Friday, April 17, 2020
By Hal Pickett, PsyD, LP, ABPP

As we continue in this battle with COVID-19, I want to join the myriad of people who are recognizing our first responders and primary care providers that continue to show up on the front line despite the personal risks.

What we are already starting to see in news presentations are instances of accumulated traumatic pandemic grief. I feel, from my experience, that we saw something similar to this during the AIDS Crisis. I am concerned that it is at a comparatively higher level in the COVID Pandemic, because of the increased numbers in places like New York City and the lack of medical supplies and equipment for the providers to effectively do their jobs.

These workers are playing many roles as they lose patients, such as fill-in support for excluded family, because of the required medical isolation. Primary care providers are geared to connect to their clients quickly and easily move into an empathic relationship with them. Each client becomes special to them. With the multiple and accumulating losses, they are losing patients faster than they can process, integrate, or even tolerate. They do not get a break before moving to the next crisis and potential death. There are no family members to hold the hands of the dying while they pass. The care providers try to take this role when possible. The anxiety and stress must be sublimated into trying to do the best job with the next patient. Unfortunately, the outcome for the next client may not be much better.

Literature discusses such topics as resiliency, the ability to bounce back from adversity, and grit, the fortitude to work through dire circumstances. But the scenario that primary care providers are facing can push even the most resilient and gritty to the breaking point.

This situation creates a very specific type of traumatic grief that leaves a permanent scar. There is no time to process the deaths, there is no time to say a prayer, there is no time to take a breath, cry, or even hold the hand of the patient as they pass. After this is over, they are expected to return to their normal jobs. They do not get time to process their grief or what has happened. What is left behind are traumatic triggers, traumatic memories, and sometimes even strange feelings like “survival guilt.”

The Role of Mental Health Providers

As mental health providers, we need to be ready for these “pandemic veterans.” Some of it is similar to the military veterans who have experienced many deaths, but it is more complex. Military members are trained to go into war, and even though it can still be traumatic to witness the deaths of their new brothers and sisters, there is support when they return home, no matter how inadequate it is judged by others to be.

For our “pandemic veterans,” their post-traumatic stress is not as easily recognized or acknowledged. They are doing their job. No one acknowledges that they are in any way “subconsciously” not succeeding in their job. But their patients are dying around them at an alarming pace, they are feeling completely out of control, and they are feeling that they are failing at their jobs. Hospice was the specialized service that emerged from the recognition that death treatment and transition is a specialized treatment – our primary care providers are not as well trained in death care.

So as mental health providers, we need to be prepared to help these professionals as they start to come off the battlefields. It would be best if they had mandatory stress debriefing on a daily basis at the end of their workdays, but even quick debriefing is based on the privilege of time. Unfortunately, we will lose some of these providers to death, but we will also lose many of these primary care providers who cannot return to their jobs because of their accumulated traumatic pandemic grief.

These primary care providers will need trauma treatment, but it must be delivered in a way that allows the client first to acknowledge that what they are experiencing is traumatic grief. The grief can also be complex. It is not simply the grief over lost lives, it is also grief over the loss of their belief systems, their worldviews, their ideals about what their chosen profession would provide. They may question their beliefs in a just and fair world, their worldview my change from hope and dedication in helping others to despair and hopelessness. Their ideals of entering a helping profession with very altruistic underpinnings can turn to learned helplessness and depression.

The Plan

The typical trauma treatments of decreasing affect around trauma memories and integrating trauma narratives may be quite successful for some, but inadequate for others. The memories may have more blurry boundaries, and some of the anxiety can be free-floating or even existential. The feelings may have a doom connection that may not be concretely tied to any specific memory except the memory of how they felt in the middle of a firestorm.

The treatment must involve Couples and Family work. Marriages and family interactions are ancillary casualties to this crisis, as well. Partners may be confused about why the client’s negative moods have escalated and seem to cycle rapidly, which can leave life partners feeling helpless and inadequate. At the extreme, domestic abuse and violence may erupt. Primary care providers who are parents may become more controlling, enmeshed, or smothering from fear of letting their own children venture out into what they now see as a dangerous world. Or, on the other extreme, these traumatized providers might become depressed and unable to parent when they do not feel like getting out of bed in the mornings.

What Can Be Done in the Meantime?

The day-to-day processes that will help are unconditional support, adequate sleep, participation in some daily physical activity, and trying to maintain a healthy diet. In the short term, it is important that the traumatized person, their spouse, and their family understand there are many negative behaviors that are expected reactions to a very unusual situation – but just because they are expected does not mean they should be accepted.

For example, many people during these times tend to overuse caffeine, alcohol, or tobacco. They may participate in more unfamiliar acting-out behaviors such as spending, obsessively doing some activity, or even increased sexual behaviors. Others may shut down and not let anyone else in to be helpful, stay in bed all day, not practice good hygiene, or skip meals altogether. With these more extreme behaviors, it is important to get help immediately with a professional who understands accumulated traumatic grief so other more serious self-harm behaviors can be prevented.

So as we look towards flattening curves, decreasing deaths, and decreasing new cases of COVID-19, we cannot forget about the front line professionals that are going to need our support for months after the daily briefings end and everyone else breathes a sigh of relief that our lives may return to some semblance of normal in the future. For many, it will take much longer before they feel normal again.

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