People who work in healthcare are tirelessly looking after patients with COVID-19, often in challenging conditions. There is a clear risk of long-term mental health issues, such as post-traumatic stress disorder (PTSD). But expert resources are available, and many rely on lessons learned from the experiences of military personnel.
Early research from China suggests that significant numbers of healthcare staff are experiencing anxiety, symptoms of depression, and feelings of distress as a result of the COVID-19 pandemic. Frontline healthcare professionals were particularly likely to report these experiences.
A new study from Italy, which has yet to be peer-reviewed, echoes this and shows that among 1,379 survey respondents in the healthcare sector, 49.38% reported PTSD symptoms.
It will take some time until the full picture of the psychological toll on healthcare staff emerges, but professional organizations have already started to provide resources specifically for this group.
The National Center for PTSD, part of the United States Department of Veteran Affairs, has specific COVID-19 resources for healthcare workers that strive to help them look after themselves as well as others.
In addition, the British charity Help for Heroes has put together an online Field Guide to Self-Care for people working in the healthcare sector, in response to the COVID-19 pandemic.
Medical News Today spoke with psychologists from both organizations about their resources for healthcare staff, PTSD, and parallels between the experiences of people serving during armed conflict and those on the COVID-19 front lines.
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Dr. Patricia Watson, from the National Center for PTSD, provided essential background information about the condition and discussed how professionals recognize and define it.
Dr. Watson: “When professionals are assessing for PTSD, they’re looking for a pattern of four different types of symptom, and they’re also looking for these reactions or symptoms to be highly distressing or long-lasting.
People can have intrusive reactions, such as thoughts or emotional reactions to reminders about something that they experienced, nightmares, or flashbacks, [which occur] when a person feels like they are back in the moment of the traumatic stressor.
It’s been confirmed in the latest diagnostic manuals that a common reaction to traumatic events is […] negative changes in mood or thoughts, such as being unable to recall events, negative changes in beliefs or expectations, or self-blame.
They may have a lessening of interest in things, have fewer positive feelings, or not want to do things they used to want to do. In fact, what can look like a negative, cranky personality oftentimes is the result of unhealed long-term exposure to stress.
Avoidance is another common response to traumatic stress, where a person avoids anything that will remind them of something that was traumatic for them. They may not want to talk about it or think about it, or avoid contact with people who remind them of it. They could, as a result, become very isolated.
While it’s natural to want to avoid things that were hard for a person, a very rigid or pervasive pattern of avoidance is characteristic of those with PTSD.
I’ve seen veterans, for instance, who don’t seem to meet all the criteria for PTSD because they’re just so avoidant of things. They don’t have intrusive thoughts or feelings because they’ve restricted their life to such a degree that nothing will remind them of the things they experienced.
The last type of symptoms that you see with PTSD are what we call alterations in arousal or reactivity, and this is where people show irritability or aggressiveness. They might get involved in risky or destructive behavior, they might have a sense of being jittery or keyed up all the time. They may have a heightened startle reaction or have difficulty concentrating or sleeping.”
“Many of these reactions are things we commonly see when someone has a hard time. But the reactions move toward a clinical diagnosis of PTSD when there are many of them and they are accompanied by high distress or they persist for a prolonged period of time.”
— Dr. Patricia Watson
PTSD is on the far end of the spectrum of what experts call “the stress continuum” in high-stress occupations such as serving in the military, fire and emergency medical services, and law enforcement. Dr. Watson also explained how people working in the healthcare profession might fit into this continuum.
Dr. Watson: “When we talk about the healthcare situation right now, we talk about a continuum of stress, where people can experience different zones of stress reactions. PTSD would be on the far end of the four-zone spectrum, in what we would call the red zone.
Leading up to that red zone, it is actually quite common for people to be in the yellow or orange zones. In the green zone, you are doing fine, you are in control. Once you start to get into the yellow zone, it means you have stress in your life.
Many of us find ourselves in the yellow zone quite frequently. This can manifest as feeling irritable, down in the dumps, less motivated, not as focused, or maybe your body isn’t feeling quite right.
“People move into the orange zone when they have exposure to a traumatic stress or loss, or if they have what is called moral injury. This is caused by many types of situations, such as when people feel they have made mistakes, have had to do things that conflict with their values or ideals, or have seen others doing things [that] conflict with their values.”
— Dr. Patricia Watson
Orange zone stress is also caused by a cumulation of stress over long periods of time. Typically, a person will become fatigued, and they don’t feel as in control of their reactions.
But they are still not in the red zone category, where PTSD occurs, until they have many symptoms that cause a lot of distress or last for a long time.
We think a continuum model such as this can help people talk about their stress and also reduce stigma because it lets people know that it is common to cycle in and out of zones of stress.
The goal is to get people back toward the orange and yellow zones with good self-care and coworker support — and formal mental health treatment, if indicated, because we know that there are treatments that work for PTSD.
They don’t have to take that long. Some are just five sessions, where a person can learn strategies to deal with their symptoms, feel less distressed, and function better.”
Dr. Watson also explained to MNT that she predicts that the incidence of PTSD is likely to rise, as healthcare professionals were often already working in pressured and challenging situations and the pandemic has only worsened these conditions.
However, she also pointed to a “shared sense of reality around the world” as having a protective effect.
In times when access to professional help might be limited, she and her colleagues have developed a framework of potential self-care and coworker support actions called “stress first aid.”
“There’s no one strategy that’s going to be effective for everyone,” she acknowledged. “People are going to have to find their own patterns of responding that work best for them, and their strategies may be different from day to day.”
Dr. Watson talked about five elements that can form the basis of the stress first aid model. These evidence-informed elements are commonly associated with better recovery from a variety of adverse events. They are: safety, calming, self-efficacy, social connectedness, and hope.
“Some people may be able to benefit from more of these elements than others,” she added. “A person doesn’t have to have access to all of them. One of our co-authors, Stevan Hobfoll, refers to these elements as making up a person’s ‘resource caravan,’ which can help them get through difficult times in their lives.
This caravan will be unique to each individual and vary according to circumstances. But the research that this framework was based on indicates that those who have more of those resources tend to do better through a variety of adverse circumstances.
Each person will have to creatively adapt in whatever ways are most helpful for them,” she said.
“It will be important to keep asking oneself, ‘What do I need today?’ If I’m a person who really thrives on social support, but I’m not able to get it in my usual way, how can I at least get some of it? Maybe there’s a hotline. Maybe I can reach out and talk to somebody for 5 minutes. Maybe I can text a friend and just say something like, ‘I need to vent or I need to send you 10 emojis to express how much frustration I’m feeling. I don’t need you to fix it, but I’m going to do this regularly just to get out some of my stress and frustration.’”
For clinical teams working under challenging conditions, she suggests finding new ways to build resilience and support.
She recounted one particular example:
“In one of the hospitals, they had a dedicated whiteboard. If somebody was feeling okay that day, they would write their name on the board. If another person on the team had the need to vent or had the need to talk to somebody, they could find one of the colleagues from the whiteboard. This type of strategy is particularly important because many professionals are worried about burdening each other. These are important conversations for teams to have.”
“All of us are going to be stressed. None of us are going to be okay. In a sense, how do we support each other? Let’s figure some small things out. Let’s figure out ways to focus on praising each other, having gratitude for each other, being polite and respectful to each other right now because we all need that right now.”
— Dr. Patricia Watson
Those who find themselves in the red zone of the stress continuum for extended periods should strongly consider seeking professional help when it is possible, Dr. Watson explained, as there are effective treatments for PTSD symptoms.
These treatments can also help prevent other negative effects of PTSD, such as feeling the need to self-medicate with alcohol, having difficulty sleeping or functioning, having conflict in relationships, and experiencing reduced quality of life, she noted.
“Treatment can help a person regain lost ground and rehabilitate them in the same way that physical therapy is helpful after a physical injury,” she noted.
Dr. Watson also suggested that this pandemic might eventually prompt a reconfirming of values and priorities, as well as long-term changes in people’s lives as a result of their experiences.
In the United Kingdom, the charity Help for Heroes has plenty of experience supporting veterans recovering from active military duty.
In response to the COVID-19 pandemic, the charity used this knowledge to put together resources specifically for staff working in the U.K. National Health Service (NHS).
MNT spoke to psychologist Dr. Sarah Jones, head of psychological well-being at the charity, about the parallels between the experiences of people serving in the military and those in the healthcare sector during the current crisis.
Dr. Jones: “There are quite a few parallels. That’s partly what drove us to produce the field guide and make it available online.
The parallels that we were recognizing from our experience of having supported veterans with their mental health for many years are the exposure to trauma and to difficult circumstances, particularly repeated exposure.
If we look at PTSD, that often arises from experiences that are significantly traumatic for a person to feel that there is a risk to their life or the life of somebody else close to them or around them.
During this pandemic — with the level of exposure that our healthcare professionals will be having to patients in distress, [given] the level of patients who are critically ill, and [considering] the number of people who are, sadly, dying as a result of this illness — we liken that to being on the battlefield or being in combat, where there is a risk to life and a risk of permanent injury or impact as a result of trauma.
There are other circumstantial pieces that are cumulative in that experience as well: things like working very long hours in highly stressful situations and having repeated exposure.
“Having less time to debrief with colleagues or […] compartmentalize that experience and perhaps spending longer time away from family and friends doesn’t allow for a de-stressing element, where you might normally allow yourself to contextualize your experiences and manage the difficulty of that situation.”
— Dr. Sarah Jones
These are the kinds of parallels that we’re seeing — that are often experienced by military personnel, particularly, that we are now seeing our NHS colleagues going through.”
The Field Guide to Self-Care is available on the Help for Heroes website.
“We had the advantage of being able to use existing material and educational courses that we have offered our veterans over a number of years,” Dr. Jones explained about the resource.
“We created this short field guide particularly with our NHS colleagues in mind. We wanted it to be easily accessible, which is why we created it with free access on our website.”
“The guide has three components, which form the foundations of cognitive behavioral therapy. This is the psychological theory that underpins a lot of the information we create and have used in courses in the past. The focus of the field guide centers around body, emotion, and mind,” she continued.
“This structure is designed to allow those using [the guide] to become aware of what they are experiencing and develop coping strategies, and to give them some techniques and tools to take way with them, to recognize and treat the symptoms of stress and difficulty that they might be noticing within themselves.”
— Dr. Sarah Jones
“This content is not purely theoretical, but based on the concept of coproduction, which is a philosophy very much at the heart of our charity,” Dr. Jones went on to explain. “We have the theoretic ideas, academically we have the research, but we work with our beneficiaries, our veterans, on what actually works best for them. We know that the material we use has come from that basis of coproduction and has a good evidence base.”
Dr. Jones suggests that people use the guide however it fits best within their lives. They can dip in and spend as little as 5 minutes with it or set aside a longer period to delve deeper into its components.
For some, following the sequence of body, emotion, and mind within the exercises in each part of the guide might be the most useful approach. Or, “It might be that somebody else is really focusing on what their thought processes are doing at the moment, and dipping into that section would be just right for them,” Dr. Jones explains.
“So there’s the flexibility to access it in whichever way is best for that person at that moment in time.”
The feedback, so far, has been positive.
Dr. Jones also highlighted that the field guide may be the first step on a longer journey for some, who may realize that they will need additional professional help.
“For us, as a charity, it is also very much about creating awareness and destigmatizing mental health [conditions], to encourage people to access support when they need it,” Dr. Jones said.
Does Dr. Jones think that PTSD is likely to become a long-term issue?
“As a psychologist, I’m already seeing some indicators of that in the media, in conversation with colleagues, and when talking to colleagues who are working in the NHS. Potentially, we may already be seeing higher incidence of PTSD in our NHS colleagues,” she observed.
She also pointed out that PTSD is not immediate and that it will likely take months for the full impact to start to emerge.
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