Chair File: Leadership Dialogue — Recognizing and Addressing Anxiety With Robert Brady of Dartmouth Health

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Tom Haederle
Money worries. The job. A personal relationship. The daily news headlines. All of these things and many more can cause anxiety and stress. In fact, experts note that anxiety and stress are 100% common, in that everyone - from all walks of life - feel some level of these things practically every day. Managing stress is more important than ever. But these emotions can gain the upper hand for many people

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Tom Haederle
and that's when it's time to reach out for help.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this month's Leadership Dialogue series podcast, Dr. Joanne Conroy, CEO and president of Dartmouth Health and the 2024 Board Chair of the American Hospital Association, invites an expert colleague from Dartmouth Health to discuss ways to manage stress. They talk about how to tell the difference between the normal, garden-variety anxieties of everyday life, and the kinds of stress and anxiety levels that affect roughly one-third of the US population and limit enjoyment of life.

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Joanne M. Conroy, M.D.
Thank you for joining us today for another AHA Leadership Dialogue discussion. It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and currently the chair of the American Hospital Association Board of Trustees. I look forward to our conversation today, and I'm delighted to have my colleague, Dr. Robert Brady, join us. Robert leads our anxiety disorder service at Dartmouth-Hitchcock Medical Center.

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Joanne M. Conroy, M.D.
He originally trained at the University of Arkansas, where he earned his doctorate in clinical psychology, later doing some post-doctoral work with the VA, and has now been at Dartmouth here for almost ten years. Robert, thank you for joining us.

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Robert Brady
Good to be with you, Joanne.

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Joanne M. Conroy, M.D.
Our health system along with many others across the country, is deeply committed to ensuring that our patients and our communities have access to the full range of behavioral health services. This is especially important given our current environment, when events from national news to personal challenges can really ratchet up an individual's anxiety. Coverage of wars, the recent assassination attempt of a candidate running for office, and various other headlines create anxiety for people across the country.

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Joanne M. Conroy, M.D.
That on top of everyday stress that people are trying to manage makes it all more important for our communities, our patients, our families and our workforce to have the tools they need to identify and reduce stress and anxiety. We know anxiety is actually quite common, and it's an issue for many people in all walks of life. Robert is going to answer a lot of questions for us about anxiety and the incidents and how we actually manage it as an individual and a community.

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Joanne M. Conroy, M.D.
But what I'd love to do is have Robert tell us a little bit about himself and how he actually got into this line of work, which for many people could be anxiety provoking in itself.

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Robert Brady
Yeah, sure. Thanks, Joanne. And you know, as you mentioned earlier, I am a clinical psychologist by training. And here at Dartmouth Health, I lead a specialty team in our anxiety disorder service that's focused on the treatment and assessment of anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias, along with OCD and PTSD.

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Robert Brady
Now my research goes a bit further than anxiety, so I'm really focused on applying implementation science methods to develop and evaluate brief psychosocial interventions that are delivered in nontraditional mental health settings so that we're trying to increase access to care overall. But in terms of how I got more focused on the anxiety disorders, it is a little personal.

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Robert Brady
And I like sharing this because it normalizes anxiety. But, I remember being an extraordinarily socially anxious, socially fearful kid. And it wasn't until I learned through my own experience of kind of approaching the scary thing, seeing that nothing bad happened, that I really started kind of coming out of that shell and being less worried about embarrassing myself and really having a fuller life.

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Robert Brady
So I'm a big believer in the value of exposure-based therapies. That's really what I specializes in, in my intervention. And ultimately I just found anxiety to be, and still do, to be a fascinating problem to people that a lot of people struggle with.

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Joanne M. Conroy, M.D.
You know, that's interesting as something that a lot of people can relate to. You're not the only one that gets anxious, you know, before a social situation or before giving a talk or presentation that sometimes can be disabling. We used to do oral board exam practice sessions with our residents, and some of my brightest residents -they were so anxious they couldn't talk and breathe at the same time.

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Joanne M. Conroy, M.D.
And, you know, actually the practice sessions really helped them actually overcome their anxiety. So it was really less about their knowledge and more about how to really manage their own anxiety in this situation. Well, how prevalent is anxiety, anyway, across the general public? How many people would self-identify as having a challenge with it?

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Robert Brady
Sure. Well, I always like the question how common is anxiety? Because if we just mean anxiety, the answer is it's 100% common. And I always tell people, everybody is going to experience some level of anxiety on a daily or at the very least a weekly basis. And I would say anyone says they're never anxious is not telling the truth.

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Robert Brady
But if what you mean, is what's the prevalence of people who will go on to have really problematic anxiety, the sort that's kind of been seeking care or getting in the way of their life, then we're looking at approximately 30 to 35% of the of the U.S. based population at least, meeting criteria for some anxiety disorder at some point

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Robert Brady
over the course of life.

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Joanne M. Conroy, M.D.
What are the criteria for deciding whether you have just garden variety or human anxiety and anxiety that probably needs to be addressed.

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Robert Brady
So, you know, without getting in the weeds of all the individual criteria for each anxiety disorder, we would say there are two kind of main, defining features. Either the problem - the anxiety is interfering in the person's life, or it's substantially distressing personally to them. Either it's a problematic symptom or it's a painful symptom. But really, any time that the anxiety has gotten so big that it's limiting life or limiting enjoyment of life, I think it's worthy of being treated at that point.

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Joanne M. Conroy, M.D.
You know, a lot of people would equate that to having a panic attack, but that's probably just one symptom that people experience and probably a kind of an extreme one. You don't want to get it to the point where you actually experience that.

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Robert Brady
Right. And so panic attacks are very common to have over the course of life. And that's going to be different than panic disorder. When we have someone with a panic disorder, it means they're having recurrent panic attacks. And maybe most importantly they're changing their life in some meaningful way. That is, they're stopping doing the things that give them pleasure, or they're not going to places that are important for them to complete their activities of daily living. That is not the panic attack, but it's the anxious apprehension of panic and the change in life, all to prevent what is otherwise an unpleasant but actually harmless experience.

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Joanne M. Conroy, M.D.
Now, the certain segments that you've seen a significant increase in anxiety. I think we all kind of are worried about young adults and teenagers, but there are probably other segments of the population that are experiencing rising anxiety that we need to be aware of.

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Robert Brady
It's a good question. What are the prevalence differences by segment or age group? You know, I don't know. That's the kind of research we're looking back on in some ways. But I can say that two of the areas that we're, kind of particularly concerned about as you mentioned, are young adults. I'm not a young adult anymore,

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Robert Brady
and I think it would be really tough to be one these days. We think about anxiety as a perception of threat somewhere in space and time, that's how I think about anxiety, that the danger is not there, but it might be in the future. I mean, kids right now, they're kind of drinking through a firehose of cues for anxiety.

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Robert Brady
They have a constant flow of information and they can't predict anything. One day, you know, some part of themselves is acceptable and appreciated and the next day it's not. It's something that has changed. And they can't be that aspect of self anymore. So that would be a really hard place to be in. And certainly anyone who's a parent or knows other young folks is understandably concerned about the risk of increased anxiety in that population.

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Robert Brady
The other end of that spectrum is our older adults. And so some folks, listening to this may be aware of or familiar with the term anxious depression and older adults. Anxious depression is a sort of milling about presence of just discomfort. We've got end of life issues that we're starting to think about. We're having fewer folks in our lives because a fact of life is as you get older, there's an increased likelihood of losing folks that are close to you.

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Robert Brady
And so all those things compile, along with trying to maintain that quality of life they're used to while also going through the substantial change of retirement and changes in your living. So that results in a lot more of that anxious apprehension. And that's another population we're particularly focused on.

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Joanne M. Conroy, M.D.
You know, a topic that a lot of people talk about is the role of social media. And I can tell you that there are times that I just don't want to open up my newsfeed because I don't think it's going to be good. But we know that a lot of our younger patients are very tied into social media.

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Joanne M. Conroy, M.D.
And frankly, for some of our older patients, that is sometimes the only contact or stimulation they may have if they don't actually get out of their apartment or their home frequently enough to interact with others. So I know you probably have written many papers on the impact of social media, but, you know, how should we approach it? As, you know, aunts and uncles and parents with these younger kids who I think are significantly affected by it?

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Robert Brady
So a simple question we might ask someone in our clinic is: is this behavior helpful to you? On balance, is this thing - whatever it is you're doing, maybe it's accessing social media - is it making life better? Or is it actually perhaps causing some problems? And sometimes we'll hold up the mirror, you know, kind of figuratively, to say, this is what I heard you describing about your use of social media, and you said, this is how it makes you feel, but I notice you're continuing it.

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Robert Brady
Maybe this is functioning more as a habit or an effort to avoid something else. Maybe it's repeatedly trying to look for reassurance in the social media and not being able to learn to tolerate the uncertainty. So a there's a lot - it's a very complex subject. It's not it is not my content expertise, certainly. But it shows up, almost ubiquitously in our population.

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Joanne M. Conroy, M.D.
Yeah. It feels like sometimes a national event can actually get amplified by the number of times it actually shows up on social media and all the social media venues, and it almost makes it feel more impending for people that they could be affected by that.

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Robert Brady
Yeah. And so in some ways, it becomes a numbers game, right? It's so omnipresent, it's so constant that you kind of say, well, it has to be important if they're putting it on the website this many times, right? Failing to remember that the normal stuff of life doesn't make social media, right? The normal stuff of life doesn't make the news.

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Robert Brady
It's the scary stuff. And the more you see it, the more you start to say, oh, it must be. This is something I have to be worried about.

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Joanne M. Conroy, M.D.
Let's shift a little bit and talk about anxiety in health care workers. You know, we have a lot of uncertainty and violence in the world that gets amplified by social media. But health care workers are often on the front line, either treating victims who are affected by violence. But also we have more violence within the health care setting.

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Joanne M. Conroy, M.D.
You know, people are angrier. And you know, we can use the example of the active shooter that we had here almost seven years ago that created a lot of anxiety within the organization. It felt like our safe little bubble of the upper valley had actually been popped, and people realize that we could be vulnerable.

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Robert Brady
Right. And we oftentimes are the most anxious about the things that we can't predict. Right? If anxiety, as I said before, is the perception of threat somewhere over the horizon, ideally the salve, the balm for anxiety would be able to predict things and those unpredictable events and the idea that they might happen. That's what provokes that anxious, that anxious response. I mentioned at the top that I've been here for about ten years.

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Robert Brady
And so I've been able to work with a lot of health care providers, both as colleagues of course, but also sometimes in my clinical work. And health care providers come across as superheroes sometimes, and I think sometimes we also think of ourselves as superheroes, forgetting that if anxiety is a normal human response, we're going to have it too.

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Robert Brady
We try to kind of push that part away, instead of kind of welcoming or accepting it and acknowledging it. The pandemic also certainly heightened that sense of anxiety, because here is an unpredictable event, and we're being asked to do things where we don't feel like we have the same sense of control and that that starts to impact our resilience.

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Robert Brady
We are not superheroes, but we have the training and ideally, we have the support necessary to remind us that we can deal with even the unpredictable parts of the work.

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Joanne M. Conroy, M.D.
Was really fascinating after the active shooter here that people surfaced with experiences before they came here. We found out we had three people that used to live in Sandy Hook and our incident actually stirred up a lot of that kind of trauma that they were still kind of dealing with, being proximate to that event.

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Joanne M. Conroy, M.D.
And it was fascinating that you would think that how proximate you were to the event had something to do with your anxiety level. But it had nothing to do with your anxiety level. It felt like it was almost a reflection of the other trauma you'd had in your life. You know, how common is that? I was struck by that.

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Robert Brady
Sure. So we think about those as kind of trauma reminders. So, you know, oftentimes someone goes through a terrible event and they say, I don't want to think about that anymore. They try to put it in a box and put it in the back of their mind. but all it takes is a little reminder to cause that to come back, to be thinking about that more. A lot of the work that we do in the anxiety disorder service at Dartmouth Health is with PTSD specifically, trying to help people understand and process the things that happened before.

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Robert Brady
And we think, you know, when you have something bad happen, if you say, I'm going to put that away, I'm not going to think about it anymore, you better hope that the way you were thinking about it when you locked it away, that that was an effective way of thinking about it. That was adaptive. Because if you don't think about it anymore, you put it aside to, I'm just not going to deal with that.

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Robert Brady
Well, you're kind of stuck with whatever thoughts and beliefs you had about it at the time. So then when someone a similar event, happens, they didn't deal with the first one. And it makes understanding how this could happen again all the much more difficult.

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Joanne M. Conroy, M.D.
What should we be doing as leaders of hospitals and health care systems to actually support our staff? You know, at some point in my career, I thought everybody would benefit from sitting with psychologists at least twice a year, almost check ins. And I think we've actually even talked about that. We do that with our residents and we have a psychologist that's hired to support the residents, but that's probably undoable for some of our health systems.

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Joanne M. Conroy, M.D.
And we have 18,000 employees across the health system. But what else should we be doing to help support our staff?

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Robert Brady
So I think this is a good point to note that most of our colleagues manage anxiety quite well. In fact, we actually did a study during Covid of health care workers in the resilience, and specifically with anxiety. And we found that the overwhelming majority of health care workers did not report anxiety that would be concerning, that would be in kind of the clinical range.

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Robert Brady
Or if they had high anxiety, it went away within a year. But what that also showed is that almost a fifth of our colleagues do have, you know, problematic anxiety. What we want to be able to do is help to identify the folks that are most at risk, because we don't want them to suffer in silence. We want to be able to promote normality of anxiety and to be able to talk about it.

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Robert Brady
And one of the other things we learned from that study was when the health care workers can't predict day to day what's going to happen, or when they're asked to do services and tasks outside of their usual sense of what I can control, control and predict, their anxiety was much higher. So as leaders, I think what folks in health care want to be able to do is both encourage people by reminding them you have the training and skill set to do amazing things, and you can cope even with uncertainty, while at the same time trying to give them the most predictable working environment that they can. Not unnecessarily inserting uncertainty, even if

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Robert Brady
sometimes that's part of the job, trying to smooth out those rough edges of unpredictability. You know, we talk a lot about encouraging psychological safety, and then other times we will talk about brave spaces. I want to encourage people to create predictable spaces so that the person knows what to expect as much as possible from day to day.

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Joanne M. Conroy, M.D.
That's probably the key to my success, because the same Joanne Conroy shows up every single day. I'm boring, but the same person shows up. I want to thank you for joining me today Robert, and I appreciate you sharing some of your valuable expertise and insight, and certainly some of your own personal insights in terms of managing anxiety.

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Joanne M. Conroy, M.D.
And I encourage all of our viewers to reflect on some of the advice that Dr. Brady has shared, whether managing individual anxiety or helping somebody get the assistance they need. Until next time, I want to thank everybody, and I look forward to seeing you next month and our Leadership Dialogue. Have a wonderful day.

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Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.