Dr. Erin Berman Oral History

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Dr. Erin Berman

Behind the Mask

January 21, 2021

GB: Good afternoon. Today is January 21, 2021. My name is Gabrielle Barr, and I'm the archivist at the Office of NIH History and Stetten Museum, and today I have the pleasure of speaking with Dr. Erin Berman. Dr. Berman is a clinical psychologist at the National Institute of Mental Health. Thank you very much for being with us today.

EB: Thank you so much for asking me to do this.

GB: Yeah! So, anxiety has been really rife during the pandemic across the board, and you specialize in understanding anxiety disorders in children, adolescents, and adults. What are signs of anxiety in these different age groups, and does anxiety manifest differently with the different genders?

EB:  A very, very appropriate question because it does look different, you know, in every person.  What's interesting about anxiety is we all have some level of it. So how do we know when anxiety is problematic? Specifically, it will look different, like you said, depending on the age. 

So, for little young ones, they're may talk less, and you may see more “do” or behaviors. So yeah, for the kids you're gonna see them stay away from the things that they used to enjoy or not approach that dog because they're feeling nervous, or look nervous, or have changes with sleep cycle, eating, those kind of basic daily things.

The teens and some kids will talk.  I definitely have some who are good little old souls who will tell me all their worries that they have.  So those are equally awesome kids, and you may be able to hear those worries, and it's really when it goes more than just a passing worry. Like, you know, a kid might worry, “Oh, I have a sore throat. Oh, is that something I should be worried about, especially in this time of COVID?” And the parent can say, “No, you're ok.” And if they leave it and don't come back to the conversation then that's a pretty indicator that they may just have a passing fear. That is not excesive worry.  However, if they keep talking about and talking about it, you know that may be a sign of when worry is out of control.  And with teens and young adults, it's when it interferes in what they need or want to do whether it's being social—and obviously with times of COVID, social looks different—but not texting or not hanging out when it's safe, not doing the sports they love, and with adults, well, we're pretty verbal. So, we're much more self-aware how are the first inclinations are: sleeping, eating, and irritability. Those basics we want to be aware of in teens. Also at times it may look different between genders.

I have to say just as a kind of general statement, you see a little bit more irritability in the words and behaviors sometimes [in males], do you know, versus the girls. The males versus females is an internalizing disorder. So many times, we don't hear and can see what's going  [on]. It is important to realize it's individual for each person as well.

GB: Yes, so some degree of stress is understandable at this time with all the things going on:  people losing their jobs or worried about getting really sick, people taking on more responsibility on the home front. So what are signs that what a person is feeling has deviated from ordinary, possibly appropriate emotional responses?

EB: Yes, it's a great point because what we need is to be a little bit more cautious and thoughtful about our goings out and our touching, in our hand washing and doing it in a regular manner. So, the way I always recommend is in the time of COVID, when it can be tricky to see when it's an anxiety or excessive, think about okay, I want to look at the CDC guidelines. They say wash your hands as often as you can, wear your mask, stay your distance (6 feet), but obviously when it starts to get beyond that—like you're never leaving your home just to go for a walk by yourself with the safe precautions—so when it's beyond doing something you want to do without the safe precautions. So I definitely have had some of the individuals I've worked with recently who don't leave their house for three days. Well, you can go outside and breathe the air. Or I had another one who would wear like two or three pairs of gloves when they go out.  I'm not saying you don't have to, but I don't know about three pairs of gloves. So it's excessive, beyond kind of what the baseline is, and if it's constant, the duration, thinking all the time versus just passing thoughts.

GB: How do you work with clients like that in helping them recognize that they can do certain things within a framework or guidelines?

EB:  Yeah, so one is first to normalize their anxiety—it is normal for them to feel super anxious right now —and then figure out what are their goals. Do they want to get healthy? Do they want to see people at a safe distance? And help them figure out those steps.  Usually baby steps are the best way to go when you're really overwhelmed.

GB: Yeah. So how has increased remote work affected cases of anxiety? There have been reports that more people are feeling paranoid because they're not with people. They can't hear what their co-workers are thinking about them. They feel left out of meetings, just things like that.

EB: Yeah, I think we're all now super sensitive to those type of details. Was I not on that email? Why was I not on that email? Because what we're lacking is those casual encounters that were so important; we realized, you know, even just seeing that person and having them smile, even if we didn't talk, we realized, oh, they probably still kind of like us, do you see? So we're not getting all those social cues in the normal way, and for sure that would lead to more paranoia. It wouldn't be weird for us if we don't have the information in our head and we're stuck in our heads, we've got nothing to dispute it because we're sitting in front of our computers just like this. So, asking questions, getting yourself out there as much as you can would be the way to deal with it, but it makes sense with such so much extensive remote work [that] this would be kicking in.

GB: Do you have any more recommendations on how to replicate a more normal work environment in this remote atmosphere for people?

EB: Yeah, I mean I think it depends on a number of factors. The first is your own. You know, having your basic schedule. Ideally your desk is not in your bedroom, however, [for] some people there's lots of family members and their desks might be in their bedroom. I was talking to someone about this this morning. We miss NPR, listening to our radio stations, so get up a half an hour early and turn it on when you're in the shower. That's like going to be your commute, I guess, so think of how your day was. I literally sometimes have people write it out and then insert “Okay yeah, I usually see this person at lunch.”  Well, can you send them a text at least or a video chat. It's, of course, not the same and so we have to lower kind of how our…change our expectations of how it feels.

GB: So another question that I have is what do you say to people who are fearful that they're not performing as well in their jobs due to COVID or they can't do their jobs in the same way as they had done?

EB: Yeah, I mean again I think it comes back to a theme that I've just been hearing with more and more people that I work with or even co-workers: changing our expectations.  So, in our lab, we would see  many people a week, and we would be able to collect this much data, and you know we're scientists so we have a real number way to do it. We're seeing you actually just can't do that number; it's not safe, so we're just on the surface. We will have to start to change our expectations. I don't like the word “lower,” but we can start to talk about how we change our expectations and realize [we need to be] giving us all a little bit of self-compassion while we're trying to do that.

GB: So I guess it works for individuals. How do supervisors, sort of …I get [that] it translates down the chain of command, so how has that worked and how do you suggest that it works?

EB: So, I do think a lot has fallen on supervisors to think of “How can I recreate the atmosphere that I used to?” Whether it's…. even humor is harder to do a bit on Zoom you know. There’re so many cues that we're missing that's changing, so what could you do, you know, is it watch an extra video, is it to tell a joke, and I'm making a really light.  These are very minor tweaks of it, but it has to go with the culture of your lab or the culture of your office, but see how can I start to translate this to my individuals. And also what I found really helpful, is supervisors that I know, is just leaving an open door, “Hey, if you're having an issue please feel free to bother me.” You're just checking in more with your personnel. I think it's a good route to go, and it leaves it open for discussion for creative ways to solve and make you feel more connected.

GB:  Yes. Can you share light at all about how the media is feeding into people's emotional responses with COVID and maybe some of your suggestions on how it can still present the facts without maybe overwhelming people? That's one of my questions.

EB:  Yeah. So again, the media has many reasons that it operates the way it does, to draw people in to make them interested, [and] to keep people, especially in this day and age of social media, so many different ways of us getting our information so I think, you know, obviously we are constantly connected. If we're like this all day, we can see banners of news, we so it's a bit on us, you know, to restrict and figure out what is healthy for us.  If you are not aware, talk to other people how they deal with it, but I do think suggestions are: obviously, limiting how much you do spend on it, limit the number of media sources because you can easily have 25 in a day. I don't mean you need just one, but it's really limiting. And the other thing is usually I say it's like piggybacking to something else you do so then you don't keep going back to it all the time. So maybe when I wake up in the morning that's when I listen to my news and then maybe as I'm cooking dinner, I want to watch 10 minutes of a show that I watch but piggyback it so then you don't keep it, so it doesn't override your entire day because it sure can.

GB: Definitely. How about with social media? How have you counseled some of your clients because sometimes it can be very judgmental at this time, which I’m sure can lead to emotional situations.

EB: In many ways. I mean I have to say I primarily with the NIMH work with children and teens, and the teen group can be a bit tricky because there's all different levels of people and families in terms of COVID restrictions, and so I have some teens who are from a family that they need to be very strict in terms of their going out and I’m sure [these] individuals, when they see that their friends are out and are taking pictures on different social media platforms whether it's Snapchat, whether it's Facebook and posting them, and then comparing yourself and feeling even more isolated in a time where we are all in general feeling isolation at a higher level.

GB: So you work primarily with cognitive behavior therapies. Can you talk a little bit about what Cognitive Behavior Therapy is and what are some examples of Cognitive Behavior interventions?

GB: So Cognitive Behavioral Therapy [CBT] is explicitly an evidence-based type of intervention that's primarily used for a number of different disorders, but we're looking specifically at cognitions, so how we think impacts how we feel. I'm not saying thoughts come first and then we feel a certain way; sometimes a feeling comes first and then we assess it a certain way.

So, I may walk out of my house in these times and go, “Oh this feels so bad!” because I haven't been out so much and then assume, “Wait, that means maybe I’m going to get COVID.” “Oh, maybe I'm worried about what's going to happen next because I'm feeling so uncertain.” It's about the thoughts we put to our feelings. So, looking at those, testing those out by challenging them by asking “Is this true? Is this something that I do need to look at in this way?” So, that is an example of the the cognitive component of CBT.  The behavioral strategies come in many different ways. It's just basic relaxation, deep breathing or visualization. The one part that I am very much involved in with children, adolescents and adults are behavioral experiments. So “What is my fear?” and again any of the fears I’m talking about are things that can't hurt you. So if you're getting out of the house alone, but it's safe, you know, so testing out that fear using a behavioral experiment: “So let me walk outside the house and see how I feel, rate how I feel, and practice it to get a little more comfortable with it.” So that is behavioral therapy in a nutshell, and it works well for many psychological disorders.  There's different CBT for depression, anxiety, and as you mentioned, anxiety disorders are my area of expertise.

GB: Yeah. So, do the cognitive behavior interventions work better in certain situations or specific populations and are they ever coupled with other types of approaches?

EB: There's many different types of just behavioral approaches out there. Cognitive Behavioral Therapy, works well for for children and adolescents with Anxiety Disorders. It's the primary evidence-based way that we know works really well to treat it.  There are some kids and adults out there that don't want to talk though, and medication is an option as well, which many times that is one [approach] that people do solely and that's usually the SSRIs [Selective Serotonin Reuptake Inhibitors]. There tend to be evidence that suggests that they work, and then some people do it in conjunction. Some people have a hard time doing the behavioral experiments I’m talking about. So, they may do medication and therapy, and there's a whole bunch of different therapies for different disorders, but this is the main one for anxiety disorders.

GB: Okay, interesting.  So how do you advise family and close friends of those who are experiencing anxiety or extreme grief on how to react to their loved ones?

EB: Hmm. That's a really good, and it's obviously very much age dependent to a certain extent, what skills do they have. The first place is to just empathize with them and listen. You don't have to fix. We're all kind of wired to be fixers in this world. I want to go in and help this person and give them good advice and help them make through it. These are tough times it is just good to listen. Active listening is wonderful so just being able to repeat and listen to what they say is a great way to support specifically anxiety and even more importantly in grief because we can't do much with that, and then we can encourage if we know there's things that you used to enjoy or that was good for them. You can always throw those in “I remember you like to play basketball. Do you want me to go with you?” You know encouraging those things but and also making sure, because as we know anxiety and/or grief can be pervasive in a day, giving yourself break if you have a loved one who is really struggling with it. You don't have to fix it all essentially.

GB: What are some common practical solutions that you are suggesting to those who are the people who are actually experiencing those emotions?

EB: Yes, so the practical solutions I always I start with  boring and simple, but so hard sometimes to implement, especially in these times, our basics. We want to  look at our eating cycle, our sleep cycle (you know, when are we getting up when are we going to bed), when are we putting that media away—the social media away, when are we eating, are we having our basic rituals in our day, right, and exercise, well, exercise although we're doing this interview in the middle of the winter.  It's hard to get out and do it, but it is helpful even for just that walk around the block, and it's amazing how hard that is for so many people right now. It used to be built into their workday to walk around or go to lunch, and wow, that one can be incredibly powerful. The other basics are what are the self-care that that helps you, whether it's meditating, deep breathing, listening to music, you know whatever kind of fits you, but think back if you're kind of in a bad space, what is it that used to help me and I enjoy and relax and do?

GB: I know we've primarily spoken about anxiety, but can you talk a little bit more about the impact isolation has had on this country's mental health?  It almost seems like it's altered people's personalities, and how concerned should we be in the long term about this phenomenon?

EB: I mean it's interesting that you bring this up because I think this is the part that now this pandemic has been going on for so long, the isolation is more amplified than the beginning.  At first most people were just trying to like get through.  Okay, we'll make it; we'll make it after three months; we'll make it after six months. It's a brilliant point that you bring up and one that I am concerned about because the more isolated we are, the more we're in our head, and the more, like you're saying, changes personality, just gets us not in the best space to be able to deal with our friends or co-workers or loved ones.  We're more irritable, upset. And we do know isolation, in studies not within the realm of global pandemic, but just basic isolation for teens, adults, [and] children from their peers or studies that have been done with parental kind of isolation of children, that increases depression so we do need to be very aware of it and how we can kind of start to think of interventions to bring more connection to other people.

GB:  Can you talk a little bit about people that have phobias and obsessive-compulsive disorders? How are you guiding them on how to navigate the pandemic, which can sort of exacerbate some of their issues?

EB: Correct. Yeah, I mean the phobias… I have to say a common one that I've been hearing is a lot more worr[y] about illness. So my individuals that had worries about vomit prior—you know emetophobia is a pretty common phobia—worrying about getting sick or  vomiting. But it's one that's really kicked in more because we're worried at any twinge or uncomfortable feeling. I encourage those individuals to continue doing their therapy, which will mean talking about vomit and going through it. The other one you bring up is OCD-obsessive compulsive disorder. I think that's very important.  Some individuals with that germ-related or that contamination-worry need to be aware of what are the CDC guidelines, have their therapist help them through, how can we meld that with your day-to-day basic daily life, and let's try not to go too much to extreme, but it's very hard right now because there's a lot of gray area.

GB: So can you speak a little bit about how has anxiety and some of the other emotional situations that you have dealt with stemming from COVID-19 been different from some of the emotional traumas that you have dealt with patients in the past?

EB: So, I think what's interesting and one of the highlights of the change, which is an unfortunate one, is the lack of the traditional rituals.  So, I’ve had a number of patients that have lost someone for various reasons, to normal [causes], to COVID, whatever it might be. And not being able to go to funerals, not being able to have memorial services, not being able to have groups to mourn together physically I think is complicating grief for many individuals. So that I've seen as a considerable change with the pandemic. And then just in general, worry about illness and death, and sickness has been kind of a higher…even higher level of concern for my younger patients than it was in the past.

GB: Yeah, what has been your role during the pandemic? You see patients at NIH and in your private practice. What other ways have you been involved with the pandemic?

EB: So, you know two of the main new things that have been added is using our knowledge as a platform for different media outlets. I've spoken to a number of different podcasts or media different outlets. Getting our information of what is anxiety, how to deal with it, and how we can help others in this tough time so that has changed quite a bit, and that's been added to my repertoire. Luckily, I have all this knowledge base, so it's been pretty easy to be able to get it out, but that's been encouraging. I also am a clinical member on the NIMHstaff support line, so individuals that work in the Clinical Center, in the hospital here, can call in if they're experiencing  any type of increase level of distress, and I am  on the other end, being able to talk to them and guide them.

GB: Yeah!

EB: And I like giving my time for that because a lot of people who are on the front lines or just you know day-to-day life are really struggling too.

GB: Do you think that might continue when COVID subsides, that those in hospital settings will have that outlet?

EB: I think that's a brilliant idea because I do think it's the one thing that the pandemic has highlighted and put in the forefront of people's minds is mental health, and hopefully with this, there can be more of a level of general acceptance that this is an issue and that there are many outlets of treating or just helping someone on a daily basis.  So yeah, I would hope it would.

GB: Can you speak a little bit about, well, one thing that you said, I am gathering that in other pandemics, mental health of the population and medical staff was not really accentuated but did you…have you gone back to see how people in the past have looked at mental health situations, and has that informed at all what you are doing, and how do you hope that what you all are doing now informs, like G-d forbid but there will be another pandemic?

EB: Correct. So I think I've looked back because you're right when you look at the data and all these questions were starting to be asked in March, April, May. What is going to happen?  What is the mental health fallout from age groups?  I looked back to a lot of the work that was done around 9/11. So a time in our country that we could say a lot of people were experiencing a significant level of stress and anxiety and life change. I know the DC area for sure. I'm pretty sure even the NIH. That's about when the gates and security went up around the Bethesda campus. I was there after this, but I do believe people told me prior you could just walk onto campus. So you know, again, I think looking at that data, reading a lot of what people did therapeutically for trauma and grief at that time, that's been really helpful to rely on, and so I think you're right, we have to kind of learn from our past to help maybe buffer the next one that might come at some point.

GB: Yes definitely.  So what have been some personal challenges and opportunities for you that have arisen due to this pandemic?

EB: Yeah, the personal challenges have been probably like any other. I have two relatively small children, five and seven right now, so that that has been obviously a massive challenge to figure out how to work from home.  I work… I go in person a little bit too, but how do I navigate doing all this safely and not coming home and looking like a completely stressed-out mess for my children? So it's really better self-care than I ever did before and relying on others, meaning my husband, or just giving the phone to my son and saying “Hey, talk to grandma for the next 20 minutes so I can have a breather,” looking at how can I be creative, and adding more people to this environment because it's been very tough.

GB: Yes, yes, I'm sure so that was one of my other questions. So what outlets or hobbies have you turned to cope with this pandemic? You help other people cope, but how have you been coping?

EB: Yeah, I mean I think it's… I am blessed with tolerating the cold very well. I know we're in the middle of the winter; I don't mind running in the cold; I do better in the cold than in the summer so that has been lucky on my part, going out staying active, but that's hard to do when you have a five and seven year old.  You can't, and there's not around-the-clock child care as easily and accessible as it used to be,  so it's a lot of indoor kind of things. And I've gotten back into art [and] I just pulled my keyboard out of the attic so, you know, music, art, and like I said, even just having time to make a cup of tea and take a breather. So just kind of the basics but going back to what I used to love to do and really making the time for that.

GB: I'm sure that makes you more empathetic to your patients.

EB:  Yes. I can relate pretty well. You're correct.

GB: Yeah, that's good. Is there anything else that you would like to share as an NIH scientist and clinician but also as a person who's living through this pandemic like every other American right now?

EB:  Yeah, I think this has really again highlighted the need for mental health support in a work setting and how do you address it and make sure that we're on top of it for all individuals. So, I do hope this has kind of kick-started a bit of change in culture and just in lifestyle in general.

GB: Well, thank you very much for speaking with me, and I wish you and your family the best and all the best with your research.

EB: You're welcome. Thank you so much.