The COVID-19 pandemic has almost instantly raised the stakes on our perception of stress in our lives. Think about the things that until very recently kept you up at night- the prosaic stressors of “normal life” in the professional, financial, community and familial realms- and you will likely find them dwarfed by the stressors of the pandemic and the “new normal”. You may be worried about whether you and all of your loved ones, particularly your older relations, will simply survive the Coronavirus pandemic. Or you may be preoccupied by the virus’s impact on the U.S. economy and our societal structure. It’s impossible to predict what the world will look like post-pandemic, and that uncertainty may be the most stressful aspect of the situation for many.
For most of us, the need to remain aware of stress has been replaced by an urgent need to manage a level of stress that is obvious and may be overwhelming. Stress is a natural part of the human condition, and while it has positive elements, chronic stress that is not addressed can have a significantly negative impact on one’s quality of life and physical health. For better or worse, right now we have no difficulty identifying the myriad sources of stress in our lives; so the question immediately becomes: “How can clinicians respond to the obvious increase in our stress levels in a way that is positive and protective?”
We’re all shocked by the pandemic’s already-massive cost in terms of human life, as well as by the its extraordinary, and extraordinarily rapid, ramifications. Look back in your calendar to about two months ago, and you’ll likely see that, although you were aware of the virus, you were still going about your business in a fairly normal manner. Now, just a couple of months later, everything has changed. We follow the global and national calculations about the quickly rising number of COVID cases, and we see the strain on our health care system. Schools are closed, most people are isolating at home, businesses have closed, major corporations are on the ropes, millions have lost their jobs. The coronavirus pandemic is clearly the defining challenge of our generation- it’s really more like several major challenges at once. It’s a medical crisis, a social crisis, an economic crisis, a political crisis and a mental health crisis. The way that we respond to these simultaneous challenges will have long-lasting ramifications for the world, for our country and for each of us. We truly can’t see what things will be like when the pandemic subsides, and it’s that very uncertainty that many find so disconcerting. Anxiety about the pandemic can be as contagious as the virus itself.
We are all likely aware of the idea that the Chinese character for “Crisis” is actually composed of two characters- representing both “Danger” and “Opportunity”. I think that’s a good metaphor for the situation that we find ourselves in. People who study historical crises tell us that a crisis creates change, and that the changes that come out of crises are frequently positive. We can already see, in ways large and small, some ways that the world has reshaped itself. One of the primary roles of government is to protect its citizens, and we are now seeing that happen in ways that were unimaginable just a few weeks ago. Our government has quickly spent trillions of dollars to ensure that individuals and small businesses have the resources they need to survive. Companies are quickly reinventing themselves, whether by starting to produce ventilators or PPE, or by drastically changing the relationships they have with their customers. Health care workers, like us, are reminding the world of the dedication we feel towards our roles. People are rising to the challenge of social distancing, and at the same time finding new and creative ways to support each other.
So, while these are undeniably scary, uncertain times, all things must pass, and the pandemic will be no exception. As they say, “tough times don’t last, but tough people do”. The world will be different when the dust settles on the pandemic, and so will we. We can’t control the pandemic, obviously, but we can, and we must, control the way that we react to it for as long as this crazy time lasts. First and foremost, we need to monitor and maintain our personal equilibrium so that we can rise to the occasion of what is expected of us now, and what will be expected of us when we come out the other side. And we will come out the other side.
While everyone in America is doing their best to navigate the stress and deprivation of the pandemic, that challenge is compounded for clinicians who will need to confront the same challenges as everyone else while simultaneously struggling with the added pressure of performing at high levels in difficult environments. COVID-19 is clearly going to place new and unexpected stress on the vast majority of clinicians, and we know that many clinicians were already experiencing stress issues and symptoms of burnout before any of this kicked in. A holistic view of burnout looks, of course, at stressors in the workplace, but also factors in the contributions made by stressors from our larger lives. Right now, the combination of these two sources of stress, the extraordinary demands of the pandemic on us as clinicians, plus the stress involved in managing our personal, home, family and financial lives, will be formidable.
So, we have perfect storm recipe for burnout, and it’s critical that we all create a survival plan that allows us to come through to the other side. The “calling” to become a clinician creates a mindset in which sacrifice is expected, “pushing through” extraordinary challenge is expected, and the notion that “the patient always comes first” is expected.
But bringing those expectations to an extended period of extraordinary challenge, is not a feasible strategy. This will be a marathon, not a sprint. And clinicians who disregard and “push through” their limits, who ignore the warning signs of stress and burnout, are less likely to find themselves on the other side of the pandemic with their mental health, their patients, their families and their careers in equilibrium.
That’s the challenge that we as clinicians are now confronted by- shaping a strategy that allows us to function optimally- for as long as the pandemic calls us to- for our patients, our families and ourselves.
Mental Health Impacts
After the metaphoric earthquake of a crisis comes the tsunami of its mental health ramifications. The U.N. defines a disaster as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources”. Clearly, the COVID-19 pandemic fits the bill, and based on what we know about the impact of prior events on population mental health we need to be prepared for significant increases in the prevalence and severity of mental health disorders.
Patients with a variety of existing psychiatric disorders are likely to experience symptom exacerbations, particularly those with anxiety disorders, depression, obsessive compulsive disorder, panic disorder, histories of paranoid ideation and chronic psychiatric disorders such as schizophrenia and bipolar disorder. Those with PTSD or histories of stress reactions from previous trauma will be challenged by both the pandemic and its multiple impacts on day-to-day life. We are already seeing spikes in calls to mental health hotlines, increases in psychotropic prescribing and many other mental health barometers, but the full force of the mental health impact may not be seen until the immediate crisis has abated but the longer-lasting repercussions on social and family structure sink in.
People with addictive disorders will be challenged by the pandemic and the social isolation that is now part of it. Maybe you’ve seen the reports of huge increases in the sales of alcohol? Then factor in the fact that those who use 12-Step programs as part of their recovery plans are no longer able to attend those meetings because of social distancing.
So we want to be on guard for exacerbations of symptoms in our patient populations as well as for new-onset diagnoses of psychiatric disorders. Let’s make sure that we’re asking all of our patients how they’re feeling emotionally, and inquire about specific symptoms, particularly anxiety. And let’s make sure that patients who need it get the psychological and psychiatric care that we can provide.
At the same time, we need to be equally vigilant about the mental health impacts on ourselves and on our fellow clinicians. As noted by Rachel Naomi Remen, “The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.” Personal protective equipment will hopefully keep us safe from the virus itself, but there is no corresponding protection from the emotional toll that the crisis may bring us.
The Individual Perspective
In Man’s Search for Meaning, Victor Frankl’s account of his experience in a Nazi concentration camp, he described the experience of the prisoners as “a provisional experience of unknown limit.” The prisoners didn’t know what might happen to them in the camp, and they didn’t know if or when they would ever get out. He wrote that those prisoners who had a hoped-for goal were more likely to survive than those who had no particular goal other than mere survival.
One of Frankl’s personal goals was to survive the camp so that he would be able to teach others what he learned about the human psyche in the camp, a goal that he was ultimately able to achieve through his book and in the creation of a form of psychotherapy called logotherapy.
To the extent that we are all now living a “provisional experience of unknown limit,” albeit one that for most of us fortunately doesn’t compare to the horror of a Nazi concentration camp, it falls to each of us to create for ourselves the future goals that inspire us to wake up each morning and do battle. In doing so, we stop being victims of circumstance but rather individuals in pursuit of a set of priorities and goals for ourselves, and that mindset can play a very protective role in helping us get through to the other side.
Your training and experience have prepared you for the clinical work ahead. Your history of overcoming personal crises along with your commitment to family and community have prepared you for the challenges you will confront at home and in your extended family.
So, this is a good time to be asking ourselves some important questions.
- What kind of clinician do I aspire to be, and how can what’s happening during this crisis help me get there?
- What kind of co-worker do I aspire to be, and how will my behavior during this crisis move me in that direction?
- What kind of spouse, parent or child do I want to be remembered as, and how will my behavior during this crisis make it more likely that I reach that goal?
- What kind of impact do I hope to have on the world, and how can what I do now help me leave that legacy?
So, it goes without saying that Netflix and comfort food, tempting and even necessary as they may be, in sensible doses, aren’t going to help us achieve our new goals. Of course we need to make sure that we are taking good care of our physical bodies through good nutrition, adequate sleep and other healthy behaviors. Of course we need to stay emotionally connected to our families and friends, in safe ways. And of course we benefit from spending time outdoors, in nature, and from staying in touch with our spiritual beliefs.
Let’s also make sure that we set meaningful goals for ourselves, as our pursuit of them will surely inform everything else that we do. The world will be a bit different after the pandemic, and so will you. Think about who you want to be when this is over and make every day a path forward in that direction. When we make decisions based on those core values, we’re much more likely to be able to handle whatever the world throws at us.
Keeping Emotional Equilibrium at Work
It bears repeating that the COVID-19 pandemic is unlike previous crises that we’ve experienced. Many clinicians have been on the front lines of mass shootings, hurricanes and other crises, but in those situations the precipitating event and the storm of patients was over in a matter of days. In contrast, Coronavirus surges and their extended impacts will last for months, or longer, so the “push through it” strategy that may have worked in the past won’t prove helpful now. In running a marathon, we save strength that will be sorely needed in the final mile. We need to adopt strategies here that will help ourselves, and our teams, in the long haul. Burnout can be contagious in an organization- we want the opposite- a contagion of positive actions among people doing the most meaningful work possible. Here are some ideas that might help:
Have team meetings: Difficult as it may be, try to meet as a team as frequently as possible. Give clinicians an opportunity to discuss both patient-related clinical issues and compare notes on what’s working and what’s not. These meetings can also be used as forums that allow clinicians to talk about their experiences, both positive and negative, around the pandemic. These brief get-togethers will save time in the long run and will go a long way to improving overall team wellness and morale.
Celebrate every victory: In the midst of the pandemic’s predominantly difficult, even tragic, moments, there will be many scenarios in which clinicians go the extra mile, find creative solutions to problems or connect with patients in profound ways. Make sure that these moments are recognized and celebrated, don’t let them get lost in the shuffle of an otherwise busy and perhaps chaotic situation.
Focus on what you can control: As clinicians, we are often powerless to save a patient- in many cases, COVID (or something else) will prevail despite our best efforts. But no force on earth can prevent us from provide the best possible care. Appreciate the fact that you did everything possible to provide the best, and most comfortable, outcome for the patient and family. You can’t do any more than that.
Keep an eye on your colleagues: When the normally cool, calm and collected become irritable, flat or tired, don’t assume they’re just having a bad day. Let them know that you’re noticing a change, that you’re concerned about them and want to know if there’s anything you can do to help.
Take breaks: Somewhat paradoxically, we need more, rather than fewer, breaks during times of crisis, because we need to pace ourselves to stay strong. And be mindful that when you do take a break, it’s really that. Downing a cup of vending machine coffee while you catch up on notes is not a break. Walking outside for 10 minutes or spending the time in a quiet place, breathing deeply, is better.
Finish your work at work: Spending all day taking care of patients and then going home to spend the night writing notes is no way to navigate the pandemic. Home should be a special place with its own people, practices and rituals. If at all possible, walk into your house with all of your work-related activities completed.
Decompress before you get home: Think about what you can do to create a buffer zone or perform a transitional activity before arriving home. This is a considered action that puts work into the rear-view mirror and establishes a clear boundary between work and home. Go for a run or a nature walk, meditate, do some breathing exercises, whatever works for you. You may have heard that the meditation app Headspace is providing free access for all health care workers, and there are many other options.
Staying Strong at Home
In some ways, the nearly-national stay-at-home scenario we’re in now is like an unplanned social psychology experiment: What would happen if everyone were forced to spend all of their time with their families at home, we became responsible for our kids’ education and we eliminated televised sports? While this situation is likely going to produce some negative outcomes, our goal is to use this period to move forward in important ways.
So, if you follow the suggestions I discussed in the previous paragraphs, when you return home from work, you’ll have put a boundary between yourself and work, you’ll be ready to fully engage in your time at home. Think not of being “stuck at home” but rather of being “safe at home,” and free to organize your time in the healthiest way possible. Many of us are spending more time at home than we’re used to, and that extra time presents an opportunity to rethink our typical patterns of behavior in a positive way. Optimally, when the dust settles, we’ll be able to look back on this period not as something we “survived” but as a time that provided the opportunity to make positive changes that lasted. Remember, it’s a crisis- but it’s also an opportunity.
At a minimum, that means having a healthy schedule and engaging in behaviors will help us come out the other side better than we started. That means creating and sticking to a schedule, eating healthy, setting aside plenty of time for sleep, avoiding excessive alcohol consumption, etc.
But we want to go beyond the basics by seizing this opportunity to change some things in positive ways. Creating and meeting goals puts us in control and sets us up for a series of satisfying victories.
A good way to start would be by using this time to significantly improve your level of fitness, which can be easily done either inside the home or outdoors. Wind sprints, deep knee bend, push-ups and sit ups all require no equipment, but they’re all you need to significantly improve your physical fitness. Keep in mind that exercise is a true mental health intervention that compares favorably, for example, with anti-depressants for mild-to-moderate depression.
On another level, this stay-at-home period is a great opportunity to focus on our relationships with those we live with. Are there new family traditions or rituals that can be initiated? A weekly “kids-make-dinner night” or family movie night? Are there new ways of communicating that can be tried? How about a regular “gratitude” practice in which everyone at home is encouraged to say one thing they are grateful for? The pandemic and the huge issues it brings up – death and dying, impacts on school, work and the economy – are all grist for the mill in terms of initiating more meaningful connecting about the things that really matter. I’d bet that many of us have had more crucial conversations with the people we care about in the last two weeks than we did in the preceding year.
Are there projects that you’ve been meaning to do for years but never seem to have the time to get started? Maybe you have the time now to re-organize your photo albums, which is a great form of life review and a good way to provide an oral history to your kids.
Do you have a bucket list? If you don’t, here’s your chance to create one. If you do, are there items on it that you can actually cross off during this isolation? You can’t climb Everest right now, but you might be able to learn how to play chess. And you can book that trip to Everest for summer 2021, which gives you something exciting to plan and look forward to.
The goal of all of these ideas, again, is to change our mindset from that of a victim who is tolerating being shut in to that of someone who is going to mindfully take advantage of an unusual period of time so as to move forward. Here are some other suggestions:
- Connect with people you haven’t been in touch with for a long time- you’ll likely find them at home!
- Start a new hobby or re-energize an old one that you set aside when school, career and family obligations set in
- Spend as much time as possible outdoors
- Find a way to engage in your unique religious or spiritual practice
- Meditate, do breathing or guided visualization exercises, yoga or progressive muscle relaxation. Free videos and apps for all of these activities are widely available
- Don’t overindulge in TV news consumption. It’s a 24/7 news cycle and an admittedly fascinating moment in history, but you really don’t need to know everything there is to know about the pandemic.
- Learn to cook if you don’t cook now. It will come in handy right now, when many restaurants are closed, and may become a valuable skill that you enjoy
- Start a journal
- Help neighbors who need it with shopping, gardening or errands that they are unable to do on their own
- Finally clean out your garage
I hope that all of you use this time to deepen your connectedness to your loved ones. You can make this a time that your young children look back on as special, that your older kids look back on as the time they learned how to manage big challenges, and that you look back on as the time when you came to appreciate and connect with all of your significant others in profound and lasting ways.
For clinicians, this is one of those “put your oxygen mask on first, before assisting others” moments. Taking good care of our own emotional well-being is a prerequisite for taking good care of our patients.
Richard Juman, PsyD, is National Director of Psychological Services at TeamHealth.