Dr. Maryland Pao Oral History

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Dr. Maryland Pao

Behind the Mask

October 13, 2021

Barr: Good afternoon. Today is October 13, 2021. My name is Gabrielle Barr, and I am the  archivist at the Office of NIH History and Stetten Museum, and today I have the pleasure of speaking with Dr. Maryland Pao. Dr. Pao is the clinical and deputy scientific director at the National Institute of Mental Health (NIMH), and today she is going to be speaking about her role as the     clinical and deputy scientific director as well as some efforts that she did as co-chair of the Trans-NIH Mental Health Response Team. Thank you very much for being with me.

Pao: My pleasure.

Barr: When did you and others at NIH recognize that COVID-19 was going to be possibly a very stressful period for the staff?

Pao: I would have to say that we recognized it pretty quickly. Having responded to trauma or disasters in the past, we had a model that we needed to go into, the quick responder mode, so, I had a whole plan drawn out by the 26th of March, in a couple weeks, about how we are going to address the various mental health needs across the campus. We recognized also, immediately, that there would be a range of responses, from very normal responses   to having something calamitous happen, and people who had already had mental illness, being stressed further by this. We recognized there was going to be a spectrum of response and that we needed to have ways to handle all the different kinds of responses. We also, pretty early on, recognized that this was not going to be a short process, so we had an immediate process, and a longer-term plan for kind of overtime, and we used a psychological aid first model to respond to the crisis and then work from there. We were kind of prepared from the beginning.

I had done previous work across the campus marshaling all the mental health resources in the past for work that we did with the Distressed Trainee Project. We were quite aware of the different areas across campus because NIH actually has many resources to try and handle mental health questions and well-being, so we had a leg up already in terms of knowing who the players were. Therefore, it was not hard for me and Debbie Snyder, who helped me spearhead the Distressed Trainee Project from 2015 to 2018, with a lot of partners like OITE (Office of Intramural Training and Education), Civil, and the Ombuds person. We knew who we were going to have to get in touch with, including EAP (Employee Assistance Program), to get this rolling. It actually strongly encouraged us to form the Trans-NIH Mental Health Response parallel to the Trans-NIH COVID Response Team that went into  action right away.

Barr: What were some of the resources that you took from other incidents that have happened?  You talked about the Distressed Trainee Program, but you said you also based it on other disasters that have occurred?

Pao: NIH has responded [to disasters] in the past. I went with a group of civilians and extramural partners to hurricane Katrina, so I know that we all know how to respond in a crisis.  We rapidly shut down the campus and were trying to make sure everyone was safe and understood how to communicate with the trainees and staff—that was the first order of  business. Making sure people could get ways to do their work at home in terms of computers, and being able to do virtual work, that took up the first couple of months for any institute, trying to make sure all was well. We already knew all of the resources, but each group developed their own resources along the way. We got more counselors and developed a lot of workshops, and we all got used to the virtual methodology. We started doing roadshow talks. NIDCR [National Institute of Dental and Craniofacial Research] was the first group to reach out to us as an institute and ask myself, EAP, and Debbie Snyder to come and talk with them about managing anxiety and stress. We went to every institute, some more than once, and some offices across the campus, and we gave over the year after the pandemic started about 50 talks to over 8,000 people.

We felt that people needed to hear information, not only look at websites, and there were a lot of websites. NIMH created a lot of websites. The OD [Office of the Director of the NIH] created the intranet by April to post information so that people could rapidly find out what was happening with COVID, with testing, with the vaccination. So information management was a lot of dealing with COVID, obviously, and being able to get the information out. We did do website information, but we also recognized that not everyone uses a cell phone or a computer or gets to the internet so we designed posters in early May on caring for yourself while caring for others that could be put on campus because there were many workers that had to come to campus in terms of health care workers in the hospital, and housekeepers, and groundskeepers, and engineers, and all kinds of people that could not stay home during COVID. It was pretty apparent, fairly quickly, that we were dealing with a variety of mental health concerns, and that we had to use all kinds of media and communication methods to inform people [how they] could take care of themselves  best.

Barr: How did you deal with the different campuses? The pandemic has not affected the country equally, especially in the beginning.

Pao: At NIH campuses, we also do virtual talks in Montana as well as North Carolina. Anyone who asked us to give a talk, we reached out to, and again they were on   people’s minds in both the Trans-NIH Mental Health Team and the Rapid Response Team.

Barr: I think we got ahead a little bit about all the activities you all did, so we will take a step back. Can you introduce what the Trans-NIH Mental Health Response Team is, and can you briefly mention how the team was organized, and just give an idea of certain centers and institutes that were represented?

Pao: We recognized pretty quickly that we were going to need to partner  with our NIH stakeholders and leverage NIMH’s expertise on well-being and resilience, coping, self-care, mental health, and mental illness, and to create a plan to proactively share information with patients and staff. We had both NIH at large but also most of the clinical staff because   I am based in Building 10 [the NIH Clinical Center hospital], and I have been previously very active as a psychiatrist on the wards. The Clinical Center staff and health care workers needed their own set of care, so we established a set of resources for them as well. We reached out to a number of folks across NIH and tried to get representation from several institutes that provide mental health care around substance abuse—members from NIAAA [National Institute on Alcohol Abuse and Alcoholism], and NIDA [National Institute on Drug Abuse], people that we felt could help  us with the mental health resources that were going to be needed. We certainly had people from the Neurology Institute as well as the Office of Human Resources, the NCCIH [National Center for Complementary and Integrative Health], and EAP; they were really important throughout this process, and we partnered with them on every step of the way. We also had representation from NIMH intramural and extramural communication experts because all kinds of people were needed. It was a team effort.

Barr: What were your thoughts?

Pao: I should say that Tara Schwetz, who was my co-chair from the Office of the Director, recognized that  this was an important committee as well, and when leadership  makes made it clear that mental health is important, NIMH partnered with them because we have the content expertise, but we really also needed an NIH support overall.

Barr: What were your responsibilities particularly as the chair or co-chair?

Pao: As the co-chair, [our committee] had also a representative from the Office of Behavioral and Social Research, and a wonderful executive secretary, Erica Landis, who really made the whole thing possible. Our job was to survey what the needs were, and we were meeting every other week, early on, to try and survey the pulse of the campus, and what questions were being asked at all the town halls, trying to keep our finger on the pulse about what people needed and what was happening. NIH is like a small microcosm of what is happening out in the world so everybody was going through this together.  We, ourselves, were watching schools being shut down, stores being shut down, the anxiety around  how contagious COVID was, people being very sick and getting hospitalized, and everybody being afraid to go out. We got together and tried to give messages that were reassuring on helping people cope with information, and if they needed to turn it off because there was too much information. There were also a lot of cultural activities and political activities going on at the same time, and we recognized that as well and had experts addressing these issues. It was a lot for people to cope with, and we tried to help people figure out what their best coping mechanisms were, and just remind them of many ways they can cope.

Barr: Did NIH leadership come to you with specific concerns or scenarios, or did you go to them with feedback that you have received and the predictions that you had—like the ways people could be reacting or feeling based on your prior experiences—when it came to creating  resources and programming around mental health and the pandemic?

Pao: OITE and other big entities out of OD were all very proactive. Each group looked after the group they needed to be looking after, including trainees, staff, or HR. We wanted to take care of our own and we went to leadership and partnered immediately with them. Everybody felt like this was important to do, leadership in the Clinical Center, and we made clear through many messages, that help-seeking was a sign of strength. We developed a peer-to-peer support program and helped them help each other; trying to help supervisors figure out how to ask some of these mental health questions that they might not have been comfortable speaking about before, we wrote scripts in plain language on  how one might approach talking with one another about it.

We are still engaged in these activities even now because we are not done with the pandemic. People have fluctuated over time and we saw at the one-year mark of March 2021, [that] people were pretty irritable and kind of feeling low. People perked up over the summer, but when fall came and school started again there was a lot of anxiety. We try to help  deliver messages and work/life advice at NIH, try to have more parenting groups, more groups about grief, because a lot of people lost people during all this time, or there was a lot of grief around events that we could not have, or be with one another. Everybody really pulled together, in my opinion, helping one another and focusing on well-being. All tried to contribute to the campus and the staff in the best way they could so Tara and I just kind of steered that.

Tara went to the White House in January of this year, and Courtney Acklin is now co-chairing with me. We are still meeting and kind of morphing on and recognizing the energy that went into maintaining well-being and mental health. That is something that should continue. The silver lining that came out of the pandemic is that people are paying more attention to their well-being and mental health and realizing that it should be an integral part of our work life, so, I think, that has been a positive for us and we want to see that continue.

Barr: Can you speak about some of the specific tools and resources that the Trans-NIH Mental Health Response Team helped generate and support? There was such a variety of programming and resources, and you mentioned a couple already, but do you want to go may be    more in detail about a couple others?

Pao: We spent a lot of time at the beginning educating and supporting staff. As  I mentioned, we made posters, and we developed the website. We actually had a partnership with the Occupational Medical Service and the Employee Assistance Program. NIMH helped  them stand up a support phone line, which was for emotional support. It was called the “Here to  Listen Staff Support Line”, that Debbie Snyder helped stand up, and for a year we staffed it with mental health clinicians from NIMH during the office hours, to handle phone calls, and people could just call and ask any question they wanted to about their mental health. We answered over a hundred calls in that year. All of the groups produced lectures and workshops, whether it was OITE, or EAP, or Work/Life, so, there were a lot of resources . .  For all the calls that we did, the Clinical Center (CC) set up a buddy system, and the chaplain set up CC connections, and was able to run groups when people felt the need to talk to other people. OITE had a lot of creative activities in terms of Wellness Wednesdays, our  leadership participated in many videos around that, and of course, Dr. Collins did the home edition and interviewed a number of leaders across campus to share experiences, because everyone was stuck at home. The first talk for the home edition was with Dr. [Joshua] Gordon, on how to cope with anxiety during the pandemic, so that was the first one launched. We acknowledged many resources around campus that are available, we made master stress cards which I can show you.  I have one here: It has a small mnemonic on, to help remember in case you cannot get to your phone, or you cannot open up a computer. You put this card in your wallet. We put these out at the vaccine sites so people could pick them up and just keep them in their wallet if they cannot remember and need to keep a few activities in their mind to ground them and remind them  that they can use these activities to help cope during stressful periods.

Barr: Some social media campaigns as well?

Pao: We did have some activities on social media as well, such as stress buster bingo and healthy active challenge from NIMHD and NCCIH, we did some yoga on campus with the construction workers, and we did always assess. There were a couple of surveys  that were taken on how was the mental health and productivity, and how were trainees and staff doing, so there were a couple of surveys done throughout the pandemic. We did make  some videos for resources and OITE had a million workshops. We kept track of our numbers and  all of these activities.

Barr: What was the feedback like, and how did you evaluate those different events because you took many different approaches, and I know it is hard to compare because  people are in different places emotionally throughout the pandemic, but did you find that some ways worked better than others or appealed to a certain group of people more than others?

Pao: I think that was a little bit hard to assess. We have a really diverse population, some 40,000 employees, and contractors, and trainees, and they all need different things so the best we can assume is by the utilization, which means web page hits, or participation  in all the workshops. We adjusted the workshops and finished out the support line when the phone calls started dropping off. Summer was approaching, and people seemed to be getting back to life at that period. It was a more positive moment before the Delta surge came back but we went with the flow in terms of what people were saying they needed to reach out to us.

Barr: You mentioned that in addition to the pandemic, there were lots of other situations going on, that were connected but separate. Can you speak a little bit about how your group  handled emotions towards those situations? Did you ever get people that were upset about how NIH was doing, and how NIH was being criticized with the public or the media?

Pao: Some people voiced those concerns about being seen negatively by the media, or not following the science. We told people that you cannot control other people's behavior, you can only control how you respond, and so you cannot be drawn into it. It is frustrating and can make people upset that their work is not being valued but they have to believe in their work themselves, and in the NIH mission, which is a great mission. We were very productive and continued working but, it was frustrating sometimes. There were also huge upheavals during  that time with the George Floyd murder and the Capitol riot events, and people were distressed. There were many discussions and many anti-racism discussions on campus as well, and emotions were flowing high about a number of different activities that were going on. It was important to articulate that, and to help people understand their feelings, and try to sort that out for themselves, and to take a step back and just try not to lose our civility because it was making people very irritable around one another. We did have to give the message that we all have to be a little patient and take a deep breath and take a step back. If we are getting too irritable, we talked to supervisors about it and to create different ways to be less stressful.  There were many creative ideas across ICs, there were some “no meeting Fridays”, there were 50-minute hours so that people have breaks between continuous zooms, there were “dress up Fridays” instead of “dress down Fridays” because everyone was so tired of being at home without changing their clothes into their work clothes anymore, so people were   very creative and shared a lot of ideas on how to help one another get through this constant  stress.

Barr: My office did a virtual lunch. That is what we did. How did the Trans- NIH  Mental Health Response Team concentrate on particular subsets   of employees that were hit very hard? I know everyone was affected, but some groups were hit harder than others, like those that physically had to be at NIH to do their job, like housekeeping and grounds trainees who live often very far away from their families, those seeing patients, and those who work with the animals they had a really hard time during the pandemic. How did you address their unique issues?

Pao: We tried to make clear that we understood that they needed to be heard, and that they were each going through different stresses. It is hard to reach all of the groups so we did what we could, and we encouraged supervisors to reach out to all those groups. OITE had a lot of activities online, and they allowed supervisors to join. We did try to reach out to housekeeping and other groups, but we could probably, always, do more. We tried   to hear if those messages came in through the town halls, and we tried to address issues if they asked  us to talk about it.

Barr: Can you speak a little bit about the origins of the Clinical Center Well-Being Program and some of the other initiatives that were specific to the personnel who worked at the Clinical Center? You talked a little bit about the chaplain program and the buddy program, but I know there are some others as well.

Pao: Well-Being is an initiative across all hospitals because it was recognized prior to the pandemic that there is a high rate of burnout in medical settings for nursing (and other) staff. Anyway, the Clinical Center had already had a Well-Being committee for the last couple of years and the graduate medical education committee also has a Well-Being subcommittee for the trainees. We were making efforts already on thinking about what the drivers of burnout are: “Are there things that are systemic that we could address, whether it is the medical record, or the system of how we have to document, or how the on-call systems work?” We were trying to look at different causes of burnout. Presently, there is a committee, and its members are using a burnout scale and they are tracking the trainees over the year, and they are having preemptive sessions with employee assistance (EAP). They meet them one time without a problem, and just kind of talk with them so that it makes it easier to go find them when they have a problem, because some people are afraid of going for employee assistance. They think it is some kind of HR punishment, but, really, employee assistance staff are trained clinicians who can answer a lot of questions, and help, at least, guide people to finding parenting resources, or finding child care resources (or other referrals). They will be willing to talk to you about a variety of problems that are work related, or not, and that is our first stop. We have tried to broaden our reach and get evaluations quicker in the community, if people need further evaluation, beyond what the EAP can offer. FAES is going to start a proposal where we are going to provide Talkspace for the trainees. Talkspace is an online asynchronous kind of methodology of getting trained mental health clinicians to talk to someone more quickly from where they are located, since we might not all be on site at this point. That also is a new factor, so we are trying a pilot for the trainees to have this availability for this year. We have a lot of ideas, but we also want the data, and we do not do anything without thinking about it in  advance and setting up to measure whether that actually is working and whether people find it useful.

Barr: That sounds very exciting and promising, and it leads into my next question. How do you think that some of the programs and resources created to help staff emotionally handle the pandemic can be extended to normal situations, where there are many of the same   stressors, like handling child care, and dealing with just a lot of different things that are persistent in life?

Pao: Well, I think that as we sort of talked about it earlier, the pandemic showed us it is okay to talk about these problems, and we have had these problems even prior to the  pandemic, but now, we do have to think about more creative ways to get people the help they need. I think that a lot of these resources are here to stay beyond the pandemic, whether  it is parenting resources, or access to parenting experts videos (which we had a few of from NIMH on the website). The NIH Work/Life also has a number of resources to try to help find child care, and so there are a lot of resources that people are not aware of, like parenting groups. I think that basically, [we will]  have to build in more flexibility on the workforce side. That is something that, I know, a number of committees around campus led by the OD are going to look into the  lessons we learn from the pandemic, and programs that we need to continue, and/or that  we could do better.

Barr: Yes, people were very open to admitting that there are mental health issues, especially, considering it during a pandemic, but what are some ways that you think that NIH still  needs to improve in destigmatizing mental health and providing outlets for its staff? Do sometimes people, now, admit that it is a problem but maybe they do not give it priority?

Pao: We have to find ways to make sure people have time to take off to get their mental health needs taken care of, and that we have better access for more people on campus. That is really an issue across the world. One of the other silver linings that came out of the pandemic was the telehealth availability, which will probably expand for many the ability to get to a mental health clinician, because they do not have to go through transportation issues, and perhaps the hours can be adjusted. I think the telehealth availability will be a real boon, but we have to make the laws to make it possible. During the pandemic, they waived all the laws regarding telehealth and where it could occur, and now, these laws are starting to come back and restrict telehealth again, so we really need to keep an eye on that, to make sure that people in rural areas and people who do not have easy access to getting somewhere where there are lots of mental health clinicians, can still have that kind of access, and we also need mental health parity in terms of payment for services, besides the access.

Barr: We are now transitioning to your role as the clinical and deputy scientific director  at NIMH. As the clinical and deputy scientific director of NIMH will you discuss how you worked with researchers on how to amend their studies for the pandemic?

Pao: Sure. Our researchers went into hyperdrive pretty quickly. They were able to leverage a lot of their longitudinal studies that they had of children or adults into online studies, because we had already been practicing doing online consents and online survey information, so that was pretty easy for us to transition to during early COVID. We were able to leverage our existing patient cohorts so we had pre-data before COVID about the mental health status of a number of healthy volunteers and patients and we could collect new information and then compare. You will be surprised to know that a lot of people were not as depressed or anxious in  the early part of COVID, as you might have expected, or no more anxious than the healthy volunteers, because everybody was anxious, since nobody knew anything about what was happening, but as time has gone on, there have been new cases of anxiety and depression and those people have started to do a little bit worse, although it did not show up in the first six months when we were doing the studies which surprised us .

Barr: That is fascinating. What advice did you give to researchers on how to approach their studies during the pandemic because research per the procedures had to change a  little bit?

Pao: Procedures had to change a lot. Fortunately, we had some procedures in place  already, and people shared broadly across the PIs so, they were able to help one another. I think there are limits to what we can do in a virtual world. I am a people person and I actually have been coming to the hospital since the beginning of the entire pandemic, but regularly, since June of 2020, and I miss seeing people, I miss the spontaneity of conversation and ideas. It is hard    on Zoom to really read people's faces, hard to have completely spontaneous conversations because you do not really know where someone is looking, you have to take turns when someone else is speaking, and if there are 20 people on the Zoom, it is very different than if you are just having a conversation with somebody sitting next to you. I think a lot is lost having to do this in a virtual world, but we certainly adapted pretty quickly and some aspects of it will be better, but I think people miss being around people.

Barr: What were some of the pandemic-related protocols that NIMH has been involved  in? I know there have been a couple new ones that have emerged just focused on the pandemic.

Pao: So, NIH and NIMH both did their own surveys regarding how people's mental health was during COVID-19, but we partnered as well with a couple of studies around other institutes, studies on the survivor long haul, or long haul COVID and the survivor study. NIH has partnered with investigators in NIAID and NINDS to look at those patients, as well, and see how their mental health has done for their cohort of several hundred patients in NIAID. We are also partnering with a vaccine study in which people had anaphylaxis in their first vaccine, so they were anxious about their next vaccines, and we were looking at the mental health responses there. People are creative and can ask lots of questions and COVID has obviously presented quite a few questions. There are also new onset psychiatric symptoms such as catatonia or psychosis thought to be post-infectious autoimmune processes, so we are developing protocols looking at autoimmune brain disorders in children, adults, and adolescents.

Barr: What was it like to transition to telemedicine for your researchers and for the NIMH participants? You said it was a boon, overall. You spoke about the field, overall, but I was just wondering during the course of the pandemic what has it been like in some ways? [Telemedicine] is sure helpful, but in some ways, you guys depend on looking at the whole person.

Pao: Right, I think a lot of researchers, both animal and human researchers, have found this period hard because of the restrictions of being able to come in, in terms of density of people on campus, in terms of space that they need to have, in terms of having to wear your mask all the  time around one another. People have had to be very creative about the hours they work or when they work. With the patients, we have had inpatients during this whole time, but it is challenging because wearing a mask all the time is not so pleasant. It is almost easier to talk one-on-one through Zoom than to wear the mask. I think patients have adapted to it, but it is not perfect.

Barr: So, in addition to all your professional roles, you are also an individual who is living through the pandemic. What have been some personal opportunities and challenges for you presented by COVID-19?

Pao: I am a psychiatrist in the hospital, a consultation liaison psychiatrist, who generally responds to crises, and this was a big crisis. We went into crisis mode and that  plays to my strengths. I think that has been a huge opportunity to try help the campus and the hospital, but I have watched my own responses, and that gave me a pretty good sense of what other people were experiencing. It is really challenging if you have very young children or older people, which I did not have, to manage during this period of time. I think it would be very hard to be doing your work with small children at home. As I have said earlier, I  am a people person so I find it is challenging even now in this hybrid world, where some people come in, and some people do not, and how to supervise people who are not here on a regular basis  is challenging. I can sympathize with many of the folks here. I also understand  that it can be a real hardship to have to come every day, but I think many people have tried to work with people on that. Of course, this job is not one where you have to come in every day so, I think I have tried to be here most days and to lead by example in that way, but there has been a silver lining here too. My daughter had a baby during COVID, and I get a little more time with her than we might have if we had been in our regular work schedule. Less travel has been both good and bad. I miss seeing new things, and my friends at these meetings, but it is also a little less hectic so there have been pluses and minuses.

Barr: Do you have any pieces of advice for how to cope at this point in the pandemic?

Pao: The main advice I have been giving folks is that we thought it was going to be a sprint, and then it became a marathon, and now it is really an ultra-marathon, and you have to adjust accordingly, and conserve energy during periods of time when you can, because we are in it for the long haul, and you kind of have to just take it a day at a time, and make each day count, and  find some positive things that are happening in order to get to the next day, and think about your accomplishments for the day, and try to keep focused on the present.

Barr: Is there anything else that you would like to share about your COVID-19 experiences and all the work that you have done in your variety of roles?

Pao: I did not do it by myself. There were many people across NIH, many stakeholders, and people in the Clinical Center who really wanted to help one another and made all these programs possible. I was just the person to try to make sure that everyone is aware of all the resources that we have and be the connector. NIH has a lot of fabulous, really caring people who want to make this a great workplace and because we have such a great mission, you can really get behind it, and even during a time like this, particularly during a time like this,  I think people can be very proud.

Barr: Well, thank you for all that you do, and I wish you continued success and health and congratulations on being a grandma.

Pao: Thank you.

Barr: Probably one of the best jobs that has been added.

Pao: Exactly.