Thomas Skovholt, Professor Emeritus, University of Minnesota; Psychologist, Minnesota

Michelle Trotter-Mathison, Psychologist, St. Paul, Minnesota

Published in JHH 19.1 – Integrative Medicine

A humble offering

We are psychologists and are not on the front line as health professionals in the Covid-19 war. We offer these words while outside the battle realizing we are not there to see, feel, and know the reality of intensively trying to provide healthcare to ill patients. We humbly offer the following observations and thoughts to healthcare professionals. Perhaps there is something of use to those in healthcare. Dr Frances Goodhart, supervising psychologist in the UK, told us she has been inspired by the courage, creativity and compassion of health professionals on the front lines of the Covid-19 war in the UK.

The professional challenge

The professional challenge is to:

• wade with vitality into the ocean of human suffering…
• be intensively present for suffering patients
• do it again…and again…and again…
• be honored to have such work.

Other-care v self-care: the moral dilemma

The inner professional world of all those caring for Covid-19 patients is being unveiled in new and profound ways through the work of photojournalists and their videos, TV presentations, photographs and media interviews. Now the world has watched and sees in every country how doctors, nurses, clergy, ambulance and emergency drivers, respiration therapists, nursing assistants, janitors, food service workers and others care for vulnerable patients.

Doctors Veena and Manish Raiji (2020), physicians in Chicago, said: ‘How do we balance between protecting our patients, our trainees, our family, ourselves and our moral sense of why we do what we do?’ Terms such as moral dilemma, moral injury and moral residue capture the complexity of ongoing choices and the fog of choice. Should the health care professional say ‘yes’ to the call to reduce acute suffering? Yes, no, maybe, perhaps.

The emotional rollercoaster intensity of the work

On the emotional rollercoaster, health professionals feel elation, fear, relief, frustration, terror, pride, despair, loneliness and anxiety. And exhaustion. They have rushed forward while citizens of the world look on in awe, admiration, appreciation. Healthcare professionals fear the virus and fear not being courageous when facing the virus.

Asked: why do you go into those spaces where you may contract the virus? Physicians and nurses reply:

• this is our work
• this is what I do
• this is the calling I signed up for
• the patients desperately need us
• we are a team fighting disease and offering hope

The greater cause: rising above the self

David Brooks, a political rabbi for our times, begins his book (Brooks, 2019) with: ‘Every once in a while, I meet a person who radiates joy. These are people who seem to glow with an inner light…They get exhausted and stressed…They’ve taken on the burdens of others. But they have a serenity about them, a settled resolve.’

Taking on the burden of others and then working as part of a team has been described as a peak human experience. In the books Tribe and War, Sebastian Junger (2011, 2016) describes the strong human need, often unmet in the modern world, to rise above oneself and belong to a larger group, a tribe or a platoon, with the welfare of the other more important than oneself. Health professionals, within the dangers of the Covid-19 war, now have many feelings of flow with deep meaning, esprit de corps, and emotional closeness with colleagues.

The search for clear, effective treatments

A dream in healthcare is to do exceptional, heroic and perfect work like Captain Sully and his co-pilot did in landing their passenger plane in the Hudson River after engine failure (Sullenberger, 2016). Oh, to be like Sully! Unfortunately, the work in healthcare, especially in extremely difficult situations like in intensive care units with Covid-19 patients, is more like what is described by Norwegian Hospital Chaplin Kjetil Moen (2018, personal communication). Moen states: ‘The professional working with the death of others is living several, partly overlapping, existential concerns (and thus carrying the pain of existence), feeling responsible for that which no one can be responsible – complex, irreversible and unsolvable situations at the border between life and death, between pleading guilty and innocent.’

In medicine, there is a ‘rage to master’ the coronavirus and alleviate patients’ pain, halt the invasion of their lungs, and intervene in their downward health spiral, the move to the ICU and death. A major stress for physicians and nurses is the medical uncertainty in a world that desperately wants medical certainty. Words from Atal Gawande (2007) fit the situation: ‘In medicine… The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency.’

About treating Covid-19 patients, Craig Spencer (2020) said: ‘Would they call us heroes if they knew we felt so helpless?’ At the same time, the intense search for treatments by so many talented health professionals and researchers is leading to new treatment procedures and methods.

Now with Covid-19, ambiguities of medical practice have been pushed to the forefront. The anxiety of uncertainty occupies space when lives depend on certainty. Thomas wrote about this in an article, Searching for Certainty (Skovholt, 2014a). The ambiguity now – the art – of medicine during Covid-19 has emerged and roared. It can be so stressful when the physician and nurse are being evaluated, by themselves and others, on unclear seemingly shifting criteria.

Lack of experience and a lack of knowledge from practice is a given for the novice as Jane Smiley (1991) summarized saying, ‘I didn’t teach long enough to know what I was doing’. This can be especially difficult for novice healthcare practitioners as found in The National Mental Health Survey of Doctors and Medical Students in Australia (2013).

In the stress of caring for Covid-19 patients, the novice nurse or physician may more acutely feel embarrassed, overwhelmed, confused, ashamed, demoralized and more. Outside of the intensity of the work, hopefully during debriefing sessions, the healthcare professional can talk about their vulnerability and uncertainty in stressful and ambiguous situations.

An emotional toxic stew threatens the health care professional’s capacity to care

Praemonitus, praemunitas – forewarned, forearm

The basic meaning of care is ‘to grieve, to experience sorrow, to cry out with’.

Nurse JN Nouwen (2004)

Here is a stew of ingredients that are occupational hazards for healthcare professionals. This stew eaten in large helpings is toxic and can kill the healthcare professional’s capacity to deeply care for vulnerable, frightened and needy patients. Eating small helpings comes with the job.

Here is an eloquent statement describing this stew:

‘The nurse repeatedly swallows a fragment of the trauma – like a nurse who is looking after an infectious patient, putting her at risk of feeling them, too. And taking in even a small part of tragedy and grief, and loneliness and sadness, on a daily basis over a career is dangerous and it is exhausting.’

Christie Watson in The Language of Kindness, A Nurse’s Story (2018)

Ingredients of the stew: fear of being infected and bringing it to loved ones, burnout, feelings of failure and guilt, emotional depletion, compassion fatigue, vicarious or secondary trauma, uncertainty, vulnerability, ambiguous endings, loss and grief.

The cycle of caring

Here we present antidotes that can promote resilience and counteract the toxic ingredients that can harm the health care professional. First, the Cycle of Caring (Skovholt, 2005) and then five resilience tips.

The Cycle of Caring is a psychological road map for health professionals in their work. One can think of the cycle as occurring in one hour, one day, one week, one month, one year. It is both a simple and complex way of the describing the work with patients in healthcare and can give structure to the emotional roller coaster for health professionals in the intensity of the pandemic.1

With each patient the practitioner must engage in a mini-cycle of closeness, and then an ending of an often intense, professional connection. For example, a nurse in an ICU. Then they do it again with a different patient in a nearby bed.

Phase one: empathetic attachment

Getting ready and then starting the professional attachment by caring for the patient. The title of Christine Watson’s book The Language of Kindness: A Nurse’s Story (2018) tells of the emotional expectation. How does one express kindness through all the gloves, gowns, PPEs, ventilators and more? And when the nurse herself is afraid of the hidden enemy, the virus.

Phase two: active involvement

This is the long slog of the work shift which may be many hours long. We are psychologists and do not know the specifics of this work for healthcare professionals in the Covid-19 war related to oxygen levels, lung functioning, blood levels and more. Does the practitioner have what they need to protect themselves and to help their patients? Consistent, sustained work for the patient makes the active involvement phase of the cycle.

Sometimes while in the middle of work, previous experiences with other patients enter one’s mind. These can be good moments; sometimes they are anxious distractions. For example, Surgeon Henry Marsh wrote, ‘Sometimes at these moments [when doing surgery] my past disasters with aneurysm surgery parade before me like ghosts. Faces, names, wretched relatives I forgot years ago suddenly reappear’ (March, 2014).

Phase three: felt separation

This is about leaving the intensity of the direct work with suffering patients and colleagues on the team. Some endings are highly satisfying and joyful, some are just another day, and others are deeply disturbing with anguish, remorse, guilt and frustration. Some practitioners develop separation rituals for themselves. These may involve internal thought processes such as thinking about the work with the patient in a certain way or external events like a short walk down a hallway. Perhaps the ability to separate well is a key attribute for long-term professional vitality in health care.

Processing the trauma during the felt separation phase

A recent article, Death is our greeter; doctors, nurses struggle with mental health as coronavirus cases grow (Jervis, 2020) clearly describes the need for processing what happened during the hour, shift, week, month. We do this alone through reflection, self-awareness, being mindful, and sometimes through journaling. It is also the time to connect and debrief with a trusted mentor, supervisor, or colleague.

Helge Ronnestad and Thomas Skovholt with others conducted a many decades-long, multi-part research program on professional development (Ronnestad & Skovholt, 2016) and described how, after experiencing difficulties or challenges, one option is premature closure, which is cutting off thinking, feeling and talking about the experience; then there is inadequate closure, which is constantly re-experiencing the difficulties or challenges, and there is functional closure, a way to process the experience, learn from it and then move one with healthy emotional boundaries.

Irish social work professor Carmel Halton has developed peer support groups for those in high stress child custody work (Dempsey & Halton, 2016). During Covid-19, emergency room MD Jay Kaplan provides ‘wellness visits’ for frontline medical staff (Jervis, 2020). Many methods (supervision, peer support, and wellness visits) serve a similar function: To help reduce post traumatic stress disorder-type reactions, discuss feelings of professional vulnerability and the ‘impostor syndrome,’ and increase positive coping and competence.

Here is another kind of positive coping helpful for some.

RA Rilke (1996) described connecting beyond oneself in Book of Hours: Love Poems to God.

Let everything happen to you: Beauty and terror.
Just keep going. No feeling is final.
Don’t let yourself lose me.
Nearby is the country they call life.
You will know it by its seriousness.
Give me your hand.

KP Mendoza, an intensive care unit nurse in New York, was interviewed by journalist William Brangham. Mendoza said: ‘I thought I was prepared to see death. I had seen enough of it within my first year in the ICU. Yet, in the last two weeks, I have seen more people die than most people in their entire lives. Now I am not so sure if death is something I am prepared to see anymore. Death is different now. Death could pick me. Some days I go in fearless, and some days I come out like a coward… waving between confidence and a fear for my life.’ (Brangham, 2020)

Hopefully Mendoza has a chance these days to have clinical supervision with a senior health care professional and also debrief in order to lessen the effects of realities like vicarious trauma and intense loss.

Phase four: re-creation

The term self-care is often used for activity during this phase. The re-creation phase can be understood using many different words that start with the letter r: renewal, rest, refurbishment, repair, restoration, renovation, repair, restitution, and return. Other terms include having fun, laughing, taking a break, time out, and goofing off. Results of one study (Zwack & Schweitzer, 2013) indicated that a key resilience practice for experienced physicians centers on time-out periods that were planned out in advance and happened with a sense of reliability.

The cycle in summary

The Cycle of Caring is a way of thinking of the work and breaking it down into parts, each with a major focus. One can think of seasons in northern climates: Spring with its newness of life, the long summer of growth, then the fall of endings followed by winter of rest until spring comes again. This could be applied, for example, to one hospital shift for a nurse.

Tips for healthcare professionals

Cultivate resilience

Resilience: the ability to bounce back from adversity. We offer this vision for yourself as a way to fight against toxic stew ingredients such as burnout, emotional depletion, caregiver guilt and secondary trauma. Yes, of course this is not simple. Yet the will to be resilient is one part of the puzzle in the struggle between other-care and self-care. Hope, optimism, self-compassion and gratitude are resilience elements to grab onto during the intense adversity of difficult work.

Being connected

A strong web of vibrant connectedness. This is the major finding of Characteristics of Highly Resilient Therapists (Skovholt, 2014b). These highly resilient therapists thrived while helping people in need, just as many emergency room and ICU nurses and doctors do. The strong web of vibrant connectedness gave vitality to these resilient therapists. They were a) drawn to strong interpersonal relationships, b) desired to learn and grow, c) possessed a core values and beliefs framework, and (d) were actively engaged with the true self, and devoted to their own wellness. A recent study of physicians showed that support from friends, family and colleagues helped them to be more resilient (O’Dowd et al, 2018).

Use your own tried and true method

We all have methods of renewal that we have developed over the years and often used successfully. At times of high stress and demands, it can be a good time to bring back an oldie but goody way that has worked for you in the past.

A few examples: shooting baskets alone, taking a long, slow bath, doing art and being in flow, watching a movie with your partner, working in the garden, petting your dog, talking to a good friend, drawing with your children, listening to soothing music, dancing in your home, special food after a difficult day. What works for you?

The key is that these are your methods. Maybe even double down on an old favorite for renewal; your own guide for hard times. The list is endless, but the important tip here is to actively use what you have learned in your life as your guide. When the car runs out of gas or electricity it stops!

Self-care

One way of assessing high work stress is when demands are high and control is low. When constantly in high demand and low control, one’s body can go into a hypervigilance state. One small part of the solution is physical activity which can ‘burn off ’ the effects of stress and kick start the ‘feel good’ reaction many have when they get the heart rate. Use slow, deep breathing – in and out – to reduce high mind and body stress. Slow, deep breathing is the single best method to reduce the body’s anxiety response. Eating nutritiously, having a warm shower, and cardiovascular exercise are all common suggestions in the self-care arena. We can all read about these methods; the key is regular use of self-care strategies to battle against the toxic stew so that the healthcare professional can show great compassion when standing in human suffering.

Relish the small victories

It is wonderful if one can relish the honorable work of healthcare. That does not mean every event feels worthwhile or successful. The novice often dreams of quickly changing lives. The reality is much different – more like slow cooking with starts and stops. It is important to relish the small victories. Time goes by, and the next challenge arrives.

Regarding the nourishing qualities of meaningful, honorable work with suffering people, Surgeon Henry Marsh writes: ‘This is the story of an all-encompassing love affair, and an explanation of why it is such a privilege – although a very painful one – to be a neurosurgeon… the operation was elegant, delicate, dangerous, and full of profound meaning. What could be finer, I thought, than to be a neurosurgeon (March, 2014)?

Thank you and words from Maya Angelou

We offer our deep thanks to healthcare professionals throughout the world for your work during these days while working during the worldwide pandemic.

No sun outlasts the sunset but will rise again
and bring the dawn.

Maya Angelou

Acknowledgements

We appreciate critiques of earlier drafts of this open letter by Dr Frances Goodhart, Dr Wanda Malcolm, Rebecca Smith, RN, Johnathan Teigland, and Lisa Yost, MPH.

References

1 The British Psychological Society Covid-19 Staff Wellbeing Group has published a helpful guide The psychological needs of healthcare staff as a result of the Coronavirus pandemic. Available at www.bps.org.uk/news-and-policy/psychological-needs-healthcare-staff-result-coronavirus-pandemic

Beyond Blue (2013)National Mental Survey of Doctors and Medical Students in Australia. Available at: https://medicine.uq.edu.au/files/42088/Beyondblue%20Doctors%20Mental%20health.pdf (accessed 21 April 2022).

Brangham W (2020) Interview with KP Mendoza, PBS Newshour, April 24.

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Gawande A (2007) Better: A surgeon’s notes on performance. Henry Holt and Co (pp 4).

Jervis R (2020) Death is our greeter; doctors, nurses struggle with mental health as coronavirus cases grow. USA Today, May 3.

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Junger J (2011) War. Hachette.

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Raiji V & Raiji M (2020) Cited in J Kantor, When a crisis arises, what’s a doctor to do? New York Times, April 18, pp A12.

Rilke RM (1996) (A Barrows A & J Macy J, trans) Book of hours: Love poems to God. Riverhead Books, (pp 53)

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Spencer C (2020) Cited in J Kantor When a crisis arises, what’s a doctor to do? New York Times, April 18, p A12.

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