Stress and anxiety after months of the COVID-19 pandemic

Breast Cancer News
May 15, 2020

Since the beginning of the COVID-19 shutdown, both efforts to stop the spread of the disease and the spread of the disease itself have been a cause of stress and anxiety. People affected by breast cancer have special concerns about their health and about separation from friends and family who provide practical and emotional support.

Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke to licensed psychologist Pamela Ginsberg, PhD, about the way emotions may change as the dramatic actions taken in March have now become routine. She speaks about how to deal with boredom, problems sleeping, financial worries, and how masks and phone calls change the way we interact. Watch, listen, or read the transcript below.

To learn more about how to manage emotions around this outbreak, we’ve collected resources for coping with COVID-19 to help you during this time.

Pamela Ginsberg, PhD
Pamela Ginsberg, PhD, is a licensed psychologist who specializes in women’s health and wellness.  With over 25 years of experience, Dr. Ginsberg works with women with all cancers at all stages, with a special interest in working with women with metastatic breast cancer. Read more. 



Jean A. Sachs, MSS, MLSP
Chief Executive Officer, Living Beyond Breast Cancer
Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.


Jean Sachs (00:01):

Hello, this is Jean Sachs. I'm the CEO of Living Beyond Breast Cancer. As many of you know, our goal at Living Beyond Breast Cancer is to provide trusted information and a community of support, and never has that been more important than in these very uncertain times.

Today we're going to talk about managing the stress and anxiety of living in our changed world with COVID-19 and living with breast cancer. We know that's a double whammy. Many of the things we're facing with COVID-19, applying greater vigilance to our body, feeling like we lack good evidence based information, not knowing what the next day may bring, and feeling less and less control over how to carry out daily functions, whether it's food shopping or taking a walk or running to the pharmacy.

At the very beginning of the shutdown, at least when we were shut down in Philadelphia, we reached out to Dr. Pam Ginsburg, a licensed psychologist to talk about stress and anxiety. We got a lot of feedback that those interviews were extremely helpful. I can't believe that it's been almost 2 months, but we wanted to bring Dr. Ginsburg back to continue the conversation.

Welcome Dr. Ginsburg. And again, thank you for being here.

Pamela Ginsberg (01:28):

My pleasure. It's great to see you again.

Jean Sachs (01:30):

Great to see you.

Before we start with the questions, tell us how you're doing.

Pamela Ginsberg (01:35):

I'm doing okay. I'm here with my family at home and I'm doing all of my sessions versus via telemedicine, so I'm still pretty busy and doing well.

Jean Sachs (01:48):

That's really great to know. We want everyone to be doing well and healthy. Can you give us a sense of [the change to] social distancing and how your patients get to interact with you? How is that impacting them?

Pamela Ginsberg (02:03):

I'm seeing a couple of things. It's interesting because it's been, I think this is the ninth week of basically the shutdown and there has been an evolution, which is interesting cause it feels like we're sitting still. But there has been an evolution and I see a couple of things.

One of the things is I see this weariness that has set in for a lot of patients.

At the same time, I also see a settling in, where people are adapting. They're settling into their current situation. The situation itself doesn't feel quite as frightening as it did at first when we knew so much less.

Jean Sachs (02:47):

That's really interesting. I think you're right. For those of us that are able to stay home, which we know is not everybody, I think we are adapting to every day. But we also know, for those people that have to continue to go out and particularly those who have to continue to go to treatment, [it’s different]. You talked about some of the changes of people settling in. Are you seeing anything else, particularly for those patients that might be actively in treatment or maybe having a new problem?

Pamela Ginsberg (03:22):

I think for the patients who are actively in treatment, there is also a settling in that's happening, settling into the routine of their treatment. Again, this adaptation of going into a treatment center, going into a medical setting with gloves and masks and seeing everybody with gloves and masks I think it was very [eerie]. It still is eerie in some ways. People are using that word a lot. It feels eerie to them. People going into, I'm in the Philadelphia area, people going into their treatment centers in big cities and feeling like the city is empty. That feels strange. But again, people human beings are really good at adapting. We get used to things and so people are adapting to that.

For those who are having new problems, I think that that's particularly scary. People who may have been settled in for a while and are having a new problem, [they] now have to deal with managing how to see their treatment team and how to see them differently. Using telemedicine as I know and you know, is not exactly the same as going in and seeing your doctor. Even when you are going in and seeing your doctor, you're seeing him or her differently because they're masked and you're not quite getting the same information because of that.

Jean Sachs (04:46):

We did talk to a doctor last week who said her patients don't know that she's smiling because she's wearing a mask.

Are you finding for the therapy sessions you're doing, are most of your patients wanting to use the camera where with Zoom or are some opting for just a phone call or audio?

Pamela Ginsberg (05:07):

I'm definitely getting both. I think more people are using the video option. I use a HIPAA-compliant video platform that's not Zoom. But there are many people who are not comfortable with it for whatever their reason is, and it's fine. So we do telephone sessions, but you don't quite get the same interaction on the phone because you're not seeing these facial expressions.

Jean Sachs (05:34):

Right. I know for some people though the Zoom camera, because we really are looking at a camera, it can be a little disassociating. Sometimes the phone feels more familiar has been helpful.

I want to talk about short-term coping strategies and then longer-term coping strategies. If you have some thoughts of things we could do right away and things we should be building or flexing our muscles to use.

Pamela Ginsberg (06:05):

The short-term coping strategies are often the same as what we've talked about many, many times — things like getting outside, exercising if possible, going for walks, certainly connecting with your friends and your family and making sure that you're not isolated.

Even though we're social isolating, we don't need to be isolated, so find ways to connect. I have a lot of patients who are doing Zoom bridge games or Mahjong games, you know any way that they're having normal interactions and conversations that don't completely center around COVID-19. Eating right, sleeping well, watching your alcohol intake, all of those normal coping strategies

Long term, I've been telling my patients this is the perfect time to experiment with some things that you may not have done before like learning how to meditate or trying yoga or some of the things we talk about often. Take some time and effort to really develop [a practice]. I'm really encouraging people to allow themselves to experiment with some, especially meditation. I talk about meditation all the time as one of the most important and effective strategies for reducing overall levels of anxiety. This is a great time to learn how to do that.

Jean Sachs (07:37):

Yeah. And there are so many, we talked about this last time, so many free apps, a lot of companies that have waived their fees. We’re encouraging people to take advantage of that. I have talked to a number of women impacted by breast cancer who have been using this time to get their nutrition in order since they're eating home, so you have a lot more control. You’re right, there are those opportunities.

We know human beings don't like to live with uncertainty. We want to know what comes next. Just like when you're on the plane, you want to know [when to] fasten your seatbelts and when are we going to take off, in 20 minutes or 4 hours. Now I think we've all realized uncertainty is our normal. Are you seeing that impacting people's long-term mental health? And what can we do to get comfortable with living with uncertainty?

Pamela Ginsberg (08:36):

You're right. Uncertainty is one of the most difficult things for human beings.

I think that we always live with a certain amount of uncertainty. Cancer patients specifically live with a higher amount of uncertainty. Now when we add code on COVID-19 on top of all of that, there's even more.

There's a tremendous amount of uncertainty around this particular virus in terms of how long it will take and how long we need to do this and what this means for us in the long term. We as humans are very good at managing acute stress as short-term stress, but chronic stress is more of a problem. And I'm seeing this uncertainty is more of a chronic stressor at this point where we don't quite know how to get ourselves comfortable here. I think that we have to accept a certain level of discomfort and we can learn to adapt and tolerate the discomfort a little bit, because the uncertainty isn't really going away anytime soon.

Again, this settling into it that I'm seeing at the same time as people are weary from it they're weary from the not knowing. It's hard. But being able to talk about it with each other, with our support system, with our cancer community, being able to chat about it has been really important to my patients because in the cancer community there are certain stressors and concerns that are unique to them — and that’s always been the case — within this environment where we're all feeling the uncertainty.

Jean Sachs (10:25):

Yeah, and I think the difference is, we're all feeling it, nobody is exempt. I certainly talked to a lot of people who are also just starting to feel bored and unsure how to fill their time. What are some of the triggers you're hearing in your practice and then what can we do to avoid being triggered?

Pamela Ginsberg (10:31):

The triggers for the cancer patients are often the same. It's getting scans, getting treatment, any physical symptom that they're feeling. Those are the same triggers they've always had. They just mean something a little bit different right now because there's these additional fears and worries that are sitting on top of the normal cancer triggers and worries.

What's really important for people to understand about triggers is that we don't have a lot of control over what happens to us emotionally when we are triggered. It's really important to understand what your triggers are so that you can expect them when they're predictable because that helps us. That gives us some level of control when triggers make us feel completely out of control. Knowing what the triggers are, understanding what a trigger is, and then having a strategy for once you're triggered.

What do you do about it? Breathing exercises or phoning a friend or talking to somebody in your support team to help work through how you're feeling. We don't have a lot of control over how we feel when we are triggered.

Jean Sachs (12:00):

I know sometimes we don't even realize that we are anxious. What are some of the physical, emotional things people can be more mindful about? I know for me sometimes my neck will start hurting or something. It'll start and I'll have to say, “Wait, what's going on?”

What are some tips for that?

Pamela Ginsberg (12:22):

Being familiar enough with your own body and the way that you respond to stress is a really important piece of information or several pieces of information. I'm hearing a lot of people who are having increased sleep problems, and I think that's due to a lot of things. I think one of them is certainly increased anxiety. It's making us more agitated and that affects our sleep. But I also think our routines are so disrupted right now that things that would normally help us to relax, to go to sleep, we're not engaged in as much. We’re not tired and fatigued from activity, we're tired and fatigued from boredom, and that affects sleep in a negative way, so a lot of people are talking about sleep problems. Some of the other things like muscle fatigue, that's something that's very common in recognizing anxiety.

Most people talk about having that feeling in their gut that's uncomfortable for them, and what I always recommend is once you recognize that you're having a problem with anxiety, don't just sit there with it. Don't let yourself just soak in that feeling. Get up, go do something, get outside, go for a walk, call a friend. There's a lot to be worried about right now and we can't just let ourselves sit in the muck of that worry and expect that we're going to be okay.

Jean Sachs (13:56):

That's great advice. I realize the days are longer because you're not getting up or commuting, so make your to do list, but do it in the order that you can do it, which might mean a break in the middle of the day.

We also know that this pandemic is causing a lot of financial stress. A lot of people are worried about their personal financial situation, being able to take care of themselves or their family members. I’m wondering, are you seeing that in any way? And how can we help people manage that very real anxiety?

Pamela Ginsberg (14:32):

Yeah, this is such a multilayered problem, isn't it? The pandemic and the cancer and everything that goes along with all of the changes including, and very significantly, the financial stress and the worries people who have lost their jobs and may have also lost their insurance. There are real problems there.

What I encourage people to do is seek help. One of the antidotes to fear is fact. It's really important to get information. A lot of people feel reluctant or hesitant to call for help in these areas. Help understanding what it means for them and what's available to them. Calling maybe a financial advisor, an accountant, or even the government trying to get through to unemployment or anything like that, it's all very difficult. But the more you get information, the more you know what to do and that helps us to feel more in control again.

Seeking information is really, really important. I wish I had the solution for the financial problems themselves, but getting information is really critical.

Jean Sachs (15:55):

Yeah, and Living Beyond Breast Cancer has been providing a lot of resources. I think the positive news is there are a lot of resources out there, and we encourage people to seek them out.

My last question is around the change in social behaviors. We've all experienced going to stores, wearing a mask, not knowing how to greet someone, not knowing how close you can get to someone. Is it 6 feet? Is it 10 feet? The anxiety and just awkwardness, we've all experienced it out in the world. And concern that if people aren't following the rules, are we being put at risk? I know for the cancer community, and certainly depending on where you are in the country it is different. That's a lot of information but I think you know what I'm saying.

Pamela Ginsberg (16:46):

Yeah. What we know is that there's no such thing as no risk so we really have to think about it in terms of low-, medium-, and high-risk behaviors.

It's critically important to understand that you do not have control over other people's decisions and behaviors. You have control over your decisions and behaviors. I want each person to think about what their own decisions are, about where their comfort is in terms of low-, medium-, or high-risk behaviors. We can figure out which behaviors fall into which category.

For those who are immunocompromised and are in active treatment, I strongly encourage staying in the low risk behavior as much as you possibly can. That's within your control. If you know that there are people around you who are engaging in behaviors that are medium or high risk, you want to stay away from those people. Know what's within your control and what's not within your control. It's incredibly frustrating to see family members or other people in your life or just in your community who are engaging in behaviors that you think are high risk behaviors. But we don't control that.

Jean Sachs (17:59):

That's a good point: We can only control what we can do. I know there are many, many people living with breast cancer who are really staying very secluded and, fortunately, have other people that are shopping for them and getting their basic needs. When they go to the hospital is really the only time they're going out, so that's so helpful.

We talked about ending this with  a really short meditation practice. I'm happy to do it with you and I thought that might be a gift we could give to our listeners.

Pamela Ginsberg (18:36):

Sure, we can do a breathing exercise. My favorite breathing exercise is something called 4-7-8 breathing. It's a simple breathing exercise that activates your parasympathetic nervous system, which is the rest and relax part of your nervous system. This is a great little thing to do when you're having trouble falling asleep or when you're feeling particularly anxious, like when you're about to walk into your treatment center. Take five of these 4-7-8 breaths, and it calms your system down quickly. The way that we do that is we breathe in for a count of four through your nose. You hold your breath for a count of seven. And then you breathe out slowly for a count of eight. We're going to do that three times. I'm going to count and you're going to breathe. I'm ready. So breathing in through the nose holding and then breathing out through the mouth. Ready? Okay.

[Breathing exercise]

Pamela Ginsberg (20:17):

Now let your breathing come back to normal. How'd that feel?

Jean Sachs (20:26):

Amazing. It's incredible that breathing is really important and we lose sight of that. Thank you.

Pamela Ginsberg (20:38):

It tells our brain to calm down, when we breathe slowly like that.

Jean Sachs (20:43):

I think we all have to keep remembering that being anxious is not going help the situation.

Pamela Ginsberg (20:49):

And over worrying doesn't help, and worrying about what could or might happen in the future doesn't help. If we are present, and we remember that right now, in this moment, we are okay. and we are controlling what we can, it settles ourselves down a little bit.

Jean Sachs (21:04):

It's so helpful, it's so simple, and yet we're so wired not to follow that advice.

Dr. Ginsburg, it's always a pleasure to spend time with you. Thank you so much.

To everybody who's watching, remember Living Beyond Breast Cancer is updating our content every week, if not every other day. We have closed Facebook pages, so please go on to our website, LBBC.ORG and join. We also have a Breast Cancer Helpline answered by all volunteers for peer-to-peer support. Lots of ways to get immediate support and we hope you'll take advantage of them.

We're in the middle of May, I'm hoping everybody stays strong and stays well and continue to stay connected to Living Beyond Breast Cancer.