suri: Dear healers, forgive me if I see you only as the humanitarian beacons of sanity and not as ordinary people who walk the empty subway platform to save lives. Forgive me if I never mentioned my gratitude before, I found myself holed up in my bedroom alone. Forgive me if I sometimes wish that I could just get back to school. Forgive me if I can’t clap and sing with everyone else. Forgive me if you’ve saved your life today, whom I infected with my sleeve a week a go. Dear healers, forgive me if all of what I know about emergency health care comes from mash, if I can only describe what you do with divine terms. Forgive me, doctors, nurses, mask makers. Sometimes I forget that you have to become numb to the site of the suffering. Forgive me if sometimes I forget that you have to watch more sick flow in and watch bodies waiting for the van flow out. Forgive me if I forget that you don’t shoot the bullet, but you have to stare into the jagged torso and not cry. Forgive me if I could only look away from the photograph of you touching your child through the glass. Forgive me if I buy masks and hand sanitizer, my paranoia in you’re lost PPE. Dear healers, forgive me if all I can understand about what doctors do comes to my fifth grade Grey’s Anatomy Coloring textbook. Forgive me if I ever think you are just mechanics of the human body. Forgive me for when I thought you were just doctors and when now you are just doctors, exhausted, sleeping in the garage to determine, to wait for the trauma, forgive me for not seeing this.

Dr. Jeremi Suri: That’s very moving, Zachary. What is your poem about?

Zachary Suri: My poem is really about what it’s like to be someone like me who never really thought about doctors and medicine that much and then suddenly to be in the midst of a health crisis and realize how important the people on the front lines are and what a tough job they really have.

Dr. Jeremi Suri: Yes. Steve, how should we begin to think about those on the front lines and what they’re going through. I think we’ve all watched in New York City, people are cheering every night at 7:00 PM. But how do we understand what the health care givers like you are going through?

Dr. Stephen Sonnenberg: Well, first of all, I think this really does demonstrate that the kind of education that we offer future healthcare providers really does encourage them to be truly dedicated. There’s a lot of talk today about how broken our healthcare system is, how much financial motivations seems to be a huge problem in really preventing us from developing a more equitable system without disparities. I do think that those cultural influences are there. But in this crisis, we’ve really seen that the kinds of thoughts that people have when they apply to medical school, when they apply to nursing school, when they apply to social work school, when they apply to be pharmacists, all of the health care professions, that when people say they want to help people, they really mean it.

Crises like this comes out because I have no doubt that there is nobody on the front line who isn’t scared. There’s nobody on the front line who is not aware that she or he or they can die, but they are there and they don’t run. That actually in itself is a very hopeful thought about what might emerge from this crisis. Because I do think that the crisis really exposes the very dark underbelly of our lack of inequitable health care system in this country and I do think there’s going to be a huge demand that after this crisis is over we really do create a more equitable system and the providers now will be on the front lines of demanding that. They’re not going to sit by and let themselves be controlled by large corporate interests. They’re going to demand that they work in an equitable system. I think that’s going to be a silver lining in what is a set of very dark clouds. I think we’re seeing the best in the health care providers.

Zachary Suri: We hear a lot about how fighting the Coronavirus is like a war and we all know a lot about how combat can affect people psychologically and can leave long-lasting trauma. What will this do to the mental state of our health care providers?

Dr. Stephen Sonnenberg: That is a very, very good question. But I’m going to change the question a little bit and say, what is that going to do to the mental health of our health care providers and everybody else. Because I think really we are all in the same boat. One of the things that I have great concern about is that we are now part of the population of a world that is being severely damaged, severely traumatized by this. I suppose it’s true that in certain parts of the world, people are constantly experiencing trauma because of poverty, because of nutrition, lack of food, because of rampant disease. But worldwide now I think the population of the Earth is going to come out of this very, very damaged psychologically and you might say that on Earth Day, we might say that the population of the earth is going to suffer from PTSD, and I do believe that.

I think that we’re going to encounter the after-effects of very severe trauma. People are going to be very vulnerable, as traumatized people are, to all psychological complications in addition to the direct effects of trauma, which we’re familiar with. So I’m very concerned about what we’re going to be like as a world when we come out of this. Now, I just said that I think that there can be positive effects such as a more empowered set of health care providers who are going to demand a more equitable system in which they will work. But I also think we’re going to have many, many people who are terribly damaged and part of the development of that equitable system is that we’re going to have to be sensitive to the damage that has been done psychologically.

We’re going to have to be sensitive to how vulnerable and fragile we human beings really are in the face of severe stress. We’re going to have to be prepared to provide very, very elaborate mental health services for the population of the world. This is something that really concerns me because I think that because mental health damage is often silent, it’s usually not dramatic, even frankly, when somebody commits suicide because they’re so traumatized and depressed that they don’t want to go on living. That in general is not traumatic. It’s tragic, but it is informatics. I think that perhaps the priorities that some people have that we have to restore the economy, that we have to open up stores, that we have to get the professional teams back on the court, back on the field, and pack thousands of people into stadiums, frankly, I think that’s going to take precedent over focusing on the mental health of the world’s population. This is going to be a problem that will have vast negative consequences.

Dr. Jeremi Suri: Steve, that’s so compelling but also so complex. Can you give us a little more of a sense of what the traumatic effects will be because we tend to, as you say, diminish those when we talk about these issues?

Dr. Stephen Sonnenberg: Yeah. Well, first of all, let me say something about trauma because everybody knows about post-traumatic stress disorder. But there’s a complimentary phenomenon. It’s perhaps a little bit controversial. It’s called post-traumatic strain disorder. It isn’t officially in the nomenclature. But if you think of a suspension bridge like the Brooklyn Bridge, there are cables that hold that up. If you put all the cables in at the same time, eventually the molecules in the steel of the cable lose their resiliency. If you put all the steel cables and at the same time and don’t do anything, eventually the bridge will literally collapse into the water. What happens is the cables are rotated, and at certain period of time, one of the many cables is changed. A couple of weeks later perhaps, and I don’t know the exact schedule, another cable is changed so that all of the cables don’t wear out at the same time. That’s threatening, and the human psyche can be strained in that way.

Most of us will not necessarily be touched by a death. Most of us will not be on the front line having patients die, but we’re all undergoing a tremendous amount of strain. We’re all frightened, we’re all worried. We’re all going to be strained, we’re all going to experience high levels of fear of doubt, we don’t know what’s going to happen to our futures, we don’t know whether our savings will be restored, we don’t know what’s going to happen to the education of our children or if we’re young, ourselves, our own education. All of this uncertainty constitutes a strain. Chronic strain does the same thing as acute stress.

The after affects or the consequences are the same. We know about post-traumatic stress disorder. We know about people who have flashbacks, about people who are hyper-vigilant, about people who can’t sleep well, about people who withdraw from social contact, whose loving relationships are corroded and eroded and destroyed. If we don’t pay very careful attention to this, we’re going to have a world’s population that is going to be experiencing high levels of anxiety, high levels of depression, many people will be unable to work, many people will withdraw from society, from social contact. This is a worst-case scenario that I believe is the likely outcome of all this.

If you have a psychologically depressed population, you have people who don’t interact effectively and successfully in the social sphere. You don’t have people capable of embracing each other, of loving each other, of collaborating together. I actually do think in a strange way the exception may be the health care providers who as impaired as they will be by the stress that they’re under, will perhaps be like the veterans of Vietnam who were traumatized by that war, but who came together and demanded justice for themselves. It’s first demanding an end to the war, then demanding proper health care for veterans with PTSD. They were energized. I’m afraid that most people will not be energized in that same way. That we will have a very depressed population.

I believe that this crisis is going to go on for a good solid year and a half. I think for a year and a half away. I’m very, very concerned that we’re going to have a psychologically crippled population. In its worst case, young people will not be achieving in the way that they need to in the educational realm. People in the next cohort a bit older, will not be achieving in the way people need to in order to establish professional careers, in order to establish vocations, in order to marry and create families. I think there could be huge impairments in all these spheres. We are not going to come out of this the same as we were before. By the way I realize I’m painting a very dismal picture, but that doesn’t mean we can’t do something about it.

Dr. Jeremi Suri: Right. We’re going to get to that Steve. I think you’re painting a dismal but also a picture that we need to hear. We need to think about this. That’s why we were so excited to have you on the podcast. Steve, what you’re describing reminds me as a historian of what we saw in Europe after World War One where the term shell-shock comes from Thomas Mann, the great novelist and famously writes of Europe after the war as a giant insane asylum in the news. Is that an appropriate historical reference for what you foresee?

Dr. Stephen Sonnenberg: Yes, absolutely.

Dr. Jeremi Suri: What are the lessons that we take from that? Maybe this then transitions us into what we should do or what we should be preparing for in light of what sounds to me like a very sensible anticipation of where we’re going.

Dr. Stephen Sonnenberg: I do think self-awareness and self-consciousness is extremely important. The previous time I spoke with you and Zachary, I was unaware that the discussion would start with a poem. Of course, I’ve become a fan of Zachary’s. I think that one of the things that’s so remarkable about you, Zachary, is that you are remarkably self-aware, and you are remarkably able to put that self-awareness into words. I wonder if you would agree with this, but I think your poems are very personal. They really speak to your growing awareness of your own humanity, of who you are as a person, and of the challenges you face, and of your own frailties which we all have. I’m going to ask a question because I want to make sure I’m on the right track here. But Zachary, do you think that’s a fair characterization?

Zachary Suri: Yes. I think that that kind of personal poetry and literature trying to explore ourselves can be really powerful in bringing us through a crisis like this, of reminding us of what’s important.

Dr. Stephen Sonnenberg: That’s exactly what I have in mind. I am a great believer in the importance of humanities education for future health care providers. That in fact, the problem we have before this pandemic, we’ve had a crisis among health care providers, of disillusionment, of burnout, of depression. One of the things we know about health care providers is that those who are connected to the humanities, actually are more resilient than those who are not. Those who read, those who write, those who go to the theater, who go to museums, who appreciate nature and wonders, which I consider to be a part of the humanities, the natural environment, the beauty of the natural environment, and the ability to appreciate that, those providers do better. There’s a lesson to be learned there, because I think what we need to do through this crisis and after this crisis is encourage our society and the entire world to pay more attention to these great gifts we have received from some of the most creative minds, the brightest minds, the most sensitive minds throughout history. Thomas Mann being one of them, by the way.

I think we need to try to create a culture that is self-reflective, and a culture that gives us time to be self-reflective, gives us time to contemplate, gives us time to learn to take in the lessons of great observers of the human condition, and to become observers of our own condition, and the condition of the people around us. What I’m really saying is we need to create, in a very self-conscious way, a culture that is contemplative.

Then I think a part of that will be the more professional side. By the way, on behalf of the poets, I think I should say that one of the professions that we need to really value as we go through this crisis and after are the poets. We need to hear their poetry, we need to really appreciate it, we need to take it in. Frankly, I happen to think that providing mental health services does have a lot in common with poetry. I think what a mental health professional does that is valuable is create a healing narrative. We have to have a culture in which professionals like me alongside professionals like you, Zachary, and alongside professionals like you, Jeremi.

Dr. Jeremi Suri: I thought you forgot about me, Steve.

Dr. Stephen Sonnenberg: No, but we need to appreciate the lessons of history.

Dr. Jeremi Suri: Yes.

Dr. Stephen Sonnenberg: We need people like you to guide us to Thomas Mann, English professors too. But I’m not being facetious. We really need to value the way we can think our way through this, and feel our way through this.

Dr. Jeremi Suri: Steve, you have taught me so much about the links between narrative and mental health. I think this is a point Thomas Mann, himself, made that human beings need to feel connected to something, they need to feel rooted. But how do we do that on the scale that you’re describing, when we have a global mental disorder, in a sense? How do we do that? How do we start?

Dr. Stephen Sonnenberg: That’s very complicated. I suppose I’m going to get political now. First of all, I think we have to have empathetic leadership from the top, everywhere.

Dr. Jeremi Suri: Yes.

Dr. Stephen Sonnenberg: By the way, when I say political, this is not a matter of red, blue, Republican, Democrat, Liberal, Conservative. President Bush and Mayor Giuliani were purveyors of empathy after 9-11.

Dr. Jeremi Suri: Yes.

Dr. Stephen Sonnenberg: We need that kind of modeling and leadership from the very top. We also need to empower our network of mental health providers with the tools they need to reach out to the population. Right now, we have a large population of mental health providers, at least in the United States who actually are terribly underpaid. They’re expected to do a lot and they don’t get paid for it. Very often, they get frozen out by insurance companies that after they provide services, telling them they’re not going to get paid.

We need to create a healthcare system where all of the people who are capable of being what I’m going to call purveyors of empathy, purveyors of understanding, encouragers of the development of self-understanding and narrative. We need to create a world in which these people are empowered to do their job, and frankly, where they don’t have to worry about working 60 hours a week to pay their rent and make ends meet. I’m thinking of the licensed professional counselors who are terribly mistreated by the insurance companies. Now, I think we have a potential workforce in this country of health care providers who really could do a lot, and really directly provide a lot of services.

Now, there’s another lesson to be learned here from my own experience. When I was first starting out in health care in the 1960s, I started medical school in 1961. When I was first starting out, one of the innovations that had been made in mental health was the development of what we refer to as indigenous workers. By indigenous, that means people in the community who have a certain natural inclination and ability to be empathetic. These people were brought in and trained, and often were the backbone of the staff of state mental hospitals. We also saw this after Vietnam, when Vietnam veterans themselves formed peer support groups. It was a federally funded program for that. I actually was involved on the National Advisory Board of that. We were really using people to help each other. We really created, in the Vietnam veteran community, a helping community. We also see that with the [inaudible] the organization of many people who’ve experienced mental problems who come together and not only advocate for themselves but encourage peer groups that are healing and helpful. Now, I’m speaking about the United States. I think we could do that in the United States. I also think, by the way, that we have a cadre of religious people who potentially could be helpful.

Dr. Jeremi Suri: I was going to ask about that, actually.

Dr. Stephen Sonnenberg: I think our priests, our nuns, our ministers, our rabbis, our imams, religious leaders of every faith group in this country could be brought together in a coalition to help provide these kinds of services. I think that faith-based organizations, including congregations, could certainly be one source where this kind of return to health is promoted. Now, I think one thing that’s problematic there is that within the faith-based community, we have people who deny science. That’s the problem that’s going to have to be addressed because we do not want to have warfare within faith-based communities about whether, for example, it is appropriate to have social distancing now, or whether it is appropriate to conduct church services over Zoom. I think we really need to work hard to create a cohesive and coherent science-respectful, faith-based community. By the way, we are seeing outbreaks in faith-based communities that do deny science. That’s another problem, I don’t want to make that a major focus of what I’m saying, but I do think faith-based communities can be part of the healing effort and should be part of the healing effort.

Dr. Jeremi Suri: Steve, this is so helpful, you’ve really put this in context for us so well. What role, and I think this will be our closing question and always is our closing question, what can we do? What role should citizens play? If we’re thinking about not just getting through the next year and a half, but also trying to think forward as members of communities and as scholars, as business people, as members of families, what should we be thinking about as we’re looking forward within these spaces? What are the things we should be doing now?

Dr. Stephen Sonnenberg: Before I answer that, I want to say that most of what I’ve said focuses on what I think is possible in the only country I really know well which is the United States.

Dr. Jeremi Suri: Right.

Dr. Stephen Sonnenberg: But given what I know about other parts of the world and I have traveled widely, I think with perhaps modification of terminology, what I’ve described is possible in most parts of the world.

Dr. Jeremi Suri: I agree.

Dr. Stephen Sonnenberg: I’m particularly concerned about parts of the world where there are huge populations living in abject poverty where access to this kind of thinking is rare because people are really just trying to live from day to day. I think this is where the World Health Organization, the United Nations, really needs to step in. Doctors Without Borders is an example of an organization that will send people to places where there is inadequate care. I think we need to organize and think in those terms. I think we have to be very respectful of the fact. If we don’t know now that we live in one world where we are all connected to each other and where we live or die together, we haven’t learned anything. I think we do know this and we do see this. I do think that we need to extend this to the entire world. But you ask what we can do as citizens.

Frankly, I think we need to first think about these things. I think I do now and I hope I do, if I’m making sense, if I’m putting this into words that bring together a lot of ideas and make sense, it’s because I think about this a lot and sure, I have a professional background and I am a university teacher and I’ve taught in medical schools for decades. But we all have perspectives, we all have ideas, we all have unique experiences, and we have to be respectful of each other and encourage each other to think and then to speak out.

I really believe we need to develop grassroots organizations where people speak about these issues and share these ideas, and from there the roots spread and we really can create a culture that can change. Then the next thing we do is we have to demand change in our leaders. We have to demand that our leaders be thoughtful and caring and loving and sensitive. In the world today because of threats to establish groups in power, and we’re seeing this all over the world, a turn toward authoritarian leaders who simply, empathy is not part of their black bag. They do not open their black bag and pull our stethoscope. We pull out anger and hate and rejection and scapegoating. We really have to demand a change at the top. Then I understand that that sounds very political, but it is what I think. I think we need to work from the grassroots and I think we need to demand a change at the top.

Dr. Jeremi Suri: It’s actually a wonderfully optimistic note to close on because if we go back to the analogy that we’ve been playing with here, that historical analogy of the period after World War I, you could see the world coming out of that crisis and going in two different directions. There is the authoritarian direction. But then there was also the direction that’s actually inspired our podcasts long before this pandemic, which what Franklin Roosevelt represented, which was an effort not simply to bring new programs from the top, but to inject an energy in grassroots activism and grassroots organization.

As many historians have commented and many novelists noted, including Saul Bellow, the New Deal was many New Deals in many communities and groups coming together to bring their communities together and provide healing, sustenance, and empathy at the local level. Franklin Roosevelt encouraged that from the national level. That might be the right way for us to think about moving forward right now. That should be a vision that empowers and inspires all of us to begin in our communities, Steve, to be having these conversations and to recognize and validate the damage that’s been done to people and the ways we have to work together to heal, not to forget or deny, but to heal that damage. I think you’ve really given us a real foundation for thinking about that. Zachary, does this resonate with young people stuck at home like you stuck with your parents and stuck online. Is this a resonant, inspiring vision that Steve has been able to come to after a pessimistic opening, I might say?

Zachary Suri: For sure, I think that my generation will not be the same after this crisis, that will come out of this looking at the opportunities we have, our education and health care workers in a completely different way and I think there’s a real opportunity there. There’s also the danger that we fall behind in that there’s a psychological crisis that doesn’t get addressed. But I think we have the opportunity and we have the ability to fix this and to turn it into something that can be a real force for good.

Dr. Jeremi Suri: Steve, I think your description of the problem and your inspiration to address it through conversation and grassroots activities, and empathetic leadership is the right way to go. I think you’ve shared so many insights with us. I hope we’ll be able to have you back on soon to talk about this in more detail. Thank you for joining us, Steve.

Dr. Stephen Sonnenberg: Thank you for giving me the opportunity to share my ideas.

Dr. Jeremi Suri: Well, we’re fortunate to have them. Zachary, we are as always fortunate to have your poetry and your insights as well. Our dark moments and these are dark moments also open up possibilities for new streams of light. I hope we’ve been able to think about that usefully here. Thank you to all our listeners for joining us for this episode of This is Democracy.

MALE 2: This podcast is produced by the Liberal Arts Development Studio and the College of Liberal Arts at the University of Texas at Austin.

MALE 3: The music in this episode was written and recorded by Harrison Lemke you can find his music at harrisonlemke.com.

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