Health care’s fight against COVID was articulated in the language of war since the start of the pandemic. Healthcare workers were “on the front line”. Practitioners and staff have been “redeployed” from their regular duties to COVID work. Frontline workers in major cities were treated to nightly outpourings of support from their communities – banging pots, hoots and howls, blaring sirens – like mini ticker tape parades.
the the similarities go even further. War and COVID present complex challenges and stressors, known intimately to those fighting and often unknown – or unknowable – to those outside the fight. These challenges are constantly changing and unpredictable, but require full attention and capacity. There is the risk of witnessing pain, suffering and death, and of having to make difficult choices in the face of these difficulties.
Despite these parallels, the line between the psychological consequences of war on soldiers and those of the pandemic on doctors and nurses has been less clearly drawn. Health care workers – doctors, nurses, technicians, support staff – are leaving the field in record numbers, with nearly 1 in 5 workers quitting their job. A main explanation offered is burnout, which already afflicted healthcare workers in worrying numbers before the pandemic. The most recent pre-COVID assessment reported burnout rates among doctors and nurses as high as 54%. Health care was difficult; COVID has made things even more difficult, according to this explanation.
We believe that a broader and more insidious stress is at play, making the crisis worse not just in degree, but in definition. While this stress doesn’t mesh perfectly with that experienced on a more literal battlefield, what healthcare workers are currently suffering from is in many ways similar to what soldiers are going through. Importantly, we can learn from the support systems put in place for soldiers and put them in place for healthcare workers as well. The stakes are high: Failing to properly address the experience of doctors and nurses in the pandemic will risk continuing to hurt our healthcare workforce.
The mental health toll of the pandemic on healthcare workers has been difficult to define properly because it doesn’t fit neatly into any box. Naming what is unique about the experience of fighting COVID – unique in standard healthcare work and unique in military service – is a step towards understanding it. First, practicing under catastrophic circumstances, forced to ration resources and sever the usual bonds of caregiving, can cause moral damage, a sense of failure caused by the dissonance between his idealized and real roles. Second, ever-changing conditions, due in part to variability in standards of crisis care between hospitals, create a perpetual feeling of insecurity. Third, coming home from battle every night and coming back the next day, jumping from reality to reality, can cause people to cope by pushing away or ignoring a reality. Fourth, health workers acted as de facto mental health providers, providing a new, and sometimes unique, outlet for the mental health needs of their patients, without the typical safeguards of mental health professionals – process groups, one’s own mental health provider – the leaving them less able to deal with their own reactions to the pandemic.
These experiences taken together form a type of trauma. In that sense, it is more accurate to think of healthcare workers in the pandemic as subject to the immense mental health toll of soldiers, rather than simply as a depleted workforce. The comparison is not perfect: the colloquial meaning of “trauma” often used in the military context is the type of acute trauma that leads to post-traumatic stress disorder, that is, a single terrifying or potentially deadly that produces lasting psychological sequelae. While healthcare workers are certainly prone to PTSD – think of the doctor experiencing a traumatic event, such as an unexpected death of a patient – the COVID experience more closely approximates a different trauma paradigm, the phenomenon of complex trauma.
Complex trauma East a term generally applied to people who live in chronically stressful and unpredictable environments, that is, it is not one life-threatening event, but several events or a chronic feeling of insecurity. Examples include children in violent homes or people living in civil conflict. Although our mind and body’s responses to stressful situations are adaptive, a flight or fight response intended to protect us in the moment, we are not meant to live with constantly ringing alarm bells. This has psychosocial, interpersonal and even long-term effects. biological consequences; we can lose our ability to regulate our emotions, engage with others, and think clearly, all while physically exhausting our bodies, further worsening our psychosocial experiences.
A portion of people with such conditions develop complex post-traumatic stress disorder, or c-PTSD. While “classic” PTSD is marked by reliving the event, avoidance of reminders, and hyper-reactivity to common stressors, complex PTSD is characterized in adults by dissociation, relationship difficulties, destructive behaviors (eg, substance use), difficulty controlling emotions, and feelings of shame and guilt. For healthcare workers, viewing uncertainty, burnout, stress, grief and lack of support as forms of complex trauma is not an exercise in the imagination. Nor is it a leap to consider the resulting dissonance, instability, avoidant coping, disorientation, and dissociation as responses to this complex trauma.
While conceptions of trauma have evolved to include chronic and complex stresses – experiences similar to the fight against COVID – what is happening with healthcare workers is nonetheless poorly understood as understudied. So it’s fair to say that it’s not clear exactly which label applies best. What is clear is that acknowledging this experience as a form of trauma and beginning to frame our assistance to health care workers through a traumatic lens will make more headway than continuing to talk only about burnout and his usual companions.
We can learn from the military on how to proceed next. The military has evolved tremendously in its thinking about mental health from an era of significant stigma around the subject to today, where mental health is at the forefront. This was largely catalyzed by World War II. Anticipating the psychosocial needs of 20 million veterans, the Public Health Service and Veterans Administration developed a formal mental health workforce where there was none. The resulting care system is now one of the best mental health service systems in the country. Currently, the assessment and treatment of mental health issues is integrated into military service. Psychological screening is an integral part of returning from deployment, and the treatment of psychological trauma, in particular, begins in the field at the time of injury; both are the standard of care.
In health care, on the other hand, a stigma around mental health persists. Hardship, including psychological hardship, is traditionally a cultural expectation of the profession, so much so that it is often revered; thick skin allows us to navigate the care of the sick and continue to provide care. This stigma is one of the reasons mental health needs are under-treated, as health care workers are less likely to seek help. The stressful nature of COVID only compounds the problem: while a doctor unexpectedly losing a patient is a time that signals the potential need for help, the chronic insidious stressors of COVID do not attract not necessarily pay attention in the same way.
For those battling COVID, we need an overwhelming response. After missing the window to be proactive about the mental health needs of our healthcare workers, now is the time to respond. In keeping with military precedent, we propose an expanded national mental health workforce, which will be trained by mobilizing a large cohort of existing practitioners and training new practitioners. Features of care would include: a trauma-informed approach; a focus on interpersonal, family-centered care; standardized criteria for identifying people at risk; and more universal mental health screening. Testing and treatment should work through state or federal means to increase coordination, minimize confusion between different approaches, and avoid exacerbating inequities between higher and lower resourced systems; an example would be licensing boards or professional organizations mediating education and treatment initiation. Moreover, a large investment in research is needed to better characterize the psychological effects of such experiences.
Improving the mental health of healthcare workers goes far beyond addressing the trauma of the pandemic. A systemic consideration is needed for known health work dissatisfactions – student loan debt, long hours, insufficient pay, and time off. Because once we begin to heal the trauma of our healthcare workers, we may be back to where we started: a chronically dissatisfied workforce prone to high burnout. Ultimately, we owe it to our healthcare workers to do better than that.
The authors would like to thank Shannon Washburn, Samuel Matias, Jillian Rork, Brad Wolcott and Chad Emrick for their various forms of service to our country and for their contributions to this article. The opinions expressed in this article are those of the authors and are not expressed on behalf of their respective institutions.
State of mind is a partnership of Slate and Arizona State University which offers a practical overview of our mental health system and how to improve it.