I write this mere blocks from Henry Ford Hospital’s main campus; an epicenter within an epicenter (Detroit), within an epicenter (Michigan) of the COVID-19 pandemic. In just weeks, a solitary confirmed case of the novel coronavirus has mushroomed into tens of thousands testing positive for the disease. Nearly 3,000 Michiganders have died so far, many of them Detroiters. The number rises even as I write. We are only at the beginning of a long, painful battle against an enemy we cannot see.
Prior to COVID-19, 9/11 was the most significant national crisis of my lifetime. I was a senior in high school when the planes hit Lower Manhattan. Living in the rural “pinky” of Michigan, I was far from that epicenter, thus buffered from the trauma incurred by native New Yorkers. Unlike 9/11, this threat cannot be remedied by identifying and dismantling a political group like al-Qaeda. Viruses, and their societal reactions and ramifications, are far more insidious. depression
In the years following 9/11, those with various manifestations of posttraumatic stress disorder (PTSD) filled psychotherapists’ offices in New York and other affected areas. Victims, firefighters, police officers, paramedics, medical staff, and others battled not just effects of inhaling toxic dust but debilitating psychiatric symptoms like panic attacks, nightmares, amnesia, or profound depression. Some committed suicide. These problems, as much as anything physical, devastated lives.
It’s up to our medical colleagues to combat this virus. It will be up to psychologists, psychiatrists, social workers, counselors, and marriage and family therapists to treat the psychological fallout.
We now sit at a vastly different but perhaps equally alarming moment in the time of COVID-19. Unfortunately, this isn’t new. Humanity has been at war with viruses for millennia and each battle ends at best in stalemate. It’s up to our medical colleagues to combat this virus. It will be up to psychologists, psychiatrists, social workers, counselors, and marriage and family therapists to treat the psychological fallout. Our front-line physicians, advance practice providers, nurses, hospital support staff, and other first responders will desperately require our services.
THE PSYCHOLOGICAL IMPACT ON MEDICAL PROFESSIONALS
I spoke recently with two friends, one a nurse practitioner in intensive care and the other a surgeon. One’s usual sardonic flippancy was replaced with a sense of shock, weariness, and helplessness. She was seeing patients with “unheard of” symptoms, “people I’ve never seen as sick as this before.” My surgeon friend, even under duress a jovial happy-go-lucky guy, was rendered worried and uncertain about the future.
During medical students’ training to become full-fledged physicians, a form of hypochondriasis called “second-year syndrome” can develop in which students come to fear they have acquired the conditions of which they are learning. For example, a dermatology rotation may produce the conviction a student has a bothersome rash.
Upon examination, there is usually nothing medically amiss. Eventually, the soon-to-be doctor reverses inward fixation into fastidiously assessing symptoms externally in their patients. The existential anxiety about their own human fallibility recedes and they become confident, competent clinicians. What does one do, then, when met with a rapidly spreading disease with no effective treatment beyond supportive care, no vaccine, and no immunity? This can rekindle existential anxieties for treatment providers.
In psychology, there is a term called countertransference, the psychologist’s reaction to the unique difficulties of the client. If a therapist recurrently feels nervous with a specific client, that pattern often tells them something useful about what brings the client to treatment. In this regard, it’s not so much the psychologist’s individual feelings speaking, but what emotions are unconsciously “ingested.”
Taken further, limbic countertransference is a neurobiological way to describe how health professionals can be vicariously impacted by exposure to trauma in their professions. In severe cases, clinicians enter debilitating psychophysiological states of fight, flight, or, the most damaging, freeze that are more profound than simply being nervous.
Direct, recurrent exposure to severe illness and death, helplessness in the face of intractable suffering, or fear of contracting COVID-19 themselves, are just some of what can psychologically damage medical professionals. The damage of limbic countertransference occurs in the right, non-verbal, unconscious areas of the brain. Some may not even realize they’re incurring psychological harm.
Many medical professionals will get by in states of adaptive dissociation. This means they temporarily detach from certain parts of themselves (for example, feeling anxious), and function at high levels with focus, clarity, and efficiency. Such states only occur for limited periods of time before the brain-body system is unable to effectively adjust to relentless, ongoing stress. Much like the bed capacity of a brick and mortar hospital, it is when these adaptive systems are strained beyond capability that the institution or person breaks down. They then enter a state of pathological dissociation, a variant of the freeze response which commonly results in symptoms associated with PTSD.
Trauma can be worsened by abandonment. It’s not just the entity inflicting harm, but the people or institutions that stand idly by. An inadequate response by leaders, institutions, and/or government can result in doctors, health departments, and first responders feeling abandoned and left with weakened structures of support. Deficient stores of supplies, such as PPE, can leave them fearful that those in power aren’t willing to provide adequate support. Left unchecked, fear itself reduces the functionality of our immune system, an internal resource we need now more than ever.
SECOND RESPONDER READINESS FOR THERAPISTS
Emergency department physicians and intensive care unit nurses treating COVID-19 patients today are the New York firefighters and police rushing into burning buildings on September 11, 2001. There may be deep trauma brewing in their psyches. Psychotherapists must make ourselves visible and available to treat these professionals, whether during the crisis or in its extended aftermath. As second responders, mental health clinicians must not abandon the front-line workers of the COVID-19 pandemic.
For therapists who have not already, consider familiarizing yourself with psychotraumatology literature or becoming certified in trauma-treatment methods like brainspotting (BSP), Somatic Experiencing™ (SE), or eye movement desensitization and reprocessing (EMDR). Unlike COVID-19, PTSD is a condition we can effectively treat. Even if you’re not a trauma “expert,” there is no replacement for empathic, thoughtful, flexible, and attuned engagement with your clients. In fact, those are the essential ingredients in all models of psychotherapy, from psychoanalysis to cognitive-behavioral therapy.
You can also advocate for the integration of psychology and medicine so physicians and patients have easily accessible mental health resources. The many who have devoted their professional lives to alleviating human suffering may often be taken for granted, until a crisis reminds us why their expertise is so important.