The U.S. entered a grim new chapter in the coronavirus saga with the recent deaths by suicide of two health care workers on the front lines of the fight against Covid-19 in New York City: emergency medical technician John Mondello and emergency physician Lorna Breen.
Health care workers are well-trained to manage the intensity of a medical crisis. But few are equally comfortable managing its mental health aftermath, in themselves or in others. Even before the pandemic emerged, moral injury and burnout were rampant among clinicians. Coping with Covid-19 has magnified many of those challenges and added new ones with the reality of resource constraints.
There is no doubt this pandemic will mark many Americans with psychological scars, but how big, how complex, and how much they will interfere with the function of health care workers will depend on how organizations respond to this newly erupting phase of the crisis.
My training in surgery and psychiatry taught me a lot about trauma, grief, resilience, and recovery. But there was nothing like firsthand experience to sharpen my understanding and misconceptions of them.
Three years ago, my husband became critically ill when a heart condition he was born with abruptly worsened. I spent three sleepless nights at his bedside in an intensive care unit, watching his condition deteriorate, feeling helpless to change its trajectory. Unimaginably, at the same time, my mother’s nursing home in Florida called to let me know she had fallen and broken both hips. Later that same day, I received a call that my only brother was in an intensive care unit in Massachusetts after suffering a stroke.
My medical training prepared me to manage these intense stressors. I had plans and contingencies for every scenario. Neighbors swooped in to take care of my kids. My two best friends were in constant communication. I had a robust network of colleagues who facilitated my husband’s transfer to a large academic center. I arranged hospice for my mother from my husband’s hospital room. I was clear-minded and analytic, assessing the information in front of me and making decisions efficiently. I was incisive and commanding. I didn’t cry. I didn’t panic. I was fine.
My medical training taught me how to get through a crisis: lock the door to my feelings and stay rational in surreal surroundings. It taught me where to find the toughest, grittiest, most courageous, best parts of myself in the very worst moments.
These crises ended as well as they could: My husband recovered, my brother went home, and my mother had a painless, longed-for release from end-stage dementia.
My training did not teach me what the other side of those crises would look like, though, when the action of crisis was replaced by the stillness of recovery. There was no plan or contingency for when, in an unguarded moment, the door to my emotions blew open and the pent-up tsunami of grief and fear and sadness and anger and insecurity and doubt swept over me.
Thinking about it later, I realized that the control I had channeled was the result of processing just enough emotion to get me through a particular moment — that hour, that day, that night. My friends helped me take sips of those emotions and then carried some of it for me. They heard my anger and fear and doubt, held it, processed it, and offered it back as dark humor or empathy or simply as a refusal to leave me alone in the experience. Asking me to do any more than take sips of of my feelings would have been akin to emotional waterboarding — inescapable, cruel, and punishing.
Denial, minimizing, and compartmentalizing are essential strategies for coping with a crisis. They are the psychological tools we reach for over and over to get through harrowing situations. Health care workers learn this through experience and by watching others. We learn how not to pass out in the trauma bay. We learn to flip into “rational mode” when a patient is hemorrhaging or in cardiac arrest, attending to the details of survival — their vital signs, lab results, imaging studies. We learn that if we grieve for the 17-year-old gunshot victim while we are doing chest compressions we will buckle and he will die. So we shut down feeling and just keep doing.
What few health care workers learn how to do is manage the abstractness of emotional recovery, when there is nothing to act on, no numbers to attend, no easily measurable markers of improvement. It is also hard to learn to resolve emotional experiences by watching others, because this kind of intense processing is a private undertaking. We rarely get to watch how someone else swims in the surf of traumatic experience.
Those on the frontlines of the Covid-19 pandemic, especially those in the hardest-hit areas, have seen conditions they never imagined possible in the country with the most expensive health care system in the world. Watching patients die alone is traumatic. Having to choose your own safety over offering comfort to the dying because your hospital or health care system doesn’t have enough personal protective equipment to go around inflicts moral injury. When facing the reality of constrained resources and unthinkable choices, working to exhaustion, and caring for patients at great personal risk, the only way to get through each shift is to do what is immediately at hand.
But as the pressure to act releases, the pressure to feel intensifies. This is already happening in in regions with overwhelming surges of Covid-19 cases. While we celebrate the down slope of the viral transmission curve, we are again distracted, this time from the ominous surge in psychological struggles.
Each of us processes intense emotions in different ways and at different rates. Some internalize, others externalize. Some talk about what they are feeling, others prefer to keep quiet. Some write or paint or build or hike or do nothing at all. All are legitimate ways to manipulate, digest, and integrate feelings. Some people process in a short time; others take months, even years, to resolve an emotional experience. Some do it in huge, almost incapacitating gulps; others will carefully titrate their engagement.
Whatever recovery looks like for an individual, there are some basic principles for preparing for it. Here are five approaches to recovery I’ve learned about from my research on moral injury among clinicians and its aftermath that health system leaders can institute to aid in their colleagues’ recoveries.
Ease up. The work of recovery is hard and highly variable. The majority of people who experience crises will recover completely. Most, though, will experience symptoms at some level, if even for a short time: disturbed sleep, fatigue, difficulty concentrating, unpredictable emotions, and triggers of negative experiences by locations, smells, sounds, or other stimuli.
Service members returning from deployment often spend time on light duty to accommodate the added burden of integrating their experiences, and school disaster plans call for additional substitutes and mental health support to accommodate unexpected crisis reactions. Planning lighter schedules for Covid-19 health care workers and providing backup coverage for unanticipated absences will give them time to process their experiences and a better chance at resolving them.
Check in — and mean it. During surges of Covid-19 cases, the main concern for the well-being of health care workers has been their physical safety, which was often grossly inadequate. A second failure to protect staff, this time their mental health, could be catastrophic on many levels. Clinicians are the most valuable asset and most expensive resource for a health care organization. They are the repository of its culture and its ambassadors in the community.
There is nothing better a health care organization can do right now — for its patients, its clinicians, and its relationships with its community — than ensuring the well-being of frontline health care workers. Be genuinely interested in how they are doing, what they need, and make those resources simple to get.
Provide support. This pandemic has been unimaginably isolating for everyone, at work and at home. Social distancing and efforts by health care workers to protect their families from exposure have derailed many common coping strategies. Finding ways to pull staff members together to support each other, and publicly recognizing their value and contributions to the organization, are essential. Using internal resources to provide support is expedient, but those resources are finite. Expert advisors and partnerships with community agencies, providers, and other supports are highly recommended.
Listen. Every organization can, and should, expect criticism about its response to Covid-19. Some of it will be pointed and accurate, offering valuable lessons for the next crisis response. Some will be expressions of grief and fear. Tolerating that feedback without defensiveness or retaliation can build trust across an organization during a highly vulnerable time.
It won’t be business as usual. As the pandemic surge slows, it will be natural to want to get back to business as usual for a litany of reasons: to recapture normalcy, reinstate comforting rituals and routines, start revenue streams flowing again, and more. But getting back to business as usual risks dismissing the experience of an important segment of the workforce.
Like most other countries, the U.S. was poorly prepared for the coronavirus pandemic. Thousands of patients suffered needlessly, and far too many of them died. At the same time, frontline health care workers felt betrayed by institutions that made them choose between their own safety and patient well-being.
Failing to prepare properly for the mental health aftermath of the pandemic would be another structural betrayal of frontline health care workers, exposing them to needless suffering and possibly death. We must choose to be ready.
Wendy Dean is a psychiatrist and president and cofounder, with Simon G. Talbot, of the nonprofit organization Moral Injury of Healthcare.
If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.