Clinicians can help ease burden of grief, trauma during COVID-19 pandemic
Patients and clinicians alike are at significant risk for experiencing grief and trauma related to the ongoing COVID-19 pandemic, according to experts.
Healio Psychiatry spoke with mental health professionals regarding the role grief and trauma have played and continue to play during the pandemic and how clinicians can help patients navigate associated mental health risks.
How grief and trauma have manifested among health care professionals
According to K. Luan Phan, MD, chair of the department of psychiatry and behavioral health at Ohio State Wexner Medical Center, trauma can be defined as a direct or witnessed experience in which there is a threat of death or physical injury.
“With COVID-19, there are multiple possible traumatic events as health care professionals take care of patients,” Phan told Healio Psychiatry. “A patient who is COVID-19-positive who acutely decompensates and requires intensive care, such as intubation and ventilation, may be a traumatic experience for a health care worker. Another possibility for trauma is the anticipation of possible patient death as their condition worsens, and then ultimately, potential patient death. Alongside these, there is the threat that co-workers on the frontline can contract COVID-19, fall ill like a patient has and then die from the virus.”
Several other pandemic-related factors are contributing to the potential for PTSD and general stress-related trauma among health care workers, Phan said. A major one is health anxiety, or the persistent fear of contracting the virus, which can be amplified or mitigated depending on whether health care systems have proper precautions in place to curb the virus’ spread. Moreover, health care workers now have the worry of contracting the virus at work and then bringing it home and spreading it to their families and others with whom they interact, Phan said. Chronic stress has also arisen from the increased pace of care related to the influx of COVID-19 patients, as well as the preparations undertaken for potential surges at hospitals.
Frontline clinicians and first responders commonly experience secondary traumatic stress related to treating individuals directly experiencing trauma, according to Zlatin Ivanov, MD, addiction psychiatrist and assistant clinical professor in the department of psychiatry at Icahn School of Medicine at Mount Sinai in New York.
“Symptoms include excessive worry and fear, feeling ‘on guard’ all the time, recurring thoughts and physical signs of stress,” Ivanov told Healio Psychiatry. “Working in an environment of challenging ethical decisions and new policy decisions, moral distress could be another common experience for providers. Moral distress is a significant issue facing critical care providers and is associated with burnout, where providers experience emotional exhaustion and depersonalization, or even dehumanization, of the patients and families in their care.”
Many health care professionals may rely on strategies of avoidance or compartmentalization to continue treating patients, which may lead to unresolved grief, Ivanov said. Further, personal circumstances outside of work, including the need for frontline workers to isolate themselves from their families to mitigate exposure risks, can compound grief.
Maureen Brogan, LPC, ACS, DRCC, program manager of Traumatic Loss Coalitions for Youth at Rutgers University Behavioral Health Care, offered ways in which health care professionals can cope with grief, PTSD and other mental health challenges related to caring for patients during the pandemic.
“One of the first steps for anyone in a health care profession is to acknowledge that these are uncertain times and that they’re going to have reactions to this uncertainty, and these reactions are OK,” Brogan told Healio Psychiatry. “We will often encourage the people that we’re serving to make sure they’re exercising, drinking water, eating healthy and to maintain the best sleep patterns that they can, and yet sometimes we’re not doing that for ourselves. Helping ourselves first is really not selfish.”
How grief and trauma have manifested among patients and their loved ones
A positive COVID-19 test result is enough to incur a mental state that manifests as the fear of potential death among patients, according to Phan.
“When patients are hospitalized or enter intensive care, those events themselves are related to the trauma of the infection,” Phan said. “Those who witness the death of a family member also experience trauma.”
For family members and loved ones who cannot visit patients in the hospital because of quarantine measures, there may be added layers of despair and sorrow related to knowing the patient is suffering alone. Health care professionals have at times attempted to alleviate the overall suffering of this experience, according to Phan.
“There are many stories of health care professionals that have communicated with patients’ family members to say things like, ‘Don’t worry. They didn’t die alone. We were right there with them.’ That gives some comfort, but it is still something that is carried forward by the family members.”
The grieving process has become even more complicated during the pandemic because of ongoing media coverage of COVID-19 that may serve as a constant reminder of painful experiences, Ivanov said.
“Another very unexpected difficulty is dealing with unusual ways to pay your last respects to the loved one you’ve lost to the pandemic,” Ivanov said. “Social isolation means you can only share your pain with those next to you during shelter-in-place, or even to face your grief alone.”
Clinicians and health care professionals can follow some steps to help their patients manage feelings of grief and trauma, according to Brogan.
“If you’re working with a frontline worker and they’re saying something like, ‘I’m not doing a good enough job,’ part of us may be tempted to tell them that’s not true,” Brogan said. “What we really need to do is allow the people we’re working with to express their feelings of sadness, helplessness or inadequacy and then validate why it’s natural that they may be feeling this way. What we can do as clinicians is help them be with their pain and remind them that it may not return to normal but that we will help them develop a new normal.”
Ivanov also pointed out methods clinicians can use to help patients deal with pandemic-related mental health challenges.
“Preparing patients/families for a likely death is very important,” Ivanov said. “There is important anticipatory grief work that can be done to decrease the likelihood for complicated grief. Health care workers are encouraged to use communication-based management, including recognizing, responding and validating emotional responses of the family to address anticipatory grief.”
Clinicians should take a direct approach, which is “an incredibly difficult conversation” that serves as a forum for discussing emotions, grief and overall patient and family distress during advance care planning, according to Ivanov. Further, he highlighted the importance of connecting patients and families to resources to help them consider post-death planning needs and receive additional grief support through telehealth services.
Phan emphasized the importance of realizing that the circumstances surrounding the pandemic aren’t “all gloom and doom.”
“We know about the strength of the individual and the community,” Phan said. “Even after the worst natural disasters or other national crises that we’ve had, including terrorist attacks, the vast majority of Americans and of people are resilient. We are likely to bounce back and, after the initial stress, recover well and become even more resilient from the traumatic experiences.”