How are you? I hope you’re managing to keep your head above water these last tumultuous hours and days. This week on Fresh Dialogues, I have some reassuring wisdom and some practical tips to bring you comfort and help you keep hope alive.
Like millions of us, I watched in disbelief last night as many of the swing states turned red. The “blue wall” that some pundits anticipated –– and said Trump would pay for –– just didn’t materialize. I found myself in such a state of anxiety that I could barely breathe.
Frankly, I’m stunned that so many people voted for Trump despite his many atrocities: the blatant lies, his anti-science stance, demolishing environmental protections and his gross mishandling of the pandemic. And with the resurgence in Covid around the world, it sometimes feels there’s no end in sight to our elevated stress levels.
As I write this, early afternoon on Wednesday November 4th, the Associated Press has yet to call several key states, but there doeslook like a path to victory for Joe Biden and Kamala Harris. I can but hope.
How do you find hope at times like these?
If you’re also feeling high anxiety, despair, or even depression right now, this advice from a wise man named Manfred will give you hope.
“It’s so important right now to take care of yourself, and in that act of self-love and compassion you may be able to reach out to another, and that person another still, until we collectively heal from these challenging times,” Manfred Melcher.
As you’ll hear soon, Manfred reminds us to “Mind your own light.” You’ll find out what he means below.
My latest report for the BBC explored the timely question: Is online connection as effective as face to face meetings?
I explored the surge in teletherapy, but I think there are important lessons to be gleaned for all of us, whether you’re seeking to connect to friends, family or a mental health expert. I was reminded of the importance of radical self care.
My report aired October 28th on the BBC World Service program, Health Check. The segment starts at 28:00 on the BBC podcast
You’ll even find some humor in the report, despite the heavy topic. After the transcript below, I’ll share some tips to help you get through these next few days and weeks. And please join me at the end of the Fresh Dialogues podcast as we do some deep cleansing breaths together. You’ll be surprised at how stress relieving that can be.
.
Here’s a transcript of the report (lengthened and edited for clarity). Names have been changed to protect people’s privacy.
The BBC’s Claudia Hammond: On the show last week, we were talking about the difficulty of patients and their relatives receiving bad news over the phone rather than in person due to restrictions in hospitals. Now something similar is happening in therapy sessions.
In the United States, a recent survey by the American Psychological Association found that due to the virus, three-quarters of therapists are now providing remote services, either on the phone, or through video conferencing software. But when people are pouring their hearts out and talking about their innermost thoughts, can a digital encounter ever be the same as a face to face session?
For Health Check, our reporter Alison van Diggelen reports from the west coast of the U.S. where, as well as the pandemic, people have been dealing with forest fires, choking smoke, and power cuts. The demand for mental health care is growing.
Alison van Diggelen: Kristin, lives alone in a beachside community in Southern California. She faced intense challenges before Covid struck. Recently divorced, she moved house and launched a new business last year. On top of her anxiety and panic attacks, there’s now another stress factor:
Kristin: Loneliness definitely has been an issue… not being able to see family: touching people, hugging people for four, five, six months. We weren’t built for that. Humans are built to connect. We have this innate need to connect with each other. Covid took that away. In order to protect each other, we had to disconnect. And find other ways to stay connected.
Alison van Diggelen: She saw an ad for the online therapy app Talk Space, featuring the Olympian swimmer, Michael Phelps.
Kristin: I did think: if he’s open to talking about it… I think people should talk about it more. We hire trainers to keep us physically fit all the time, and our mental health is just as important. That’s what a therapist is there for: to help us work on those issues which are just as hard, and if you don’t address them, it’s very dangerous. I said, there’s nothing to lose to try it.
Alison van Diggelen: Six hundred miles north, Arthur, a recent college grad, is adjusting to life back home with his parents and starting a new job in Northern California.
Arthur: All these feelings overwhelm you: mainly anxiety. depression, it’s been a tough time… especially family matters.
Alison van Diggelen: Even further north, Justin, a millennial, based in Washington State suffers from obsessive compulsive disorder (OCD) and depression. He obsesses about finding perfection and has regular compulsions to wash his hands.
Justin: One of my biggest triggers is unstructured time so when I started working remotely after Covid, it just really messed up my productivity and work habits. It became challenging to focus. I need a good separation of work and life…
Alison van Diggelen: When he visits his extended family, he faces even more triggers:
Justin: One of my family members triggers my intrusive thoughts, makes me feel invalidated.
Alison van Diggelen: Kristin, Arthur and Justin are some of the 50 million Americans with mental health issues. A 2017 study from the Substance Abuse and Mental Health Services Administration revealed that only 43% received treatment.
Of those who’ve managed to get help, since Covid struck, most are unable to meet with therapists in person and have begun using online platforms like zoom or similar technology to connect via video or audio.
But how does it compare to traditional, in-person therapy? Leslie Moreland is director of the Regional TeleMental Health Program at the San Diego Veterans Administration Health Care System. She cites peer-reviewed studies showing that video conferencing can be just as effective as face-to-face therapy for treating post-traumatic stress disorder, depression and anxiety. She says telehealth can help close the gaping needs gap.
Leslie Moreland: The studies have shown repeatedly that in terms of clinical efficacy, meaning symptom reduction, that the video conferencing modality is comparable, so you can achieve the same clinical outcomes, in terms of clinical effectiveness, feasibility and safety.
Alison van Diggelen: Moreland also examined what researchers call “therapeutic alliance” – which is when you feel comfortable with a therapist, that you can trust them, and that they attune to and validate your experience. Is it possible to establish all of that, when the patient and client aren’t even in the same room?
Leslie Moreland: The research has found that the therapeutic alliance is quite comparable, and is comparable enough that the benefit of the treatment still stays intact. Research has shown that patients do like to get therapy this way. More times than not, if you have the option to sit in the same room as someone, that’s often better, it feels more comfortable for folks.
Alison van Diggelen: Moreland believes that even before Covid, busy schedules, and juggling a family and a career, made teletherapy the only practical solution for many people, especially those living in remote areas.
For Kristin, saving time driving to and from therapy sessions was a huge advantage of moving from traditional therapy to teletherapy.
Kristin: Right away I felt connected, well taken care of. It was very professional. I liked the therapist I was matched with.
Alison van Diggelen: After a couple of video conferencing sessions with her new therapist, she used the texting feature exclusively.
Kristin: The technology of just having it on my phone. I liked that so much better than seeing a therapist at a certain time, and having all that stuff bottled up, writing it down in a journal. It was easier, if I was dealing with an issue or triggered by something, I could just take out the app and text her. I would get a response within two hours. I just LOVED that. It felt like having my own personal mental health trainer in my pocket.
Alison van Diggelen: Justin also likes the flexibility that teletherapy offers:
Justin: The best thing about teletherapy is the freedom to do it wherever I feel comfortable doing it. I like to pace a lot, move around when I do therapy. I like doing it outside. It’s nice to have fresh air. I get stuck in thought loops easily and therapy helps me parse out everything I’m thinking of sequentially. That helps me feel able to move forward.
Alison van Diggelen: But Leslie Moreland warns against treating therapy too casually – and has learned to set boundaries with clients. She’s even had to ask some to save that glass of wine or beer for after their session.
Leslie Moreland: There’s an informality that can influence the process… People get very casual, we have to remind them you need to wear a shirt … people are in the drive-through ordering food! If you don’t have anywhere in your room that’s safe, you can sit in the bathroom but we prefer otherwise.
Alison van Diggelen: Andrew finds technology glitches, rough connections and lagged responses can make the challenge of communicating with his male therapist harder.
Andrew: Some things are tougher to explain on Zoom. If he asks me a question, I have to find more words to convey the message. In a sense that facial expressions, body language and being able to read the tone of voice: It’s better in-person than on a call.
Alison van Diggelen: But he has learned some valuable life lessons from teletherapy:
Andrew: I used to feel I had to climb the whole mountain, it was just overwhelming. I realize the problem can be broken up into smaller chunks. You take each one by one….You don’t need to find the one answer to deal with the whole problem. It’s a process.
Alison van Diggelen: And how is teletherapy working for therapists? Manfred Melcher is a California based therapist with over 20 years of experience. He conducts about 70% of his therapy sessions online, but has mixed feelings about teletherapy.
Manfred Melcher: I notice if I do too many in a row, I get fatigued more than I do in in-person sessions. So much takes place in person with a client, the nuances of connection… While a video is quite good, it’s not the same. ..I try to do two in a row, then schedule someone who wants to come in in-person, or I’ll take a break. I try to do not more than 5 a day, that’s my limit.
Alison van Diggelen: He also cautions against the “app-ificaton” of mental health: the spike in online apps like Talk Space that offer text based therapy.
Manfred Melcher: We interact with technology with a lot of casualness….That could hurt people. I’d advise people to see apps in a realm of entertainment. They could contribute to your knowledge of psychology, understanding yourself emotionally, but the treatment… If you’re going to technology for treatment for a psychological issue, a medical issue: Woah! I’d be very cautious.
Alison van Diggelen: Experts predict that teletherapy is here to stay, except for severe cases of mental illness (like psychosis), where in-person therapy is vital. Most therapists and patients expect they’ll adopt a hybrid approach to therapy after the pandemic.
Therapist Manfred Melcher anticipates that the mental health crisis has yet to peak. Even he admits to moments of despair and finds the mantra “Mind your own light” sustains him.
Manfred Melcher: It’s so important right now to take care of yourself, and in that act of self-love and compassion you may be able to reach out to another, and that person another still, until we collectively heal from these challenging times.
That is my greatest hope… that we realize how connected the world is, and how dependent we are on each other. We are one human family in a deep relationship.
Our survival depends on each of us minding to our own light, and honoring the light of the other. And in lifting up the other, we lift up ourselves.
Alison van Diggelen: Justin, the young millennial dealing with depression in Washington gets a lot of the support he needs from teletherapy – but hopes to see his therapist regularly, in person, soon…..
Justin: I think everyone can benefit from therapy… it’s incredibly helpful and very grounding. For me it’s important to be face to face with someone. It makes me more comfortable and helps me focus better.
END of report
Simply put, we all need each other, and deep connection more than ever right now. But we must remember to first, mind our own light.
If there’s ever a time for radical self care, this is it dear friends. Do whatever nourishes you this week:
Finally, I hope this breathing exercise will help you get through the next few challenging days. Here’s a handy video that helped me cope with last night. Many thanks to the team at The School of Self for making it.
If you’d like to try this breathing exercise, please turn off your phone, close your eyes and put one hand on your heart and one on your belly. Are sitting comfortably? Then we’ll begin…(Take three long, deep breaths: in for five…out for five, in for six…out for six, in for seven…out for seven).
Remember: Mind your own light, and then share it with others who need it right now…
Thanks again for reading and listening to Fresh Dialogues. I sincerely hope the next time we connect, we’ll all be breathing more easily.
Find out more about radical self care at Fresh Dialogues:
I’m excited to share my latest BBC report with you and introduce a remarkable woman who changed the way I see the world. When I heard my report on the BBC World Service last week, I was moved to tears. A lot has happened since I filed it in early August…
Animals help us reconnect to a wise and ancient part of ourselves that naturally knows how to find balance and alignment. A good deal of our resilience to stress and change comes from our self care practices.
Animals show us how powerfully soothing it can be to just sit and breathe together. Sit close to your pet and focus on your breath and his or hers for a few breaths. Give your dog or cat a light pet. Put your other hand on your heart and soothe your inner human animal. Now, think about what human relationships of yours might benefit from such a gentle and wordless check in. Beth Killough, Psychotherapist
In July, it seemed that things could hardly be worse here in Northern California. Covid rates started to tick up and with that came another round of tighter lock downs and restrictions. And then a freak lightning storm sparked dozens of fires. Overnight we had friends who faced evacuation, and others unable to go outside, as air quality spiked far beyond Beijing levels. Overnight, my 95 year-old friend had to evacuate and find refuge with her little dog, Buddy. Overnight, we all became experts at analyzing Purple Air, the air quality app where anything over 400 is classed as an “emergency condition” for public health. One morning, I woke to see one Bay Area monitor at 666 on the scale of 0 to 500.
The things that had become the “new normal” were suddenly out of reach: simple things like taking a walk in the nearby park to relieve cabin fever, doing yoga class on the lawn of the local fairgrounds, and eating outside at our favorite dog-friendly restaurant. Now we all have to dig even deeper to find silver linings and nurture some optimism for a better day.
Did you know that one in three Americans are showing symptoms of depression? It’s likely even higher than that. A close friend who’s a therapist tells me she’s never been busier. We’re all taking one day, one hour at a time. That’s why we could all do with a Beth Killough in our lives. She’s a deeply insightful person who suggests we need a toolbox of choices to help us deal with stress and anxiety. Here’s her story:
Seven years ago, Beth bought a ranch and let go of her traditional office-based talk therapy practice. Now she uses her psychology insights and her barn full of horses to teach resilience, radical self care and leadership skills. She helps her clients tune into their own instincts and pivot to new projects and passions. Thinking her wisdom could hardly be more timely, I talked to my BBC editor in London about making her the focus of my latest report.
You might think that equine therapy –– working with horses to improve your resilience and well being –– is a niche thing, something for the affluent or the physically impaired. But Beth explains that some of the techniques are easy to practice at home and timely for this time of high anxiety and Covid related stress. They might even help you navigate this challenging time more easily and pivot to more joyful relationships and a sustainable career path.
Here’s a transcript of my report for BBC Health Check, including some bonus material that didn’t make the final cut:
Alison: Beth Killough works on her Northern California ranch and has seen a spike in clients looking for help for anxiety, trauma and loneliness since the pandemic began. Today her client is a 50 year-old woman named Michelle and they’re in the barn with Riva, a brown mare with a black mane and tail.
Beth: Notice as you brush her, she gives you feedback. She’s telling you…
Michelle: I can’t tell. I’m not sure what her feedback is…
Beth: If I stop talking and you start observing, it’ll help you tune in…
Michelle: Yes…with my dog it’s so incredibly obvious. If you stop, he’ll buck my hand to keep going.
Beth: Right as I stopped talking, she started licking and chewing which is her nervous system going into a relaxed state. She also took some steps forward. What is she showing you?
Michelle: I’m going to adjust so you’re doing (brushing) where I want you to be.
Alison: Beth Killough has been working with horses for four decades. She pivoted her traditional talk therapy practice to equine therapy when she bought the ranch 7 years ago. She examined equine research that showed physiological healing in people with PTSD and decided that you don’t have to be in trauma to benefit from working with horses.
Beth: If you look at where you are. Just pause. You got yourself in a little tight spot there! Did you feel it?
Michelle: Umm no.
Beth: The more focused you are picking up on her, the less focused you’ll be on your own pressure. This is a safe horse… However, you’re in between a thousand pound animal and a wall! So where are the places in your life you get in a tight spot without even realizing how you got there?
Michelle: Ummm..
Alison: The healing power of horses dates back to the ancient Greeks who used them for therapeutic purposes. In modern times, equine therapy still has its skeptics but anecdotal evidence is now being supported by growing clinical research.
Ellen Kaye Gehrke runs an integrative health program at National University in San Diego. She has been researching the human-animal bond for 15 years and her latest peer reviewed research examined the treatment of PTSD in nine war veterans. It showed remarkable results.
Ellen: We were at a conference a couple of years ago and a bunch of public health people came up to us and said: What pill are giving those people? The effect is like a drug.
Alison: Kaye Gehrke works with small groups of war veterans, some of whom have lost hope and are suicidal. Her eight week programs help them build connection with the horses through grooming, and interactive activities. More recently she has them saddle up and ride.
Ellen: We wanted to get the veterans up on the horses, not to go galloping away but just to have some movement.
We did notice there was quite a bit of difference…Their spirit, their physical carriage, the way they stood, the openness around their faces. The main point of my program is the heart connection.
Alison: What does Kaye Gehrke mean by “the heart connection”?
It relates to heart rate variability (HRV), the variation in the time between consecutive heartbeats. A normal, healthy heart does not tick evenly like a metronome, but instead, there is constant variation. In general, the higher the variation at rest, the fitter you are and the greater your ability to handle stress.
Professor Michael Myers, chair of health sciences and a research physiologist at National University has found that being with horses improves your HRV.
Mike: Horses are prey animals so they’re constantly alerted to their surroundings and that seems to trigger some response in humans: The response we see is documentable…
We use a technique…It’s basically reflection based bio-optical imaging. Photoplethysmogram or PPG for short. We’re able to measure the heartbeats of the subject. Something around horses changes the heartbeat variation. When the heart is beating the same, that’s stress. It’s fight or flight response, when you’re running from the tiger.
What’s really good is this: a couple of short beats then a long beat. Horses seem to have that effect….
Alison: Myers was surprised to measure an almost immediate physiological effect in the war veterans.
Myers: Within the first visit, within three hours, their heart rate variability has changed in a positive way.
Ellen: Their heart rate variability improved the first day but their self report took four weeks for them to have confidence…We could see they were getting better, but they were still in these messages of self destruct…By the fourth week, they started changing their self report about how they were feeling: less agitated, less irritable, more joyful. Their psychology was lagged, compared to their physiology.
Alison: Beth Killough has found that the practices used for PTSD treatment can benefit her clients. In sessions of two to four hours, they are introduced to the horses in the pasture, choose a horse and spend time interacting and grooming it. Killough helps them reflect on every interaction, allowing them to become aware of patterns in their own behavior and tune into their own thoughts and actions, both at home and at work.
Back in the barn, Killough explains how horses deal with new challenges…
Beth: When something new enters, the horses experience and respond by circling up and moving their bodies until the pressure releases. Then they’ll circle back and examine…
They’re taking care of themselves 100% of the time, it’s radical self care and it’s safety in numbers.
If we go into a freeze state or try to think our way through it, it makes it worse.
Beth: If you get scared and reactive, you have to ask yourself: what do I need right now? You’re not going to go galloping off, letting the cortisol and adrenaline release…
That’s why you can’t sleep. It’s coursing through you and hasn’t anywhere to get out. So when we don’t know what to do to take care of ourselves. We get into habits where we do something relational…
Alison: … like fighting with a family member
Beth: What we need to do first is take care of ourselves.
We need to build a bucket, a toolbox of choices: Things you can do when you feel that way. You can’t think of these things when you’re in the panic.
Alison: Killough recommends we move our bodies: go on a walk in nature, get a punching bag, find outlets to physically express yourself.
Beth: A lot of our anxiety symptoms are caused by not giving ourselves little moments. We deprive ourselves of it, so we’re thirsty for it.
It’s first pressure, then tension, then stress, then pain, then anxiety. There’s a sequence.
There’s some unlayering that will happen… The smells, the textures you noticed: That’s the vibrant part of our humanity we miss out on when we’re focused on our thoughts, our worries, other people, and either the past or the future.
Those are the things most distracting…Did that make sense?
Michelle: Yeah…
Alison: Of course, we don’t all have access to horses. Can our pets improve our mental health, and our adaptability to change? Killough recommends learning self care from our pets. For example: shifting our mindset about walking our dogs. Instead of a chore, consider it from your dog’s perspective. Could it be an exhilarating adventure that sparks curiosity, playfulness, and joy? Switch off autopilot, and consider it your resilience practice. You and your dog are two mammals venturing into the world together….
Here’s Beth Killough with one last thought:
Beth: Animals help us reconnect to a wise and ancient part of ourselves that naturally knows how to find balance and alignment. A good deal of our resilience to stress and change comes from our self care practices.
Animals show us how powerfully soothing it can be to just sit and breathe together. Sit close to your pet and focus on your breath and his or hers for a few breaths. Give your dog or cat a light pet. Put your other hand on your heart and soothe your inner human animal. Now, think about what human relationships of yours might benefit from such a gentle and wordless check in.
Last week, as demonstrations and outrage continued across America, I received an invitation that made me very nervous: I was invited to join a live BBC World Service program to discuss the view from California. I felt ill-equipped to contribute. What could I say that would be valuable to the dialogue? This is a challenging time to opine on the tinder box that is America, particularly if you’re a white immigrant. But I did my homework, listened to a lot of diverse commentary and read widely.
I can’t claim to have all the answers (who does?) but in preparing for the program, I did some personal growth. I changed from from feeling tongue-tied and unworthy, to fired up about speaking out. How? My research taught me three important things (see below).
Or listen to the Fresh Dialogues podcast below which features highlights of our discussion and more about what I discovered.
.
We began by discussing Trump’s executive order introducing police reforms, and then listened to the insightful perspective of Philip McHarris. A researcher at Yale University, McHarris is a vocal member of the Community Resource Hub for Safety and Accountability. He makes some excellent points about the need to prioritize education and economic opportunity for the black community, and has written a provocative New York Times Opinion piece that concludes: “We need to reimagine public safety in ways that shrink and eventually abolish police and prisons.”
I agree with his call to reimagine public safety, but it’s hard to imagine that abolishing police and prisons will ever be a wise idea. What do you think?
BBC transcript (edited for length and clarity).
Philip McHarris: Police are largely arresting people, and putting people in jail and ruining lives and communities, when people need resources and opportunities, and not a prison cell and policing.
Defunding police means shifting resources away from policing and getting at the underlying causes like not having quality schools, employment options, housing healthcare. The communities that are the safest don’t have the most police but they have the most resources. Because of specific decisions and political inaction, housing policies have created legacies of racial and economic inequality. People often are forced into survival economies which are then criminalized.
So the first step is funding community resources and institutions. The other side is developing alternative emergency response systems where police –– who have guns and a license to kill with immunity –– are not showing up when people need a wellness check, a mental health intervention or domestic violence support.
Jamie Robertson: Alison, this idea of defunding the police…is it getting traction? The idea of withdrawing the police and replacing areas of police enforcement with social workers?
Alison van Diggelen:There is support for defunding police and looking at the root causes (of police brutality). The fact is: We all have bias. It’s what we do with it and how we manage our first impulses (that matters most).
The police force needs to build new protocols and new partnerships, as Philip said, with social workers and psychologists. It needs to invest more in anger management and de-escalating violence, rather than inciting violence. And perhaps making Malcolm Gladwell’s book Talking to Strangers mandatory for police officers?
This pandemic has exacerbated the tinder box of despair and rage in America. Perhaps America also needs to face its horrific history of slavery. That legacy continues today. We need to borrow practices from South Africa and Rwanda and hold Truth and Reconciliation hearings.
Here are the three things I learned in preparing for the BBC program:
Speak out: As influential psychologist and author Adam Grant says:
“Just as sexism is not only a ‘women’s issue,’ racism is not only a ‘black issue.’ In social movements, research has repeatedly shown that when majority groups stay quiet, they inadvertently license the oppression of marginalized groups.” Adam Grant
So, no matter who you are or where you’re from, this is time for speaking out against injustice and inequality. It’s also a time for mindful listening, reading purposefully and amplifying the voices from the black community.
“Let’s not excuse violence, or rationalize it, or participate in it. If we want our criminal justice system, and American society at large, to operate on a higher ethical code, then we have to model that code ourselves.” Barack Obama
It’s a version of Michelle Obama’s powerful mantra: “When they go low, we go high.” Here’s her full explanation of the mantra:
“‘Going high’ doesn’t mean you don’t feel the hurt, or you’re not entitled to an emotion. It means that your response has to reflect the solution. It shouldn’t come from a place of anger or vengefulness. Anger may feel good in the moment, but it’s not going to move the ball forward,” Michelle Obama.
3. Champion what works
The United States has a appalling history of slavery; but it’s not the only country that’s ever dealt with systemic racism. Think about the last century of German and Rwandan history. And in South Africa, racism wasn’t just systemic during the Apartheid era, it was an integral part of the constitution and the law of the land. Many people predicted a bloodbath when apartheid ended, but instead Nelson Mandela helped to make a peaceful transition. The country’s Truth and Reconciliation Hearings were an integral part of this.
My fellow BBC contributor, Barrett Holmes Pitner writes eloquently about what we can learn from other countries and concludes:
“Rwanda, Germany, and South Africa have reckoned with their troubled past to make a better future, but America has long preferred to ignore the past, and proclaim the inevitability of progress. America today must define and confront the Original Sin of slavery.” BBC contributor Barrett Holmes Pitner.
Here are some other insightful perspectives worth reading:
“Everyone deserves dignity at the end of life,” Isabel Stenzel Byrnes, bereavement counsellor and hospice care worker.
This week’s podcast is a deeply personal story of how the Covid-19 pandemic impacted my family. A shorter version aired this week on the BBC World Service program, Health Check. I dedicate it to my beloved mother, to those fearful for vulnerable family members, and to anyone who’s lost a loved one recently. And I offer sincere thanks to Isabel, Laura and Mary who shared their poignant and hard earned wisdom about dealing with death.
Listen to the full story at the Fresh Dialogues podcast or below:
.
The Covid-19 pandemic has forced me to have a deeply uncomfortable conversation with my sisters. The topic? Our mother’s death. Despite warnings not to visit the elderly, my younger sister drove 500 miles from Kent to Scotland to visit our mother. A puzzling phone conversation convinced her that our 88 year-old mum needed help, urgently. So we made a pact one night: if mum did catch Covid, we’d keep her at home, come hell or high water. The thought of our sociable mum lying alone in a hospital bed, struggling for breath with no one holding her hand, broke our hearts.
Just a few hours later, I woke to the news that hell had arrived. Mum fell during the night and broke her pelvis. My sister watched, impotent, pleading as the ambulance crew –– decked out in full body protection –– stretchered her away. Grimacing in pain, she grasped at my sister’s hand, “Don’t worry, I’ll be OK,” she said. “You know I’m a tough old woman.”
We feared that would be the last time we’d see her alive.
To make matters worse, I’m 5,000 miles away from Scotland, sheltering in California, where I’ve lived for more than two decades.
Earlier this year, the BBC’s Health Check asked me to explore a watershed moment in American healthcare: For the first time since the 1970s more Americans are dying at home than in hospital. My first reaction was: Nope, I can’t go there. Like many of us, I feared facing death.
But now it hit home for me, like an avalanche of mother-daughter worry. Witnessing the isolation of Covid hospital patients in painful technicolor online –– and the inability of loved ones to say goodbye –– has brought it all into sharp focus.
So whyare the majority of Americans now choosing to die at home, and not in hospital? Do they miss out on specialist care and pain relief? What is “a good death,” and what will be the lasting impact of Covid on all this?
“Medicine historically has said: We’ll throw everything we can at a person to keep them alive and is not necessarily what people want,” she says.
Today about 80% of Americans say they want to die at home– or at least not in hospital.
In response, hospice care has grown rapidly over the last 10 years. The modern-day hospice movement was started in the UK in the late 1960s by a former nurse, Dame Cicely Saunders, who wanted to focus on the relief of symptoms like pain, whilst attending to their emotional and spiritual needs away from a hospital environment.
According to the National Hospice and Palliative Care Organization, the number of hospice patients on Medicare– the federal health insurance program for over 65 year-olds – has grown from 44% in 2012 to 50% in 2018. In the US, unlike the UK, in-facility hospice care is the exception, not the rule. So most American hospice workers provide care in patients’ homes.
“Everyone deserves dignity at the end of life,” she says. “Death is the ultimate equalizer. It doesn’t matter if you’re rich or poor, black or white, American or from another country. We will all die. So one of the philosophies of hospice care is to give everyone a death with love, support, presence, understanding and dignity. We want to honor the life they lived, and exit this world with grace and support.”
Stenzel Byrnes points out that unlike being in hospital, where unfamiliar surroundings and staff on constant rotation, and unexpected tests in the wee hours which can cause anxiety, dying at home can give people more calm and control.
“It’s different at home with a handful of close caregivers … who know your life story… can share stories and laugh. You can be understood and known at the end of life by the people surrounding you,” Stenzel Byrnes adds.
But, she cautions, there’s a risk of romanticizing death at home. It’s not always calm and predictable.
“Death is hard hard work for the patient and carers, and the family members,” Stenzel Byrnes points out. “It’s a long process of making peace….it can still be something that most of us will fight against. As Dylan Thomas said, most of us will not go gently into that good night. People die the way they lived. If people were defiant, and angry, hostile to other people, they’re probably going to be that way in the end.”
Hospice care can provide all the pain medication patients need in their dying days at home, but unlike in hospitals, it’s rarely 24/7, so family members can face a heavy burden.
Since 1982 Medicarehas paid for hospice care services – providing their doctors say they have less than 6 months to live and they decline curative treatments like chemotherapy and ventilators – this can save patients exorbitant hospital bills. Instead of trying to prolong life at all costs, Mission Hospice’s Mary Matthieson explains that her team focuses on the quality of life, an approach she calls: “Cabernet over chemo.”
But dying at home isn’t just about saving money – it’s also driven by educational and cultural factors.
Influential doctors like Atul Gawande –– and Britain’s Rachel Clarke –– have helped shiftattention towards palliative care, as well as “death positive” movements like Death Cafes, where people are encouraged to meet for tea and discuss death – and online awareness sites like “The Conversation”, help to reduce the cultural taboo around death.
So does Stanford’s Laura Carstensen believe that Covid-19 has jolted the worldinto considering the option of dying at home?
“I’ve already said to my husband: If I had Covid and having difficulty breathing: don’t take me to the hospital,” she says. “A lot of people are saying that – do NOT take me to hospital. It’s the last place I want to go at the end of my life. We’re doing ourselves and other people a favor by talking openly and we’re obliged to help people we care about get what they want.”
The forced isolation of Covid patients is necessary to protect the wider community, but it’s troubling to think of patients dying alone.
“It’s even worse than that,” says Laura Carstensen. “Medical professionals are incredibly stressed themselves, overburdened. It’s hard to imagine that people have time to sit and hold the hand of someone. There’s every reason to think that a lot people are ending up in their very last minutes of life are very much alone.”
Isabel Stenzel Byrnes is also a bereavement expert – and worries that the speed of the virus doesn’t allow anticipatory grief.
“I’m very concerned that bereavement will have added regret, guilt and what we call counterfactual thinking: I would’ve, should’ve done something differently,” she says. “The one solace is the collective grief we’re all experiencing. Everyone on this planet is impacted in some way. You’re not alone if you’ve lost a loved one to Covid. There are thousands like you that are grieving…”
But Byrnes also believes a silver lining will come from this pandemic. That it will produce an awakening and help lessen the taboo of death – helping us to realize that simply talking about death will not make it more likely to happen.
“The epidemic is a natural source of anxiety and stress. It awakens a primitive survival instinct: we want to control as much as possible…” says Stenzel Byrnes. “It confronts us with death and we can think about death without it happening. There’s a myth if we talk about death it will happen. That’s like saying if we talk about sex we’re going to get pregnant. That’s a complete myth. What Covid is doing is: it puts death and dying as a more familiar topic…the idea of death becomes a kitchen table topic that we can openly discuss with friends and family and what is most important to us and what our wishes might be, when our time comes.”
And that’s exactly what Covid did for my family. For us, the kitchen table was the sometimes precarious connection of a Skype call.
After the ambulance crew whisked our mother to hospital, my sisters and I spent an agonizing eight hours waiting, pacing and trying to reach the hospital for news. Late that night, they called to say that mum was coming home.
For the last few weeks, my sisters have been caring for her in her crowded little granny flat. We’ve all had some powerful conversations –– and some hilarity –– about what matters most in life, and in death. My mother tells me how delighted she is that the potatoes in her garden are beginning to sprout vibrant green shoots. She’s also said several times: I’ve had a good life, I’d rather go quickly…
I take a deep breath and feel sad and impotent, so far away. But I’ve also had time reflect on this wisdom from Isabel Stenzel Byrnes, the bereavement counsellor:
“Ultimately the more we talk about death, the more we embrace life,” she says. “Death and life go hand in hand and if we love life dearly we also have to love this idea that it will end. And we can live more fully by accepting that.”
“Mother Nature is a very powerful educator” and her power has never been more apparent than during Covid-19.* But what have we learned from this unprecedented pandemic?
Firstly: That what was once impossible, is now possible. Who’d have predicted that governments facing a global crisis would put humanity ahead of the economy? Despite all odds, they did and for the most part, continue to do so.
Secondly: With many economies in the deep freeze, we have a rare opportunity to create a “new” new normal, one that’s less carbon intensive and more environmentally friendly.
This week’s podcast explores these important questions: Is the Earth sending us a message? And if so, can we rise to challenge, before it’s too late?
OK, here’s a sobering statistic: A recent IPSOS Mori poll revealed that over 70% of the global population consider that, in the long term, climate change is as important a crisis as the coronavirus. Think about that for a minute.
Climate activists –– like the team at Global Optimism –– have renewed confidence that this pandemic has produced the wakeup call we need to re-examine our priorities. Instead of returning to business-as-usual and locking in higher emissions, some leaders are using the slogan: “Build back better.” The BBC’s Roger Harrabin writes about the need for the UK to avoid “lurching from the coronavirus crisis into a deeper climate crisis.” Britain’s Climate Change Committee Chairman, John Gummer has called for rebuilding the economy with a focus on green jobs, and boosting low carbon industries like clean energy and electric cars.
The pandemic has taught us that, instead of denial and inaction, basic risk assessment and preparation could have avoided mass chaos and deaths around the world. I’m sure you’ll agree that witnessing over-stretched intensive care units and the Hunger-Games-like scramble for ventilators, face masks and personal protection equipment was excruciating. It didn’t have to happen. Over five years ago, Bill Gates warned us about the risk of pandemics. Why did no one listen?
Today, Bill McKibben, Greta Thunberg and others are warning us about the risks of climate change. Calling them all Cassandras -– prophets of doom and gloom -– is no longer an option. We’re all in this together and we are woke! Let’s harness this united mindset and act NOW to green our economy, before it’s too late.
Some people might scoff at my idea that the pandemic could mean the Earth is sending us a message: the FT’s Robin Harding couldn’t conceal his mirth, as you’ll hear soon! But Jamie Robertson supported my idea, recalling his high school “Fruit flies in a jam-jar” experiment. Thanks Jamie! So think about this: Is the jam-jar sending the flies a message? It’s clear that you don’t have to be a sentient-being to send a message.
Here are highlights of my conversation with the BBC’s Jamie Robinson and the FT’s Robin Harding, (edited for length and clarity). We start by hearing from Tom Rivett-Carnac about this once-in-a-lifetime opportunity to change direction, as governments use unprecedented levers to jumpstart their economies.
Tom Rivett-Carnac: If we now just subsidize fossil fuels, previous ways of doing things, we’re just going to end up with another boom and bust and very quickly be back to where we were in terms of pollution. An interesting correlation between climate and the pandemic: In both cases, relatively small amounts spent yield massive returns to benefit society.
Recent analysis suggests that if world leaders had spent $3.4 Billion annually preparing for Covid 19, it could have prevented at least $4 Trillion in costs, not to mention the human costs of the pandemic. That’s also true of climate. Taking action to prevent further impact is the cheapest thing to do and we should learn from the experience of the virus and invest now to prevent the impacts of climate change, and reap the benefits of the transition to a green economy.
Jamie Robertson: Robin, how does that argument fit in Japan?
Robin Harding: I don’t think that argument plays very strongly in Japan. I disagree with it strongly. The virus has revealed how miserable we are if we can’t go on holiday, see people, go out to work. I think people will be keen to get back to normal. What it reveals about the climate and the environment is that shutting everything down, avoid traveling to improve the environment isn’t going to wash with people. Instead we need to think about ways to decarbonize… Japan tends to prioritize the economy over the environment and always has.
Jamie Robertson: Now I want to go to California and see if the feeling is any different there, Alison?
Alison van Diggelen: There is a change in mindset, the pandemic and climate change are connected: we’re united against a common enemy. And we are learning to work from home more and that’s having a positive impact on climate change and it’s going be a lasting legacy.
Today on Earth Day, it’s worth framing it like this: When Europeans came to The Americas, they brought smallpox and other diseases that decimated the Native American population because they didn’t have immunity. Now, the tables have turned: we humans are the invaders of the natural world. We’re now being exposed to wild animals’ pathogens; (from bats etc.) and we don’t have natural resistance. So it LOOKS like Mother Earth is fighting back. So I’m hoping, and I think many people are hoping, that this pandemic could stimulate a shift in mindset: we might become more inclined to protect rainforests, rethink farming and rethink our use of oil. If not, if we keep encroachment on wild areas, we could face more pandemics like this one.
Jamie Robertson: Robin, I imagine you’re not going along with that?
Robin Harding: I don’t feel this is the earth is sending us a message, that we’re doing something wrong (laughter)…
Jamie Robertson: There is the argument that if you put a large number of people in a small space: we have 8 billion people living on earth, you’re going to get more diseases. If you put fruit flies in a jam jar, they expend in number and then they die off…
Robin Harding: That’s belied by our actual experience. As we’ve become richer and more developed, we’ve succeeded in taming diseases. This disease came from a wild animal market that wasn’t properly regulated. So to me, the lesson is you need to regulate wild animal markets, not that you need to need to revert to nature.
Jamie Robertson: Alison, final word from you on this argument?
Alison van Diggelen: I appreciate your support here, Jamie. Arguably we’ve crossed a line here … and I don’t think regulation itself is going to help us.
*In 2019, during a must-read interview with the Washington Post, environmentalist and author, Bill McKibbon, famously said “Mother Nature is a very powerful educator.” Here at Fresh Dialogues, we couldn’t agree more.
