Tips from Counselors

Pay Attention to the 5 Domains

The following domains are all uniquely unto themselves yet they all rely on one another, change often, and consist of both positive and negative aspects inside all of us. When explored and analyzed in terms of how each fuels and takes energy away from us all, they can often be recalibrated, seen from a different POV or used to create positive change in behavior, mood and perception.

1. Relationships: These may include friends, lovers, peers, professors, cohort members, community members.
2. Family: Many at Downstate live at home so this may be particularly salient.
3. Health: Eating, sleeping, exercise, sex drive, body image, physical strengths/limitations.
4. Academics and Career: This is a very demanding domain for many of you.
5. Internal Life: One's parts involving depression, hope, anxiety, happiness, fear, frustration and curiosity

When exploring how each domain helps or harms you at various times, how some are incredibly taxing and burdensome while others are always sources of strength and motivation and value, you can often find small patterns or locations in which you can center yourself or use for motivation or self-esteem. It is sometimes useful to create a list of strengths and weaknesses within each of these domains to give you some added insight into your own behaviors, emotions and moods.

Relationship Tips

Maintaining relationships in graduate school can be incredibly challenging. Whether we are working to keep up with various groups of friends, managing time with family, trying to date, or working to nurture a committed relationship, graduate school presents a unique challenge to our relationships.

Graduate school generates many practical disruptions to the time and energy we would often like to devote to our relationships. Simply put, we have less time and often less mental energy to devote to our interpersonal interactions. So what can be done to help sustain and grow meaningful relationships in our lives as we continue in academic courses of study that often take many years? Here are some tips for nourishing the relationships in our lives and working to find reciprocity and balance interpersonally, despite constant impositions on our time and energy.

Say what you are saying and what you are not saying

This is one of the most useful tools we have in any relationship. It may sound strange, and certainly can be difficult, but provides us with an opportunity to share where we are coming from and to work against being misunderstood. When both parties work to use this approach, especially around topics that expose vulnerability and tension, we can generally feel more heard and more supported. In addition, we generally are better able to understand the other person — in turn, the relationship feels stronger and communication is more effective.

For example: John and Maria have been dating for two years and live together. They are both in graduate school. John likes to process his day and reflect on his course work when he gets home at night. Maria likes to watch Netflix or go for a run. Lately, John and Maria have both been feeling frustrated when they get home at night, and this has led to more frequent irritation with their partner’s habits, in general. If John were to use the strategy, “say what you are saying and what you are not saying” it might look like this: “I am feeling a little rejected and unsupported when I get home at night and you don’t seem to be listening. I am not saying that I don’t encourage you to take down time in your own way, but I am saying that I would like us to try to fit in time to process my day where you seem engaged. Can we brainstorm ways that you can do what you like to do at night and also fit in time for me to process my day with you?” Maria might use this tool saying, “I am not saying that I don’t care about your day or what you need to feel supported by me. I am saying that I really need time to myself to unwind to feel balanced. Maybe, we can plan to talk about our days after I go for a run or watch an episode?”

Invite them into your world

This might feel difficult to do if the friend, family member, or significant other is not in our professional field of study. However, this is a significant way to nourish our relationships by making both of us feel more connected and accessible. There are countless ways to accomplish this, and certainly they need to be unique to you, but here are some examples.

• Ask them to join you at a coffee shop while you study.
• Give them a tour of the school and talk to them about your day-to-day schedule.
• Share a movie or book that captures some of your experience, such as What Patients Taught Me: A Medical Student's Journey, by Audrey Young.
• Share your schedules with each other, including down time, exercise, etc. so that you each know more about what the other person is up to.
• Ask them to help review a topic with you that they might find interesting. This helps you to organize your understanding of the content, and invite your friend/family member/significant other into your experience.
• Plan a weekend get together in your neighborhood. You can enjoy the time without worrying about travel and missed study opportunities.

Redefine quality time

Meaningful conversation and quality time are crucial for any relationship. No matter what our preferences look like, both provide some of the glue that holds our relationships together and makes us feel supported. When we are busy, or feeling limited in our energy, it can be very helpful to our relationships to redefine meaningful conversation and quality time, for a period. This involves thinking about the things that make us feel encouraged or relaxed, understood or cared about, and working to find briefer and more specific opportunities to create them with our friend/family member/significant other. Here are some examples.

Invite them to hang out with you while you do laundry, exercise, grocery shop, organize notes, etc.
Plan an afternoon or evening each month just for you and your friend/family member/significant other. This will give you both time you can count on to talk and enjoy spending time together, even if you don’t get more during the month. You can even come up with a place you save just for these meet ups, like a great restaurant or special place in the park.
Find small ways to keep up with their lives. For instance, use ghcat, etc. during the week to share the small details. Regular interfacing can make you feel closer and can take the pressure off uploading all these details when you are face to face.

Discuss the things that each of you needs to feel supported/connected

This one can be hard as we aren’t always aware of what we need to feel connected. However, some quick reflection can usually yield helpful hints. It may take some work to communicate them well, and you can use the first tip (“say what you are saying and what you are not saying”). Here are some common things that tend to make people feel supported/connected.

• Time alone without feeling like you are disappointing someone by taking it
• Time together without having to “accomplish” anything
• Asking specific questions about people’s lives or work based on previous conversations
• Showing up at specific events — birthdays, anniversaries, etc.
• Doing chores around the apartment
• Small gestures from time to time like sending packages with favorite teas, chocolates, books, etc.
• A quick phone call on your walk to the subway
• Reading the same blog/watching the same TV show and sharing your thoughts each week

Look ahead

Of course, this is an obvious one! But, it can be hard to plan ahead when we are so focused on what we have to accomplish right now. Planning ahead can make the people in our lives feel more considered, and it can give all of us a sense of continuity.

Resilience

Resilience is a psychological concept with a history of empirical study. It is defined as the process of adapting well to significant sources of stress. Stress can range in severity and derive from a variety of sources such as interpersonal relationships, the workplace, financial strain, or a traumatic event. Contrary to what the term may connote, people do not necessarily demonstrate resiliency by exhibiting no distress in the face of difficulty. In fact, resiliency may involve experiencing significant emotional pain. Resiliency is not an extraordinary quality but encompasses behaviors, thoughts, and actions that can be learned and developed by anyone.

Research psychologists have empirically examined what underlies resiliency. An article focused specifically on physician resiliency, but applicable to other professions too, details recommendations for the development of resilience. The authors’ primary suggestion is to focus on increasing self-awareness and self-regulation. Self-awareness involves being mindful of the earliest signs of stress, whether that is in our thoughts, bodies, or emotions. A formal meditation practice can be one way of increasing self-awareness. Informally, it may be useful to pause to take stock of your thoughts, emotions, or bodily reactions in a given moment (Epstein & Krasner, 2013).

Employing adaptive ways of self-regulating, another way of cultivating resilience, may require some personal exploration to find what works best. Some common ways of self-regulating stress are exercise, use of relaxation techniques, or allowing enough time for sleep. Having caring and supportive relationships, within and outside of one’s family, may be particularly important. Relationships lead to the development of love and trust, which in turn provide encouragement and reassurance. Accepting help from supportive others or working out kinks in existing relationships may therefore be of the utmost significance. A study examining common factors in physician resiliency also noted the importance of collegial professional relationships. Cultivating relationships with colleagues can serve to reduce professional insecurity. The emotional pressure engendered by experiencing one’s fallibility as a physician or treating complicated medical issues can be reduced by exchanging views and experiences with other physicians. This idea is not just important for physicians and can apply to any health science or other professional setting (Zwack & Schweitzer, 2013).

It is also never too late to form new relationships, perhaps through involvement with a school-based, faith-based, or other group organization. Being of service to others in need is another way we can help ourselves, as altruistic activities have been proven to offer the helper benefits, too.

Self-regulation is related to our particular style of coping with problems. Psychologists have categorized common coping styles and studied their relationship to resilience. Three common styles of coping are task-oriented, emotion-oriented, and avoidance-oriented. Individuals who use task-oriented coping approach stressful situations actively and endeavor to develop solutions to the problem at hand. In emotion-oriented coping, an individual may ruminate or become emotional in response to stress, perhaps blaming him or herself for the situation. Lastly, an avoidant-oriented coping style is characterized by a preference to evade stressful situations. In a study that assessed the relationship of resilience to personality and coping styles, results indicated that task-oriented coping was positively related to resilience and emotion-oriented coping was associated with low resilience. Interestingly, the authors of the study found that resiliency levels moderated the relationship between reports of childhood emotional neglect and current psychiatric symptoms. Those with relatively high levels of emotional neglect during childhood were found to have higher levels of current psychiatric symptoms only if they scored low on resilience. Of note, the group with the lowest psychiatric symptoms of all was those who experienced significant emotional neglect but scored high on resilience. This finding points to some researcher’s beliefs that resiliency creates not only recovery from stress but growth, too (Campbell-Sills, Cohan, & Stein, 2006).

The holiday season in particular can engender emotional challenges. The holiday season is often viewed as a time of rest and relaxation and it certainly can serve that purpose. However, in light of time spent with family and other stressors like financial strain, this time of year can bring up many other, less comfortable feelings.

We receive messages from the media and advertisement industries about the joy of the holiday season, which can place undue pressure to meet such an expectation and cause us to feel distressed when this expectation is not met. It may be helpful to prepare ourselves for what the holidays are likely to bring. It is important to keep in mind that we can’t make anyone else different and can only resolve to do something differently ourselves. It can be helpful to arrive at realistic expectations for yourself and your family. Perhaps there is longstanding volatility in your relationship with your parents or siblings. In such a case, accounting for the likelihood of an unwanted comment or two and planning how to productively respond can be useful. Asking for what you need from others may also prove critical during the holidays. This may include gently asserting time to be alone or alternatively, reaching out to others for company if feelings of loneliness arise.

Building resiliency is important because it is related to our mental health, a significant component of overall health. Research shows that approximately 15 to 20 percent of physicians will experience mental health problems at some point in their careers. This is true outside of this specific group, as approximately 20 percent of Americans, or about one in five people over the age of 18, suffer from a diagnosable mental disorder in a given year. Resiliency is a quality not limited to a specific group of individuals. It is instead a way of being that anyone can inhabit. It is an individualized process of self-awareness and self-regulation, becoming aware of our personal stressors and ways we can handle them best. This can help us to be our best selves, both personally and professionally.

Works Cited

Brennan, J. & McGrady, A. (2015). Designing and implementing a resiliency program for family medicine residents. The International Journal of Psychiatry in Medicine, 50(1), 104-114.

Campbell-Sills, L., Cohan, S.L, & Stein, M. (2006). Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behaviour Research and Therapy, 44(4), 585-599.

Epstein, R.M. & Krasner, M.S. (2013). Physician resilience: What it means, why it matters, and how to promote it. Academic Medicine, 88(3), 301-303.

Zwack, J. & Schweitzer, J. (2013). If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine, 88(3), 382-389.

Wellness Tips

Entering Third Year

The transition into third year can present some unique challenges. At the Student Counseling Service, we have heard a lot from students over the years as they make this transition. Here are some thoughts and helpful tips as you begin your third year.

Time management is something you probably have in the bag by now, but balancing clinical work with your academic demands often creates a need to reevaluate your time and routines even further. Many students find that they have less time to spend with friends and family, and even less time to engage in activities that provide much needed respite and stress relief. This becomes a time when it is crucial to make time for the things that provide you with relaxation and recharge. While it may feel impossible to make the time, you will quickly notice the ways you feel clearer and more energetic during your working hours. In addition, some of the ways to accomplish this don’t need much time. Planning ahead and preparing a healthy and appealing lunch and dinner for the day, buying comfortable shoes, listening to music on your breaks—small things like this can go a long way to helping boost your mood, provide some respite, and decrease stress.

Third year also brings with it new challenges in terms of patient interactions and relationships with other medical providers. In this new role, many students find themselves confronted with feelings and questions that they have not considered or dealt with previously. Having a much more direct view of things like patient’s feelings of helplessness, the limitations of medical organizations, family expectations for loved one’s care, patient’s resistance to your recommendations, and even the experience of codes and patient death—can all be hard to digest, and may elicit your own difficult feelings or thoughts. Finding your own way to process these experiences is crucial. Some students find speaking to a friend or partner confidentially helps, others find writing about it privately helps. Some students find speaking to peers about their reactions or thoughts helps, as well. Other ways to process some of the experience can include, exercise, reading memoirs from other doctors, and mentoring other students earlier in their studies.

Another tough experience for third year students is finding their place on the unit. It can be exciting to finally be more actively participating, but also can present some unmet expectations or disappointments, like any new experience. Even when it is hard, students find it helpful to reach out to residents, teachers, and friends if they need to think more carefully about the goals they have for the rotation and how to advocate for them, when possible.

Sleep. We know you have worked out your own routine with sleep by now. But, as any new experience can do, third year can disrupt even your carefully managed sleep habits from 1st and 2nd years. You may have a sense of good sleep hygiene and share it with your patients already-- however, we can often ignore them even despite a lack of restful sleep. Think about incorporating some good sleep hygiene into your routine, whether you are sleeping like a baby, or a first semester medical student. See the link below which describes many useful tips.

Sleep Hygiene

For other wellness tips and resources, including: guided relaxation, mindfulness, and stress management, please see the Student Counseling Service website. We are always available to you and are happy to meet with you once, or many times, to talk through your experiences and goals. You can email us to set up an appointment at any time: counseling.downstate.edu

Prioritizing self-care in order to cope with stress

Are you finding yourself stressed out a lot? Worrying about school, exams, or other life pressures? Do you find yourself feeling down: unable to motivate yourself or not experiencing much pleasure? Let’s face it: school is tough! Whether it’s a higher workload than you’ve experience before or juggling school and work or family, graduate school can get to the best of us! (Shorter days and colder weather might not help either.) How do you cope with such difficulties? Over the years, we in the Student Counseling Service have heard many great coping strategies and we want to share them! So here’s Wellness Tip #1:

It can be very tempting to forgo sleep, food, exercise and socializing with the rationale that the extra hour or two spent studying is more important. Beware! While this may lead to a short-term gain, it is not sustainable for very long. Think about a time in your life when you felt especially calm and happy. Were you getting more exercise then? Were you reserving Friday or Saturday nights for socializing? These activities are not only intrinsically beneficial, but also can lead to more focused and more productive studying later on. So an hour spent at the gym is truly an investment in your overall wellbeing!

So try to keep activities in your life that you know make you feel good or good about yourself. Remember you’ll be at your best performance if school is NOT your focus 24/7. And if you find yourself struggling or feel that you could use a little extra support, the Student Counseling Service is here to help. Individual counseling appointments are available to all Downstate students by emailing us at counseling@downstate.edu.

Have an idea on coping with stress or another aspect of student life that you’d like to share with us? Email us tips at counseling@downstate.edu.

Stress management and relaxation

During times of stress and especially when we are feeling things intensely, like anxiety, frustration, and exhaustion—we tend to neglect ourselves—our bodies and our emotions. Making time to connect with little things that provide a sense of nourishment, enjoyment, relaxation, and relief can dramatically affect your overall well being, and in addition can improve your memory, attention, and concentration. In order to identity a few things that you can engage in to provide this re-charge you can start by reflecting on small things that typically improve your mood or provide relaxation during periods when you are experiencing less stress. Often, I hear students mention things like exercise, conversations with close friends, a hot shower, or a funny episode on Netflix. It is common to treat the things that feel nourishing as a reward, or to “save” them for a time when you are less stressed. We know that setting aside a small amount of time each day for even one thing that provides some relaxation and re-charge—in the midst of the rigorous schedules you keep as students—can support you in your body’s ability to manage stress, physically, emotionally, and cognitively.

Here are some things that students have found encouraging, relaxing, and re-charging:

• Coloring
• Taking care of plants
• Spending time with a pet
• Watching an episode of their favorite TV show
• Eating their favorite childhood snack
• Going for a walk
• Cooking a meal
• Talking to a good friend over video chat

Studying and test-taking anxiety

Studying and Test Taking

Many students describe experiencing recurring thoughts of anxiety while studying, and during test taking. It is easy to get stuck in our heads and to focus on thoughts that keep our anxiety going, causing us to lose focus and confidence.

When it comes to studying and dealing with distracting or anxious thoughts, here is one exercise that can help us to manage them. Begin by visualizing a large solid box with a lock. If you are inclined, you can create as detailed an image as you like. When you are studying and a thought intrudes, you can practice sending it to the box and locking the lock. While you do this, remind yourself that you will process the thought when the project or exam you are preparing for is complete. Over time, you will be in the habit of rerouting the thought, not dismissing your anxiety, but focusing on the task at hand, and saving the anxious or disruptive thought for a time when you have more energy to process it. This can be a useful technique when you are in the middle of an exam, too. Often, students find themselves thrown off by worries about their abilities, preparation, or the exam outcome in such a way that they become physically and emotionally distressed and distracted. This can disrupt you so much sometimes that it takes from you the opportunity to demonstrate what you know and to honor all the hard work you have put into preparing.

In addition to the box technique, here is another tool you may find helpful during an exam. Take two slow deep breaths. Being mindful to breathe in as deeply as you can and then out through your mouth slowly and evenly. After this, take 30 seconds to absorb all of your attention and energy on the objects in the room. Name them to yourself in your head, one by one, slowly. When you have completed these steps, you should have relaxed enough, and distanced briefly enough from your anxious thoughts, to re-focus on your task. You can extend this to 60 seconds or longer, if you like.

Remember, you will have to practice these techniques in order to truly experience their benefit, but even on the first go they can be quite helpful.

Heading into your exam

Don’t forget to head into the exam on your own terms. Try not to surround yourself with things that will stir up anxiety or cause you to lose focus close to an exam. Some common things to avoid: emotionally provoking conversations prior to an exam, and speaking with classmates about their preparation directly before an exam. Some people find it useful to listen to soothing music or energizing music while they travel to the exam.

If you have any other tips that have helped you to share, or any questions, please email us at counseling@downstate.edu