I sit writing this in the heart of Detroit, the Michigan epicenter of the coronavirus outbreak. In just two weeks, a solitary confirmed case of COVID-19 has mushroomed into thousands testing positive for the disease. Nearly 1,000 Michiganders have died so far, most of them Detroiters. The number rise even as I edit this. Sadly, it seems we are only at the threshold of a long, difficult battle against an enemy we cannot see with the naked eye.
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 those events’ epicenter, thus buffered from the trauma incurred by victims, their families, first responders, and New Yorkers. Unlike 9/11, this threat cannot be remedied by identifying and dismantling a political group like al-Qaeda. A virus is far more insidious.
In the months and years following 9/11, those with varying degrees of post-traumatic stress disorder (PTSD) flooded psychotherapists’ offices in New York and other affected areas. 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. Many committed suicide. It was these problems, as much as anything physical, that devastated lives.
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 until it is vanquished. It will be up to us, psychologists, psychiatrists, social workers, counselors, and marriage and family therapists, to manage the psychological fallout. Our front-line physicians, mid-level practitioners, nurses, and hospital support staff will desperately require our services.
I spoke this week 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. Only two weeks into the medical field’s battle against COVID-19, 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” develops in which the student comes to fear they have acquired the conditions of which they are learning. For example, a dermatology rotation may produce the conviction the 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, and administering well- vetted treatments. 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 nobody with immunity? Most assuredly, this rekindles existential anxiety accompanied by helpless and dread.
In psychology, we have a term called countertransference, which is the psychologist’s reaction to the unique difficulties of the patient. If a therapist recurrently feels nervous or irritated with a specific patient, that pattern often tells them something useful about what brings the patient to treatment. In this regard, it’s not so much the psychologist’s individual feelings speaking, but what was is unconsciously “ingested” from the patient. Taken further, limbic countertransference is a neurobiological way to describe how health professionals of any ilk are vicariously impacted by exposure to their patients’ trauma. In severe cases, clinicians enter debilitating psychophysiological states of fight, flight, or, the most damaging, freeze that are more profound than simply being nervous or irritated.
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 is psychologically damaging for medical professionals now. The damage of limbic countertransference occurs in the right, non-verbal, unconscious areas of their brain. Most don’t even realize they’re being harmed.
Many medical professionals will get by in states of adaptive dissociation. This means they temporarily detach from certain parts of themselves (for example, an anxious part), and function at high levels with focus, clarity, and efficiency. Such states can 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 may eventually become intensely fatigued, mentally “checked out,” and begin to develop symptoms such as severe forgetfulness, panic attacks, insomnia, anger outbursts, or depression. This affects them, their loved ones, and patient care. Some may not become psychiatrically symptomatic until the dissociation recedes, long after the COVID-19 crisis has resolved. They then enter a state of pathological dissociation, a variant of the freeze response.
Trauma is vastly worsened by abandonment. It’s not just the entity inflicting harm but the people or institutions who stand idly by, failing to rescue or render aid. Reasonable people can quibble over the role of big government in their day-to-day lives yet few disagree a pandemic requires anything less than immediate action on the part of federal leadership. Effective leaders provide an accurate sense of external reality while also outlining a coherent path forward (consequently, this is also what good therapists do). They must be prudent, honest, and empathetic. Our most essential leaders have failed at this, and miserably.
The result is our doctors, health departments, and other first responders have been in many ways abandoned and left with weakened structures of support. Deficient stores of supplies, such as N95 masks, leave medical providers experiencing fear 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. The lagging, incoherent federal response has left our health professionals with greatly diminished resources, both tangible and psychological.
As second responders, mental health clinicians must not abandon them as well. Emergency department physicians and intensive care unit nurses are the New York firefighters and police rushing into burning buildings on September 11, 2001. There is deep trauma brewing in the petri dish of their psyche. It is essential that we make ourselves visible and available to treat them, whether during the crisis or in it’s extended aftermath.
If you aren’t already, familiarize yourself with psychotraumatology literature or become certified in therapy 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 patients; in fact, those are the essential ingredients in every psychotherapy, from psychoanalysis to cognitive-behavioral therapy.
Advocate for the integration of psychology and medicine so physicians and patients have easily accessible mental health resources. Health professionals and other first responders deserve the public accolades (rightly) afforded to combat veterans. They incur heavy emotional burdens, work in physically risky situations, make drastic sacrifices in their personal life, and take on tremendous financial debt to become expert in their craft, whether it be medicine or clinical psychology.
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. When the medical professionals are done fighting coronavirus in the trenches, we, as psychotherapists, must be ready to join them there and let doctors be the patients in need of healing.