Mental Health Care in Dentistry: A Trauma Informed Approach to Suicide Prevention

Course Author(s): Lara Mekhitarian, LMFT


Speaker - Lara:
Hi, everybody. I hope everyone can hear me okay. Welcome to today's discussion on mental health in dentistry. As she mentioned, my name is Lara Mekhitarian and I am a trauma specialist here in Southern California. When I was approached to discuss the topic of suicide within the world of dentistry and medicine, I knew now more than ever we need to have a conversation about the impacts of trauma and how that plays a role in the development of depression, which can lead to suicide if left untreated. Just in November 2011, there was an article from the Journal of Affective Disorders that found the risk of suicide is increased among health professionals and dentists are held in the highest suicide rate at 7.18% for men and women combined. The national average for men and women was reported as 0.42%. Male dentists especially hold the highest suicide rate at 8.02%. Female dentists hold the fourth highest suicide rate at 5.28%.

Likewise, this continues with physicians, pharmacists, nurses, hygienists. And I know that considering that we are now going through a global pandemic where we've been in our homes, some have lost jobs, some have had to close down practices, some have gotten ill, they've lost family members. And especially recently, especially within this country, given the tragic events that have occurred in the last few weeks and all the protests, we're all going through a form of trauma in one capacity or another. The truth is, safety is not a guarantee anymore. And when COVID and the stay at home order started, life turned upside down for all people in one capacity or another. As professionals, business owners, employees, family members, friends, colleagues we faced a reality that no one is exempt from. And the trauma being experienced in this time right now is very challenging and very difficult.

So today, my hope is to equip you with some of the information related to understanding trauma from the mind body perspective, the realities of depression and suicidality, and ways to manage and overcome it. So let's get started. My goal today is to make sure to psycho-educate you as best as I can to help you develop both self-awareness as well as learning how to play close attention to the warning signs of those around you. Sometimes it could be that it's not us that's experiencing it directly, but we can see the signs in the people around us or the people that we love. And of course that doesn't just mean in the world of dentistry. It also applies very much to our personal lives. So I think it's important to pay attention to that. And then once you've learned about how trauma and stress present internally and externally, the different reasons depression worsens, how to identify the realities of suicide, we can create safety which is necessary to build resiliency.

Let's talk about understanding trauma. I think developing a clear understanding of what trauma is and the different types of trauma, the realities of traumatic stress are all very essential, especially if the goal is to help us overcome the increased realities of depression and suicide at this time. I know that when we started talking about doing this topic, it was because there's been physician suicides happening and it's been very daunting and very, very tragic for many people, many families, many coworkers. So let's get into what trauma really is and what it looks like when we feel it internally, when we express it externally, and go from there.

So, let's start with defining trauma. Psychological trauma is the response that debilitates our abilities, emotional, cognitive, physical, spiritual, social, all of it, following an event that was perceived by our nervous system as life threatening to oneself or others, especially if they're loved ones. Now, the key word here is perceived. Even if there isn't an actual event happening, if your body interprets it that way, it creates the same physical response of being in an actual trauma. And trauma can either be a one time event, a prolonged event, or a series of events, and trauma can affect a community, a country, and now especially globally, and that's known as a collective trauma. I think especially right now with COVID-19, the riots, the protests, the racism, the lack of support all can be seen as a version of trauma.

When you get that stress response, it changes so much of our lives. It immediately makes coping debilitating, especially because if we don't have those tools already ready to go, it's very difficult to reach for things that you can do to help support you and to help you work through these challenges. I think the one prompt on here that causes feelings of helplessness, this is our focus. This is where depression can increase so much. And that feeling of helplessness can lead to hopelessness, which then brings us to points of such severe depression that the will to live or the will to die play a big role.

I think the other thing too is it really does diminish your sense of self and your ability to feel a full range of emotions. It impacts your worldview, the lenses where you see reality or understand the meaning of life. It can really impact you physically, which we're going to talk about next, which is important. It also really impacts how you think about things, how you see things, how you reflect on things, how you process things. All of this goes hand in hand when we're talking about trauma. And it's important to understand what it is because developing the knowledge, educating ourselves is the thing that's going to help us move forward and know what to look for both within ourselves as well as externally to help us heal, help us move forward.

Let's talk about the different types of trauma. So, let's start with the large T traumas. Large traumas are the really jarring experiences that bring about severe distress and helplessness. They may be like a onetime event such as a horrifying car accident or catastrophes, domestic violence, sexual assault, acts of terrorism, murder. These are big, big traumas. Or they may be prolonged kind of trauma such as war, child abuse or neglect, violence. And they are much more difficult, sometimes even impossible to overlook or overcome, yet they are often actively avoided due to being very overwhelming. Small T traumas, on the other hand, are circumstances where one's bodily safety or life is not threatened, but can cause the same symptoms of trauma nonetheless. These events can still shock and disrupt normal functioning in the world, in the workplace, within your family, and they don't certainly seem small at all when they occur. But most will have an easier time recovering from small traumas than the large traumas.

On the other hand, small traumas are sometimes disregarded since they seem surmountable. This can be really bad as the cumulative effects of unprocessed trauma or traumas may trail a person relentlessly. Examples of small traumas can be things like moving to a new job or a new position, getting married, experiencing a loss. Divorce is another big one. Losing a job is another big one, especially now when people across the country have lost so much work and are struggling. And I think that more recently, especially with COVID, it impacts us in the realm of little traumas. And unfortunately in some cases for people who've experienced traumatic grief, for example, which is when you've suddenly lost someone, that plays a really big role in how we grieve and how we work through things, especially with the traumatic grief.

I think right now, especially when the stay at home order started, so many things got canceled. Weddings were postponed. Birthdays, graduations, especially for one of the populations I work with is high schoolers. The difficulty they have in not being able to experience major milestones in their life. Part of my work with Cedar Sinai in supporting the employees there, one of the things I saw was how much they're impacted by how many families couldn't be with loved ones that passed away during this time because they weren't allowed to be in the hospital or in the room. So, tragic grief is a really, really big one.

I think it's also important to talk about acute versus chronic trauma. An acute trauma would be something like a car accident. A chronic trauma would be something more like war or childhood sexual abuse, which can be ongoing. And depending on the severity and the experience, it can either really stay with you for a long time where you're not able to work through it, or you're able to move through it much quicker because it isn't that overwhelming. I think especially being in any kind of medical profession, vicarious trauma is a big one. Vicarious trauma is like the emotional residue of exposure with people as they're hearing traumatic stories, becoming witness to pain, fear, terror that trauma survivors have endured. The recent experiences I think of seeing different videos and posts and all those types of things really play into vicarious trauma, where the world you look at and the lens you look at it through don't feel safe anymore, don't present the same way.

And secondary trauma, especially now, and I feel like every one of us can relate to this in some capacity, is when a situation is very close to you. Not necessarily happening directly to you, but the sight, the sound, the knowledge of the loved one involved in a traumatic situation plays a role in how those around them become impacted. I think especially now, we all know somebody that's been impacted by COVID. We know people that are very impacted by the situation that's been happening in the last two weeks. And that kind of secondary trauma stays with us because there's a very personal element to it. And so being able to within yourself identify what type of trauma am I experiencing. And I'd like to add that in talking about big traumas and small traumas, there's also an importance of understanding. There's an element of relatability, right? Where if something is very overwhelming to you where it feels like a big trauma, nobody can take that away from you. It is your absolute right to experience it in whatever way really and really works for ... or whatever you relate to, and working with that instead of trying to rationalize it or fight against it.

I think it's really important that we focus on the body's response to trauma or stress, also known as the fight, flight, freeze response. A stressful situation, whether something environmental such as maybe a work deadline or persistent worry about, "Am I going to find work? Am I going to be able to get back to work? Am I going to be safe at work?" Even things like this can cascade a big amount of stress and hormones that produce very well-orchestrated physiological changes. I think this combination of reactions to stress is definitely the fight, flight, freeze response because it evolved as a survival mechanism. It's what enables people and other mammals to react quickly to life threatening situations. It's almost like the body's alarm system, right? Where if it's triggered, the sirens sound and you know. It's like, "Mayday, Mayday, I got to do something about this."

For example, most sexual assault victims freeze, which is something we don't often talk about, the idea of freezing. We hear flight, fight all the time, but even something like freezing can actually preserve your livelihood and help deescalate a situation. So, we all respond in different ways. I think the important thing to remember is that there are certain things that are going to be noticeable within the body when this is triggered and there's going to be things we don't even realize are happening. Some of the hidden effects include where the brain gets the body ready for action. Your adrenaline releases to instigate that fight, flight, freeze mode, your blood pressure rises, your liver releases glucose to provide energy for your muscles. Your digestion can completely stop or slow down, and the cortisol release depresses the immune system greatly.

But the things that we tend to notice the most that are noticeable are the pupils being dilated. Your mouth goes dry. Your neck and shoulders tense up. Sometimes people hear ringing in their ears. Your heart's just beating really fast. Sometimes the panic and the physical reaction is so strong, you can experience actual chest pains where it feels like you're having a heart attack, but it's just your body being very overwhelmed to a stressful situation. Another thing too is excessive sweating. Your breathing becomes fast and shallow. You may start going into shock or hyperventilating, and when the body doesn't get respite from the constant triggers of stress, our health, our minds, our functioning, our relationships, our self-care, they all suffer. And so I think recognizing what's happening within your body when this response is triggered is important.

Now, depending on your ability to cope with different situations, and everybody has different levels of resiliency, this can get triggered by something that's not even life threatening. It can be something like sitting at traffic jams or work pressure, or becoming sick, or somebody you love getting really sick, family conflicts. All of these things can trigger this type of response. Most especially if our landscape already doesn't have the coping skills necessary to contain a reaction like that. And I'm sure most of you can relate to this. When we were growing up, no one ever sat us down and said, "Okay, honey, I'm going to teach you how to cope with different viewings." You know? And so we don't really grow up with the mindset of these are coping strategies. We just kind of make things work as we go. I think a big result of that is sometimes we don't have any skills ready to go. Or the skills that we do have could potentially be negative and maladaptive. So if the body's not getting a chance to recuperate, it causes this symptom to keep coming up over the smallest little things and changes.

So, let's talk about the ways trauma presents. I think educating ourselves in terms of the emotional, physical, and behavioral experiences is essential. Taking pause and allowing for a moment of reflection where we can gain clarity and recognize how our experiences impact us is so vital to cultivating self-awareness. And I encourage you as you continue to listen to this webinar, that you pay attention to what's true for you. What are the things that as you listen to these things, you recognize, "This is happening within me. I can relate to this." And if it's not even you that can relate, do I know someone that has these things coming up for them that I'm seeing around me? I think once you learn what's happening within you, then have to fight against all those symptoms and behaviors, and build tools that can positively impact your life.

I think keep in mind that things don't happen magically overnight. A lot of these symptoms that we're going to talk about and the impacts we're going to talk about are not things that developed overnight. They're things that have grown over time. And so don't be naive to think that just because you're going to learn about something one time that it's magically going to cure a symptom or change a physical impact or a behavioral impact. It's important that you reflect on your own experiences and gather the information so that you can then build ways to overcome it. And that overcoming it may take more time than we've anticipated.

Let's talk about the psychological and emotional impacts of stress, and we'll start with mood swings. I think that emotional reactivity can feel like we are on a carousel. Sometimes we're moving up and down much faster. Sometimes it slows down, but these mood swings can really take a heavy toll on being able to cope with challenges, where your reactivity is so on edge that again, the smallest thing can set you off and set you into that upswing or downswing. Denial is important because this is also the first stage of grief. And when we are faced with life challenges, denial can kick in and it gets us stuck in a place far from reality which can be very dangerous. Also it's dangerous because reality sometimes feels too overwhelming, so this is our brain's way of protecting us. Except that if we're stuck there long enough, we're not aware of our symptoms. We're not doing anything to overcome it, and over time, this builds into a much bigger situation than if you were able to face it head on from the get go. Sometimes we don't even realize denial is happening, so it's important to check in with yourself and just reality test. Ask yourself, is this what's really going on? What's happening here?

And then talking about confusion, I think being in a psychological state of stress can impact our comprehension, our ability to focus, sometimes even our ability or desire to even articulate ourselves, right? Where our minds become so muddied, we don't even know how to let out what's happening. Anger being the second stage of grief as well is a secondary emotion. Most people don't know that, that anger is a shield. It's supposed to protect you from the most vulnerable emotions, the most vulnerable circumstances. And it's kind of like body armor protecting our most vulnerable, vital parts, except emotionally, that could be pain, hurt, worthlessness, helplessness, feeling unlovable for example. And that shield may protect those primary feelings underneath, but it's also a powerful way to push people away, and to also not deal with what's really happening internally, which kind of goes back to the idea of denial.

Anxiety. Anxiety is both a friend and an enemy. That's kind of how I explain it to people. It's like the home alarm system. It's designed to be there to protect you, to instigate the fight, flight, freeze response. However, just like some home alarms, if you accidentally opened the window without turning it off, you can hear sirens blazing. Pretty soon the cops show up. You're like, "Sorry, I just opened a window." But when it's working well, anxiety can be an ally. However, when we're dealing with a lot of stress, that anxiety is always looming, and it's the thing that's keeping that stress response active all the time. Now, fear and hypervigilance go hand in hand. It's that continuous worry that things will inevitably go wrong, like catastrophizing. You know, where if something small happens, immediately you're thinking of the worst case scenario, or being afraid to go places or see people, especially now with COVID-19. I know that there's many people that have been very afraid to be out, to even go to the supermarket. That's a big reality of what we're facing today, especially in the elderly population or the high risk population. You never know what you're going to come across, especially with this pandemic, and that level of fear and hypervigilance really increases the stress response.

Depending on the situation, shame can be a heavy level of worthlessness. And this often severely impacts someone's will to live, where that worthlessness is so heavy that they don't feel like they even deserve to be around. Thoughts like, "I wish I wasn't born," or, "I wish I could just sleep and never wake up again," or, "I wish I could just go away and never come back." These things come and are rooted from a place of shame. When we look at depression and hopelessness, that sadness, the inability to believe better is possible, the challenges with self-worth. If these are left untreated, these can become severe enough to develop no will to live. Hopelessness being the most dangerous because without hope, what are we looking forward to? Are we able to see forward when we're stuck in a hopeless state? We're just feeling like this is it. This is where I'm going to be. This is where I'm going to be stuck, and that's very overwhelming.

When we talk about numbness and disassociation, this is where we just check out. It's like our brains are so overloaded with everything that's happening that it just takes a break. A perfect example of this is let's say you're going to take medication at night or in the morning and you walk in, you walk out of the room and you're like, "Wait, did I take the med? Did I not take my pill? What did I do?" Or another great example of this is when you're driving to work and you park the car and you're like, "I don't even remember how I drove over here. I didn't even remember the drive here." And that's our body's way of numbing and dissociation because we need respite. It's dangerous because this can kick in at any time, but it's also the body's only way to regroup.

Ruminating thoughts. I call this like the mind's hamster wheel. It spins in circles, getting us nowhere. These thoughts can feel daunting and it can feel like you can't get the wheel to stop. Oftentimes, this is very much related to feelings and worries about things, some things that haven't even really happened. And again, this kind of goes in hand with anxiety where you're either thinking about something that's already past or you're thinking of something that's going to happen in the future. Because if you were in the exact present moment, like right now for example, there's nothing traumatic really happening. So when we're stuck in anxiety and the ruminating thoughts, it's because we're not present. And so learning how to bring yourself back is really important. And as those ruminating thoughts grow and the anxiety grows, it can cause severe impacts in our functioning and also again in our sense of being hopeful or feeling hopeless.

Frustration and irritability are very much related to emotional reactivity, and this can be related to feeling misunderstood, feeling really lonely, and maybe even the inability to control the situation or develop the outcome that you would like. I think left long enough and coupled with hopelessness, this can cause depression to become very severe. And especially because it's in relation to anger when we talk about frustration and irritability, that can also be the motivating factor to take action when we're depressed and feeling suicidal. Apathy is a completely emotionally dissociated state of mind. Nothing phases you. You don't feel joy. You don't feel pain. You basically just don't care. And especially if this continues long enough, I think that also plays a very big role in how people's suicidal ideations develop and how severe they become. I think especially now, one of the things that I've been hearing with people that have lost jobs is feeling as though, "What's the point? Why should I even care? There's nothing I can do about it, so I'm just going to check out and just not do anything to help myself or to move forward or to be better or to take care of myself in any way."

So, let's go into the physical impacts of stress. All of these different things don't just happen one time. I mean, they can if it's a one-time trauma, but the physical impacts of stress, what you're looking here on this screen, are the things that are long-term. And I think the human body is designed to experience stress and to immediately react to it. Stress can be positive, keeping us alert, motivated, ready to avoid any danger, but it can become really negative when a person continuously faces these challenges again without relief or relaxation. The body's autonomic nervous system has a built-in stress response that causes physiological changes that allow the body to combat stressful situations. However, prolonged activation of stress responses causes wear and tear on the body long-term. Things like a racing heartbeat which can lead to hypertension or just cardiac difficulties. Body aches, migraines and muscle tension, I would say are big ones. Usually when we feel really overwhelmed and our bodies are tired, most of the time what we do is we feel it in our neck and in our shoulders. That tension is what can cause the headaches, cause the migraines to develop.

Challenges with sleep. Now, this can either be insomnia where you're not able to sleep or you have difficulty staying asleep. Nightmares, for example, are a big one, or hypersomnia, where you can sleep 12 hours a day. You have no desire to get out of bed. Changes in appetite where you're either overeating or you're not eating enough and you're restricting, or you just have no appetite. And this also can cause damage, because we're not giving our bodies a chance to recuperate with sleep or being fueled with food. Anhedonia is a big one, especially when we're talking about depression. This is the inability to feel anything positive or pleasurable. Nothing feels good. Not physically, not emotionally, not mentally, nothing. Where you just don't enjoy doing the things you used to do anymore. That also impacts our motivation of being able to move or want to move, so that being lethargic and maybe binge watching for hours and not wanting to get off the couch is very related to the physical impacts of stress.

Another big one, and I actually see this a lot with sexual abuse survivors, is the gastrointestinal problems, where your digestive system becomes so sensitive to different situations where it's almost like your body's sending you a message saying something's just not right. And I know we mentioned hypertension, but it could also be really cloudy for your mind, right? Changes in short-term or long-term memory can happen because of untreated stress that ... And it could be changes in memory of things that we've experienced before, but it could also be simple things like, "Did I text that person back? I could have sworn I did." And then you check and see you haven't. Remembering to do self-care things. Excessive sweating, which we also talked about, but I want to talk especially about sensory sensitivity. When we've been under enough stress that we have physical impacts, our sensitivity to sound, to sight, to taste, to touch can become very, very overwhelmed. So even the smallest thing can be very triggering.

I know a client that I was working with who's really physically feeling everything stress-related. Obviously when the mailman comes and you've got a little dog, they're going to run, they're going to start barking. It's their arch-nemesis. It's what they're trained to do. But if you're dealing with physical impacts of stress, something very simple and innocent like that can feel very, very jarring. And like we talked about in the previous slide with the hypervigilance, it can actually trigger that stress response over and over even though it's not something negative. We mentioned the excessive sweating before where the moment you feel any of that anxiety or that stress response come up, immediately your body just starts reacting to it. And then flashbacks and intrusive thoughts are big ones. So when we're faced with things like PTSD, flashbacks are the scariest because it almost feels like everything you experienced is happening in vivo right now, even though it isn't. However, your body is not taking it that way. Your body doesn't realize this is something from long ago. It's something that it's experiencing as if it's happening right there in the moment. And sometimes those intrusive thoughts that pop in can create the flashbacks which are a complete physical stress response to a previous situation or trauma.

So, pay attention to your bodies because there's a huge mind body connection where our bodies are constantly talking to us and letting us know what's going on. If you've been in a situation where every time you're hanging out with someone, let's say, you just notice you leave with a headache, your body's telling you something. Right? So paying attention to where these things are coming from is important. And unfortunately when we're faced with really severe stress, that umbilical cord that connects the mind and body is completely severed. And a big part of that I think is because you're protecting one thing or the other. Right? So if you're completely cut off from your body, it's because everything in your mind is overwhelming and vice versa. Let's say you're somebody that's very sensitive and very aware of what's going on. You might not be able to fully check in with yourself on the emotional experience of everything you're going through.

Let's talk about the behavioral impacts because this is where things can get severe enough that lead to suicidality. The first is the withdrawn and isolative behaviors. This is where you're just pulling away. You're pulling away from family, you're pulling away from friends. You're pulling away maybe from social media. You're pulling away from anything that's even good for you, right? Maybe pulling away from exercising or pulling away from reading or writing. That withdrawn isolative behavior can increase loneliness and hopelessness so exponentially that the severity of that can move pretty quickly. And so if you've noticed that you have been pulled away or if you have been withdrawn, or you know somebody that's been withdrawn and isolated, especially now with the stay at home order, it's so tough to tell, right? If somebody is being withdrawn because or isolated because of the stay at home order or because there's a lot happening emotionally. So, pay attention to that. Look into that because that's a really big red flag.

And then substance use and self-medicating are huge. Huge, especially now where people are home more, alcoholism has increased exponentially. Self-medicating to take the pain away, to numb that pain, can cause really severe repercussions down the line where you might develop an addiction or you might create so much damage physically and within our brain that recovering from that feels impossible. maladaptive coping strategies or negative coping skills like people that engage in cutting behaviors or people that engage in difficult relationships even, like getting involved with somebody that you know isn't good for you or participating in something that isn't necessarily healthy and checking yourself to see what are my coping strategies and are they healthy? I know in relation to substance use and self-medicating, that's considered a maladaptive coping strategy. Even with the withdrawn or isolated behaviors, it's a maladaptive coping strategy. By pulling away, you think you're helping yourself, but you're actually causing more harm.

A big red flag is poor self-care. People who are dealing with severe depression, severe stress are not able to even do simple day to day things like getting up out of bed in the morning, being able to shower, brush your teeth. I mean, very fitting here, right? Brushing your teeth. But it does. It impacts the way you take care of yourself. Your ability to even eat sometimes gets impacted because you have no will to do anything. And that leads down the self-sabotage spiral where you're either lying to yourself or others, cutting corners, putting yourself down, not giving potential opportunities to chance because of how poorly you feel about yourself. And sometimes, even doing things that perpetrate shame and guilt you may be stuck in. The belief of, "I don't deserve better," is a big underlying theme to all of this.

Difficulty maintaining or developing relationships. I think right now, definitely it's difficult developing relationships because we're all stuck at home. We're not in the same social environments we were. But maintaining relationships that you already have can be a sign of what you're doing. And are you making an effort to be on those Zoom calls? Are you making an effort to connect with the people that you miss? If you are working, are you able to maintain a job or continue to build your practice or work in your practice? I think especially in the dental industry, where when this pandemic hit, the biggest fear was contracting COVID, right? And some people weren't able to continue working whether they were high risk or had employees that are high risk. So this has impacted people in a lot of different ways. And again, disassociation. Sometimes you're actively choosing to check out, whether that's gaming, social media, pornography, other bad compulsive behaviors, binge watching on Netflix. All of these things are taking away from your ability to take care of yourself and to check in with your emotions and do something productive. And it's just numbing. It's just pulling you away from having to deal with it.

Let's also talk about the window of tolerance and how to do a personal inventory and how to tune into your body, because these are really important, and building that self-awareness is essential. The window of tolerance is something really, really important to learn. As you can see, the window of tolerance is the optimal arousal zone. When you are in your window of tolerance, you're able to deal with the ups and downs of life. You're able to deal with let's say somebody dinged your car. Or if you're in dental school, let's say, and you didn't do well on an exam or a research project, whatever it is, you may be bummed, but it might not be the end of the world. However, depending on the size of that window, everybody's got a very different window of tolerance. So you can have a bunch of resiliency that can help you deal with big things, or you can have a very, very narrow window where even the slightest thing can kick you out of that.

Now, what happens when we get kicked out of our window of tolerance is we either move up or we move down. When we move up, that hyper arousal zone, that fight flight response is very, very much triggered. And I say flight fight, not freeze. This fight flight response is where you're very reactive. You're very scared and hypervigilant. You might even be experiencing flashbacks. You can't think straight. It totally sets you in a tailspin. The opposite of that is what's called hypoarousal. This is where you're just disassociated. You're numb. Sometimes this leads to people being completely catatonic, not being able to move, and it's that freeze response. It's that immobilization of anything really, because you're not able to step outside of that. So as your time goes after this webinar, I really invite you to check in with yourself and figure out how strong is that window of tolerance? How big is it? Are you able to deal with things or are little things setting you off? And the goal is to learn things that bring you back into your window of tolerance instead of feeling stuck and outside of yourself. I think that it's important to recognize also what are the triggers that kick you out of your window, and if there's a pattern to that, right? If it's the same thing that upsets you every single time, that can feel really overwhelming.

I think it's so important to read, to watch, to listen. Having resources at your fingertips is endless right now. I mean, we've got a million different apps and YouTube videos and just all kinds of different things that we can reach for that can make a difference. I think that journaling is a huge one. A huge one, because that's something you can use to develop a baseline. And when I say journaling, I think people assume you have to write pages and pages, and freely associate your thoughts. That's not what I mean. Even if you just take a piece of paper and write down bullet points of what you're feeling, where you're at, whether it's in your mind or your body and the things that are impacting you, you've already externalized this. And when you've got it on paper and it's tangible, you're able to look at it and gain a very different perspective.

The other thing too that's very helpful is accountability buddies and doing regular check-ins either with them or with yourself and making sure that you have a partner who you can check in with to take care of one another. I think that can make a very big difference. And if there's not anybody that you have, keep in mind there's endless resources like Facebook groups let's say, or just different support groups in your area that could be available. So it's important to check in and see how you're doing and to force yourself to be more aware of what you're experiencing within and externally so that it doesn't just become something that you get used to. That stress response doesn't just become something that's numbing and just stays there.

Let's talk about the mind body connection because I think learning how to get into your body and move in your body is really, really important. And so I think also when you identify the hotspots, find out what it is that's triggering those parts of your body. And [Jed] is going to play a wonderful little video that we have that you can find a lot of these on YouTube that can make a very big difference in terms of how you can learn how to use different strategies. So, body scanning is learning how to check in from the top of your head all the way to your toes and to identify what's happening and how to take care of yourself. So Jed, if you want to take it away and play that video, that would be great.

Speaker 2:
Body scan. The purpose of body scan is to simply check in to see what's going on in your body with open curiosity. There's no need to judge or try to change anything. We're just bringing attention to each part of our body in sequence, noticing how each part is connected to the next. Start by bringing your attention to the general position of your body. Are you sitting up straight with your feet flat on the ground and your hands on your knees? Or maybe you're lying on your back with arms resting by your sides. Notice the relationship of your body to the space around you. Notice where you are, the time of day. Notice if you have any tension or tightness in your body. Notice what you're thinking and feeling. Are you restless or grounded? Agitated or calm? Just notice what's going on without judging or trying to change anything.

Now bring your attention to your breathing. Become aware of where you feel your breath most. It might be in your nose or in your chest or stomach. Breathe in deeply and notice the breath as it fills your body. Breathe out and notice the breath as it goes out. Simply be aware of the sensations in your body, allowing them space to just be. Now, bring your attention to the top of your head, then to the back and sides of your head, and down to your ears. Bring your attention to your face, your forehead and eyebrows, your eyes, cheeks, mouth and jaw. Whatever is experienced, just allow it and let it be. Now, move your attention down into your neck and shoulders, just noticing how your neck and shoulders feel with a sense of curiosity. Move your attention into your arms, your elbows, down through your forearms and into your wrists and hands, fingers and thumbs. Just notice the sensations you feel. It's as if you were traveling through your body with your mind, just seeing what's there.

Now move your attention to your torso and your chest and upper back. Notice your heartbeat and the sensation of breathing. Now move your attention into your stomach and lower back. Your stomach is the home of digestion, and for many of us, a place where we hold many emotions. So just spending a few moments paying attention to this area, feeling what's here and just letting it be. We don't need to do anything. We are just noticing the sensations in our stomach and lower back and letting them be. And now, move your attention to your hips, down into your legs, your thighs, knees, shins, and calves, and into your ankles, to the tops of your feet, the sides of your feet, and to the bottom of the feet. And finally, feel how each part of your body is connected. Feel your foot connected to your ankle, your ankle connected to your knees and legs, your legs connected to your hips, to your stomach and lower back, connected to your torso, chest, upper back, shoulders and arms. Your arms connected to your shoulders and neck, and your neck connected to your head. Feel the skin around your whole body. Notice the sensations on your skin, the temperature and texture.

Become aware of your whole body in this moment. You don't need to think about what's right or wrong. Just relax in a sense of physical wholeness. Feel how your whole body is connected. And now let your attention rest on your breath. Breathing in and breathing out, feeling your body expand and contract with each inhale and exhale. And when you're ready, bring your attention to the touch of your body on your seat and open your eyes.

Speaker - Lara:
How was that for everyone? I hope that was something that was very peaceful and also made you connect really well with your body in a safe way. And you know, when you use body scanning, the whole point is to feel safe within your body and to take care of your body. So I love little guided meditations like that because I feel like sometimes if you're not used to doing something on your own or you're having difficulty, I know some have mentioned that no matter what they try with meditation, it doesn't work. Sometimes having somebody guide you through that can make the biggest difference. So, let's move on. How did we get here? Let's talk about the causes of high stress in dentistry that lead to depression and suicidality.

The first is confinement. I know that even when people are in dentistry school, you're working in confined spaces. I mean, even think about the mouth; it's so confined, right? But oftentimes because you have to do so many lab hours, you're in a tight enclosed space working on something and it's also causing severe isolation. A lot of the time, spending so many hours on your own trying to perfect a treatment or learn or memorize, it can make such a big difference in how we feel. And if you keep that isolation and that confinement together, you start to feel really lonely and also feel really overwhelmed, like what is the point of all this? And I think the biggest one, and I actually interviewed a few different dentists for this because I wanted to really get their perspectives, I talked to a few that are seasoned. I talked to a few that are in school. I talked to a few that have just gotten out of school and the one running theme was an addiction to perfectionism. It's like they're constantly looking to do things as perfectly as possible, especially again we're working with such a small area in the mouth. And there's such a finite amount of things you can do, but you're trained to look at all those tiny little details and it creates a habit of perfectionism that can play out in different areas of your life, and that can impact you greatly.

I think the other thing too that's part of being in school and having that addiction to just making sure everything's perfect is also the approval addiction where you want to do things so perfectly and get the approval and the grades or the praise or a client being happy. These can play a big role in how depressed people get and how that can eventually lead to suicide. I think the economic pressures from school and building a practice also play a very big role. You know, you leave dentistry school whether it's as a hygienist or a tech or as a doctor and you've got this huge amount of money you have to back almost immediately. You know? And if you're having trouble finding a job or if you just started and you're trying to build a practice, it's not like they teach you all of business in dental school. You're learning the technique. It can feel really overwhelming because you're not getting the results you thought you would be getting at that point in your career.

I think another one that's big is compromised treatment frustration. You are taught in school how to do something a certain way and perfectly. Unfortunately when you do get into practice, your client or your patient may not be able to afford all those things or their insurance may not cover it. And so you're left doing work that isn't your ideal choice in that situation. And I think that can make a big impact too. Patient anxiety is very, very real. Talking to someone who's terrified of getting those injections, I'll tell you. Patients come in very highly anxious, very worried. They treat going to the dentist like it's like the plague. I don't want to be there. I don't want to be near it. Unfortunately you're going into this profession with such great intentions designed to help people, and so emotions being as contagious as they are can make a very big impact in how you see yourself, how you see your profession, how you build your identity as a dental professional. And also I think our own personalities play a role in how depressed and anxious we get and how that can lead to suicidality. So I think unrealistic expectations, putting so much pressure on yourself that you feel like you're going to crack at any moment, these things are very much causes that lead dental professionals to start feeling such high stress. And when those things go untreated or unaddressed, that's what leads it to suicidality.

Now, I want to talk about passive suicidal ideations versus active suicidal ideations. Passive suicidal ideations are things like, "Oh, I wish I was never born," or things like, "Oh, I don't want to deal with anything. I wish I were invisible," or, "I wish I didn't have to be on here. What's the purpose of living?" Right? Active suicidal ideations or when you are looking for means, you're thinking of ways how. And if you notice this whole thermometer I got up here where it tells you the different degrees of suicidality where if your will to live and your will to keep going and you're hopeful, you're motivated are there, you're in a good place. But as this thermometer increases, as your stress increases, as your experiences increase, this is what can lead you to a place where you have a very high will to die and a very low will to live. So it's something that you can do. It's almost like you got to just take your temperature sometimes and say, "Where am I on this scale? How am I feeling?" So that you know what you could do to move ahead.

So, let's talk about signs of suicidality because I think it's important to recognize how something like depression or anxiety can morph into something that's very serious and severe. Sometimes it's as simple as somebody saying, "I want to die," or saying, "I wish I could just kill myself." I don't know. Sometimes we say that to be funny or to be dramatic. In some cases, someone will say that because they have that intention or because that's exactly what's happening in their mind. I think checking in with people if you hear them say that. Say, "Are you just being funny or are you serious right now?" And they'll be like, "Obviously I'm kidding," or they're going to be like, "You know, I actually don't feel that great." And so you shouldn't be afraid to ask the question, because it is a tough question to ask somebody, "Are you feeling like you just don't have a will to live? I know you've joked about this a few times, but I actually want to check in with you." And it's important. It's important not to shy away from having tough conversations, because that could be the thing that the person needed to hear is that somebody's paying attention. Somebody's seeing them. And likewise, if you're the one experiencing, it's so important to want to be seen and want to be heard.

I think another obvious one is when somebody's finding ways to harm themselves, whether that's going out and buying a weapon. I know gun sales increased when COVID hit and now especially with all the rioting, it's very scary out there. But there are those who are looking as a way to harm themselves because of this situation or because of how they're feeling. I think usually talking about feeling hopeless and feeling like there's no way you're going to get out of a situation or you just feel trapped or stuck and you're in this unbearable pain can play a really big role. I think another thing too is talking about feeling like you're a burden to others. Like, "I don't want to bother them. I feel like I'm just a burden to them. I feel like if I open up, I'm just putting my problems on somebody who's already dealing with their own problems." You would be surprised how powerful the reciprocity of sharing your emotions is with another person. What happens when you're able to open up and say, "This is what's happening with me." You're also inviting for them to feel safe enough to talk to you as well, and I think that makes a very big difference.

Self-medicating with lethal substances, we talked about that earlier. Sometimes this can be so severe that you're blacking out or you're passing out. You're not aware of your surroundings. You're completely detached and dissociated, which is when you can make really harmful decisions. I think being agitated is another one where you just feel like there's something you got to do and you just got to get it done. And that can play a really big role in depression, and that agitation is the motivating factor that can cause you to act. I think behaving recklessly too, things like driving under the influence let's say, or going to work with either substances in your body or alcohol in your body and trying to perform your job and putting others in a dangerous situation are all signs of severe depression and potential suicidality.

Another thing too is just an ambivalence about living, right? We talked about apathy earlier where you just don't care. That's also another piece that's important to remember when we're talking about signs of suicidality. So pay attention to see if that's something you either experienced or you've seen others experience. But it's important that we focus on how to develop resiliency, finding that self-awareness within us, and growing. I talked about self-awareness from the very beginning and I keep repeating it, because it's so important to check in with yourself to see where you are at? And oftentimes we're so on the go that taking that step back, it's like I don't have the time for that. Well, especially now with COVID, we've all got the time for that. So it's a good opportunity to check in with yourself and see where you are at? Also, part of developing resiliency is creating an arsenal of coping strategies that can help you to grow, to become more emotionally intelligent, to deal with things in various different ways that aren't destructive. And that growth is only going to build your motivation to know more, to learn more and to do more.

So, let's talk about 10 coping skills to combat depression. The first one is the most simple; it's get moving. And I don't mean get moving like go for a two mile run. I mean something as simple as stretching at your desk can be something really powerful or something simple that you do during the day takes no more than a few seconds. So something you all can do that's really really simple, I know that we've spent a lot of time sitting while we're at home. Again, it's just something as easy as putting your arms up in the air and just arching your back And then just slowly moving your arms forward and then just dropping your head into a very gentle roll all the way around. And then again counter-clockwise. And see, that's something that took no time at all. It took less than 30 seconds. And so when you get moving, this is a really powerful one. If you can commit to something as small as giving yourself a 30 second stretch every morning when you wake up, that's a coping skill you're developing. And maybe it'll take a little bit of time till you start to notice a difference in maybe how you approach mornings, but making something small and actionable like that can make a very big difference.

Leaning into love is the big one. As I mentioned earlier, one of the signs of suicidality is feeling like you're being a burden to someone. And especially when you're feeling down and you're feeling depressed or you're feeling anxious, reach out to the people that care about you. Let them know how you're doing and just lean into it. Even if you're not giving them all the details, just reaching out for that support and that connectivity can make a very big difference. Conscious breathing is a big one. I think that learning how to pay attention to your breath, and we can actually play that video towards the end, can be an important one as well because you're forcing yourself to focus on your breath. Again, doing this in a guided way makes a very big difference, because a lot of the time what happens is if I'm sitting here and I'm like, "Okay, I'm going to focus on my inhale and exhale." By the time I'm taking my third breath, my mind has wandered to so many different places. So always trying to bring yourself back to breathing even when that happens is very important.

Let's talk about the feel-good menu because I love creating a list of coping strategies you can use, and my favorite one on the list is using your five senses. So I invite you whether it's your pen, whether you have a cool little fidget you can play with, whether it's even your cell phone. Just hold that firmly. Hold it in the palm of your hand. And what I want you to do is I want you to check in with yourself and think of something that's distressing to you on a scale of one to 10, at maybe like a five or six. And when you have that idea or that thought in your mind, go ahead and close your eyes for a second. Take a big deep breath in and exhale. And now as you open your eyes, out loud to yourself since we can't hear you, describe what you see. So I'd say, okay, I see a black screen. I see pink glitter everywhere. I see it's heavy. It's not very light. And then ask yourself, if I move it, does it make a sound? If I take a whiff of it, does it smell like makeup, maybe? Or if I were to bite into this object, would it be hard or would it be soft?

What I'm doing is I'm using my five senses, and when you're focused on something that's tangible, you're bringing yourself to a mindful present moment. And that is huge. It makes the biggest difference because you're not stuck in the past. You're not thinking about the future. You're completely centered in the present where nothing is really happening that's triggering your stress response. You're actually okay. And you're giving your body that respite and you're teaching yourself, wait a second. I don't need to always be in that state of mind. I can do a really quick strategy to help bring me back to a place of calm. Physical self-care and wellness is huge. Whether you focus on nutrition, whether you focus on exercise or yoga or walking around the block, or even standing outside for a few minutes a day just to be around nature can make the biggest difference. Also, what we put into our bodies, how we nourish ourselves is very important. I know that in the dentistry world, you know exactly how that plays into your teeth and everything. And sleep hygiene. Maybe stop any kind of cell phone usage or anything half an hour before you go to sleep. Don't check your emails first thing when you wake up. Give yourself a 15 minute respite. Things like that can make a very big difference.

Keep in mind that you can always reach out for professional support. I'm sure counselors, life coaches, therapists, support groups everywhere. One of the things two of the dentists that I spoke to talked about was mastermind groups; people that you can connect with who are going through some of the same things you are, where you have an ability to share and to talk about different suggestions, which I think is very good. Replacement strategies. I think if you're ... you know, especially like let's say you're using substances. Find something else you can do instead. Like if you are excessively drinking and just staying on the couch binge watching TV shows, maybe replace that with something like drinking a lot more water and watching something that's teaching you something like a webinar, which is great, because it gets your mind working. My favorite thought is guided meditation, and I love this because again if we're not used to doing all these mindful strategies we keep hearing about, having somebody guide us through it is really, really powerful.

Let's talk about safety planning. I think it's very important to identify the warning signs, kind of like when we were looking at this thermometer here. Let me see if I can go back to that. One second. Yeah. So when we're looking at this thermometer here for example, what are your warning signs? Maybe even draw out a thermometer for yourself and identify what are the different things, what are the different parts that are being impacted when my depression or my anxiety or my stress increases? Then you come up with your feel-good menu, which is all the different coping strategies. There are things that you can do internally with yourself. It doesn't necessarily involve other people. But the positive distractions can. So social situations, playing a game with a friend, making a few phone calls that day to just check in with people and have a fun conversation or to tell a joke. Those can be really good distractions to have to help you snap out of a situation.

And then identify supportive people. When you're making a list, a safety planning list which I very much suggest you put in writing and you put up somewhere, especially if you're experiencing any of the things we've talked about today, identify supportive people you can call and say, "I'm feeling really crappy right now and I feel like I just need to talk to someone." And that can be a family member or a friend. Again, getting professional support is so important. I think mental health now more than ever needs to be an important focus because the world we're in, 2020 especially has been tumultuous. There's a lot going on. And being able to reach out for supportive figures can make all the difference. A great website is that has a ton of resources whether it's articles, whether it's finding a therapist in your area, whether it's finding support groups in your area it's something small that can make the biggest impact.

And finally, if you are at risk, if you feel like you cannot keep yourself safe, call 911. Go to the nearest emergency room. Call the National Suicide Prevention Hotline and create an environment that doesn't create room for self-harm. So if I have clients that are actively cutting for example, because of how severe their suicidality is getting, one of the first things we talk about is removing any self-harming objects from the home to make them inaccessible even if that means getting rid of scissors, for example, or putting knives away, or anything that's going to promote your wellbeing, I think is important in that regard. So write this down and hang onto it, because it can make a very big difference.

And finally, create a community of support. You're all in this together. There's 800 participants I'm seeing right now, and you are all connected. You're all doing the same type of profession. You all know the ups and downs of it. And I think that helping each other as colleagues is very important. Likewise, if you own a practice, you want to make sure to support your employees and create an environment where people are able to open up or speak up or to ask for help instead of creating the stigma against that. One of the things I've seen happening a lot especially at Cedar Sinai right now is creating debriefing opportunities in the workplace where they designate 45 minutes or an hour in the work day once a week where they can hop on a Zoom call with myself or another mental health professional and just create space to talk about what's been going on in their lives and what's been impacting them and how they're feeling. And it's not necessarily to try to change anything; it's to build that comradery and that relatability that people really need.

Developing or attending support groups is so important. Facebook groups are huge. That would be a really good way to go too, to see if there's maybe a hygienist support group on Facebook you can join and see if there's a community of colleagues there that can relate. And I think the other thing too is when COVID is over, things like, for example. Create a group for dental professionals where you can get together and go on a hike or get together at a local coffee shop and talk about different interests. This kind of support makes such a big difference in terms of the piece about being withdrawn and isolated, which is the most prevalent thing when we're talking about suicide. The most important thing you can give to yourself is to stay away from that isolation and try and surround yourself with as much love as you possibly can, because it can make a huge difference. And if you feel like you don't have those people, reach out to professionals. Reach out and find a mentor even within your profession. That could make the biggest difference too in terms of feeling like you have an anchor in relation to your career and your identity there.

And then finally I just want to let you know that the suicide prevention lifeline is there for you. Anywhere in the nation that you're at, you can call this number. You can reach out for support. You can let them know what's going on. Sometimes you're able to talk through it over the phone and it makes the biggest difference, and sometimes they'll do everything they can to get you immediate help. But don't feel caught in the stigma of, "Well, I don't want to be the person that calls. I don't want to be that person." There is no that person. When you're dealing with something that's that emotionally damaging and difficult, it's so important to be able to reach out for support because you're valuable and there are people in your lives that value you. One of the reasons we're even doing this webinar is because we want people to know that resources are out there. Help and support is out there. And as professionals, as a mental health professional myself it's on us to make sure to show up for you guys. So use us. This is what we're there for.

And just keep in mind there's so many resources. When I took a little gander at the chat earlier, people mentioned Headspace. People mentioned the Calm app. The Calm app is absolutely my favorite because you can look at different imagery that has sounds. So if you like the sound of birds chirping or rain falling, all of that's there. It's got great little stories you can listen to, like bedtime stories to help you sleep. And these are affordable resources, so be sure to reach out for them. And if you have any questions, my information's on here. Don't hesitate to reach out to me one-on-one. I'm more than happy to answer any questions.