Gertie Quitangon, MD

Coronavirus disease 2019 (COVID-19) blindsided the world. It exposed gaps in public health emergency planning at every level, including in the strategic planning to support mental health and wellness. Studies of the SARS and 

 epidemics as well as natural disasters have taught us 

 about the importance of planning for and responding to the mental health needs of health care and frontline workers.

 Thus, this is a pivotal moment, a chance to implement systems and structures for staff support in every organization and advance staff wellness and resilience initiatives.

The literature on disasters and public health emergencies describes pervasive emotional distress, feelings of extreme vulnerability, uncertainty, and threats to life, particularly during the rapid spread of an outbreak.

 A recent COVID-19 web-based survey supports this finding. More than 40% of respondents reported symptoms of depression, anxiety, traumatic stress, substance use, and suicidal ideation. Symptoms were notably elevated in black and Hispanic individuals, essential workers, unpaid adult caregivers, and those with psychiatric conditions.

 research has shown that, ultimately, most people are resilient even after the most severe traumatic event.

 In the immediate aftermath of large-scale catastrophes, a majority of negative mental health symptoms are recognized as distress reactions to intense and overwhelming events. They are not pathologized or labeled psychiatric disorders. The disaster literature emphasizes the importance of acknowledging the normality of distress reactions, identifying high-risk populations, promoting effective coping and adaptation strategies, and encouraging overall wellness and resilience.

 Disaster mental health assistance during the acute phase is often more practical than psychological in nature. In this case, such assistance includes Centers for Disease Control information and updates, access to food and cleaning supplies, access to COVID-19 testing, protective equipment, financial assistance, and links to community resources.

After the acute phase of the disaster, long-term stress responses can emerge. Lancee et al.

 that 2 years after the SARS outbreak, health care workers who treated these patients had elevated rates of smoking and drinking, absenteeism due to stress or illness, decreased face-to-face contact with patients, and decreased work hours.Yet rates of depression, posttraumatic stress disorder, and other mental illness were not elevated. This is consistent with existing research, which has found that the long-term impact of massive 

 is predominantly in the range of subsyndromal stress responses rather than an increase in psychiatric morbidity. Limited long-term studies suggest that post-disaster symptomatology peaks in the first year and then declines, but the course of recovery is variable.

 The challenge for mental health clinicians is to distinguish normal distress reactions to catastrophes from exacerbation of existing mental health susceptibilities or new-onset disaster-related pathology.

Disaster trauma is characterized by exposure to personal loss and community disruption. Cultural, political, and socioeconomic factors all influence the shared 

 Looking through a disaster trauma lens, a better understanding of the emotional stages of public reaction can help: anticipate community responses to large-scale catastrophic events (

), identify the changing goals of recovery at different phases (

), and inform mitigation strategies. It is important to note that the timing of the phases is fluid. They do not occur in an exact sequence. Phases can overlap and move forward or back across a timeline, depending on the type of disaster.

 depicts the stages of public reactions to natural disasters like 2012’s Hurricane Sandy and even the 9/11 terrorist attacks in 2001, but the community response to a pandemic seems more unpredictable. The immediate COVID-19 experience in New York state in the spring of 2020 was marked by safety concerns, deaths in the thousands, food and job insecurity, financial hardships, and anger at government response. We do, however, see a heroic phaseexemplified by the emergence of heroes, such as Anthony Fauci, MD, on the national level and Governor Andrew Cuomo in New York state. We then witnessed community cohesion typical of the honeymoon phase as New Yorkers connected with each other from stoops, windows, terraces, and rooftops, all cheering for frontline workers at 7:00 PM each night to show gratitude and appreciation.

New York successfully flattened the curve by the summer. The number of daily deaths fell dramatically, from a high of nearly 800 per day across the state down to none in New York City by June. Now the focus is shifting to economic recovery, while keeping community viral transmission low and bracing for a potential second wave. This could be the beginning of the reconstruction phase: figuring out a new normal and how to live with a persisting virus. Disillusionment is certainly felt when other states are unable to control the virus, in spite of the availability of immense resources and clear and concrete directions from world-class health experts to wear 

, avoid crowds, maintain social distance, and wash hands.

 that during an infectious disease outbreak, the operational response of an organization is likely the single most important factor influencing staff perception of both stress and safety.

 Traumatic events can disrupt feelings of safety, trust, control, esteem, and intimacy. As a result, staff can exhibit maladaptive behaviors or experience traumatic stress symptoms.

 Best practices to mitigate the disruptions and support staff during a pandemic involve 4 key elements: leadership, communication, education, and social support.

 Strong leadership and supportive teams influenced the resilience of health care workers during the SARS and Ebola outbreaks.

 Capable and effective leadership over the course of a major disaster makes staff feel safe and supported by the organization. Best practices include:

Visible and prepared leaders at organizational, departmental, and team levels.

Setting the tone for a positive and supportive organizational culture.

Skilled assessment of team strengths and weaknesses.

Proactive outreach and crisis support from all levels of leadership.

Creativity and innovation in increasing staff resilience and reducing stress.

Role modeling infection control and safety practices—wear masks, practice physical distancing, and wash your hands.

 is communication, coordination, and collaboration.

 Delivery of clear, transparent, timely, trustworthy information in a rapidly evolving situation is essential. Organizations should be prepared to:

Communicate timely and trustworthy COVID-19-specific guidance.

Acknowledge and normalize feelings of anxiety related to the pandemic.

Communicate efforts to address the negative impacts of the pandemic, including financial concerns.

Communicate supportive organizational practices (eg, working from home, flexible work schedule, reduced hours, job rotation, location rotation, availability of PPE, testing).

Widely disseminate available self-care and wellness information and resources.

Training and education on the issues of infection control, disaster mental health, and the disaster response system increases confidence and moderates the risk of stress. Just as Federal Emergency Management Agency (FEMA) provides appropriate resources and training for disaster responders before deployment, organizations have a responsibility to provide education and training to better prepare for and respond to a pandemic. Organizations should be prepared to offer staff:

General information on disasters and pandemics.

Education on infection control and universal precautions.

Targeted education on key sources of distress from COVID-19 (eg, quarantine-related distress, fear of contagion, concern for family, job stress, financial concerns, interpersonal isolation, stigma).

Studies indicate that social support, both personal and professional, is a consistent protective factor and a strong mitigator of emotional distress in the wake of a massive disaster.

 Unfortunately, the battle against COVID-19 calls for decreased interpersonal contact. Quarantine, physical distancing, and remote and virtual work have all increased social isolation. This unprecedented public health crisis requires creativity and innovation to restore a sense of community and connectedness. In order to provide much-needed social support during difficult times, organizations should prepare to:

Hold virtual meetings and virtual lunch/coffee breaks/happy hours to improve team cohesion and morale.

Build in formal time during work hours for peer consultation to reduce feelings of isolation and increase feelings of efficacy.

Use in-person or virtual service meetings and huddles to build relationships and improve responsiveness.

Establish buddy system to check and balance each other’s stress level.

The scarcity of existing research on staff support and mitigation strategies during pandemics presents an opportunity to develop new programs that can be tailored to specific organizational contexts and cultures. Evaluation of best practices and robust analysis of the impact and sustainability of staff support plans during COVID-19 can inform future strategic planning and policy recommendations for staff wellness and resilience.

is clinical assistant professor of psychiatry, New York University School of Medicine and psychiatrist at the Department of Veterans Affairs New York Harbor. Dr Quitangon discloses that she receives royalties from Routledge for her book

 Vicarious Trauma and Disaster Mental Health: Understanding Risks and Promoting Resilience.

— The author wishes to acknowledge Mary Docherty, MA, MBBS (Hons), MRCP, MRCPsych, for her work in planning and development of the COVID-19 staff support response at St Thomas’ Hospital and King’s College Hospital in London, England.

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Vicarious Trauma and Disaster Mental Health: Understanding Risks and Promoting Resilience.

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Articles

We have learned that in order to provide much-needed social support during difficult times, organizations should prepare to take certain steps.

Managing Distress in Health Care Workers During COVID-19: Lessons From a Disaster Trauma Lens

Psychiatrists and other mental health clinicians have a distinct susceptibility to vicarious trauma from repeated exposure to aversive details of patients’ traumatic experiences. Understanding trauma has evolved since combat stress was first observed in soldiers returning from war, and the advent of the #MeToo movement heightened awareness of the prevalence of trauma in the general population. The recognition of a wide range of traumatic experiences-physical or sexual assault, motor vehicular accidents, life threatening illness, unexpected death or serious injury to significant others, bearing witness to severe human suffering, natural disasters, war, terrorism-has implications for understanding the vulnerability to vicarious trauma inherent in a clinician’s practice.

Empathy in validating another’s suffering makes the clinician vulnerable. 

 refers to negative changes in the clinician’s view of self, others, and the world resulting from repeated empathic engagement with patients’ trauma-related thoughts, memories, and emotions.

 This construct is based on the Constructivist Self-Development Theory (CSDT) of personality that conceptualizes trauma as a disruption of human development and adaptation, specifically disruption of the basic human needs for safety, esteem, trust, control, independence and intimacy. From the CSDT perspective, the clinician’s efforts to adapt to exposure to patients’ traumatic memories and emotional responses is disrupted. Empathic listening to story after story of human suffering challenges the clinician’s deeply held beliefs, assumptions, and expectations, which can manifest as intrusive thoughts and images as well as other emotional and behavioral manifestations.

Overlapping work-impact concepts: burnout, compassion fatigue, vicarious trauma

There is consensus in the professional community that secondary exposure to patients’ trauma has the potential to negatively affect quality of care and professional well-being. However, the overlapping theories and constructs are not commonly well understood by service providers. In reviewing the literature, the most frequent constructs used interchangeably with vicarious trauma are secondary traumatic stress, compassion fatigue, and burnout.

Compassion fatigue was originally referred to as secondary traumatic stress syndrome observed in caregivers and family members of trauma survivors who mirrored symptoms of PTSD but with lesser intensity.

 The term compassion fatigue, coined by Charles Figley, is thought to be a less stigmatizing characterization than secondary traumatic stress. Defined as empathic strain and general exhaustion resulting from caring for people in distress, compassion fatigue is most often associated with helping professions such as first responders, nurses, physicians, and disaster recovery workers.

 Similar to vicarious trauma, it involves empathic engagement and secondary trauma exposure, which could present as PTSD-like symptoms. Unlike vicarious trauma however, symptoms can manifest without cumulative secondary trauma exposure, and compassion fatigue is not associated with cognitive disruptions.

Unlike vicarious trauma, both compassion fatigue and burnout are not specific to clinicians who work with trauma survivors, but all three constructs describe manifestations of emotional and physical exhaustion. Burnout is defined as a persistent state of exhaustion, cynicism, and inefficacy as a result of work-related stress.

 The central domain of burnout is emotional exhaustion due to high work demands and often presents as frequent absenteeism, chronic tardiness, and underperformance on clinical and administrative responsibilities.

Is vicarious trauma a specific form of burnout?

Vicarious trauma is the only construct that specifically describes a cumulative, long-lasting impact on clinicians’ personal beliefs and world view. However, on closer examination, two of the three domains of burnout-cynicism or depersonalization and reduced sense of accomplishment or inefficacy-describe shifts in cognition, emotion, and behaviors. Vicarious trauma and burnout have been considered conceptually distinct from the assumption that cognitive disruptions associated with burnout are limited to work conditions while the effects of vicarious trauma are wider in scope. There are more polemical arguments about all the overlapping concepts than evidence in the literature to support this assumption. Conducting more research has been widely recommended and the accumulating literature on burnout in recent years could direct the path to conceptual clarity and significant implications for management.

Congress created the Occupational Safety and Health Administration (OSHA), under the auspices of the Department of Labor, to assure workplace safety by reducing hazardous conditions that could cause worker illness and injury. OSHA interventions modify the work environment to minimize job-related risks from exposures to physical, biological, chemical, ergonomic, and psychosocial hazards and stressful work situations.

Vicarious trauma is a psychological hazard for mental health clinicians and safe work conditions should demonstrate efforts at mitigating the effects of exposure to secondary trauma. In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria DSM-5 and they added “repeated or extreme indirect exposure to aversive details of a traumatic event” as a qualifying stressor to meet criteria for diagnosis of PTSD. This criterion supports the assertion that secondary exposure to trauma is a job-related risk and suggests that if left unaddressed, vicarious trauma and burnout could progress to PTSD.

Studies have shown that integrating work safety and wellness programs is more effective in reducing chronic conditions.

 Wellness and self-care practices reduce individual risk-related factors while work safety reduces work-related risk factors. Examples of wellness programs are smoking cessation, weight control, healthy nutrition, physical activity, flu vaccination, meditation, and mindfulness. Combining wellness practices and psychological safety at work for clinicians is a comprehensive risk management approach to prevent vicarious trauma and burnout and foster resilience.

Meaningful action to foster resilience and prevent vicarious trauma and burnout

Integrate vicarious trauma education and training in curriculum

Residency training programs, internships/externships can adopt a primary prevention approach by integrating vicarious trauma and burnout in the academic curriculum. A course on trauma and PTSD is not complete without teaching vicarious trauma and a forum on burnout without discussing vicarious trauma is an oversight. FEMA and SAMHSA have recognized the need to better understand the negative mental health outcomes of disaster work by mandating programs to include training events and support services on compassion fatigue, secondary traumatic stress and vicarious trauma prior to deployment.

Screening is a secondary prevention strategy and many employers screen for workplace stress and offer health coaching, stress management and related programs when appropriate.

 Forensic workers responding to massive disasters undergo screening for stress-related disorders to monitor emergence of negative mental health outcomes.10 Similarly, offering self-assessment and screening tools for vicarious trauma raises awareness of personal strengths and vulnerabilities and establishes a baseline of symptoms that could be monitored over time.

There are a number of standardized tools that can assess symptoms of vicarious trauma (

). Most of these standardized tools were developed to measure other work-impact concepts and has not been psychometrically validated to assess vicarious trauma. However, they have been adapted for research purposes and accepted as screening tools for vicarious trauma. They are not meant to be diagnostic tools. Rather these tools can used to monitor changes in symptomatology longitudinally. Self-administered tools available electronically increases access and privacy and encourages staff participation.

Enhance personal and professional supports

Social support, both personal and professional, is a protective factor and has been associated with a decreased risk of vicarious trauma. Consultation with colleagues and peers has been shown to reduce feelings of isolation and increase feelings of efficacy.

 The role of managers and supervisors is key in enhancing staff support. Managers can use one-on-one supervision to provide support for challenging cases and manage caseloads, ensuring a balance of volume and complexity of trauma patients for each clinician. Research has shown an association between a high caseload of trauma victims and an increased risk of symptoms of vicarious trauma.

 Supervisors can also assist staff in the development and implementation of self-care plans. A survey of therapists and hospital workers revealed that while the majority believed that self-care strategies can reduce the risk of vicarious trauma, very few actually reported using the strategies.

Research has shown an association between a high caseload of trauma victims and an increased risk of symptoms of vicarious trauma.

 Managers can use one-on-one supervision to provide support for challenging cases and manage caseload, ensuring a balance of volume and complexity of trauma patients for each clinician. Supervisors can also assist staff in the development and implementation of self-care plans. A survey for therapists and hospital workers revealed that while the majority believed that self-care strategies can reduce the risk of vicarious trauma, very few reported actually practicing the strategies.

Supportive organizational culture that build resilience

Primary prevention strategies that build resilience begin with the alignment of organizational values with an individual’s goals and values. These values solidify a culture of strong communication, ethical management practices, and visible leadership support.

 Incorporating professional well-being in the organization’s mission and vision and adopting the value of personal, family and work life balance is foundational in guiding behaviors that promote resilience in the workplace.

Dr Quitangon is Clinical Assistant Professor of Psychiatry, New York University School of Medicine and Medical Director, Community Healthcare Network, New York, NY. 

Dr Quitangon reports that she receives royalties from Routledge for her book, Vicarious Trauma and Disaster Mental Health: Understanding Risks and Promoting Resilience.

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The recognition of a wide range of traumatic experiences-physical or sexual assault, motor vehicular accidents, natural disasters, terrorism-has implications for understanding the vulnerability to vicarious trauma inherent in a clinician’s practice.

Gertie Quitangon, MD

Articles

Managing Distress in Health Care Workers During COVID-19: Lessons From a Disaster Trauma Lens

Vicarious Trauma in Clinicians: Fostering Resilience and Preventing Burnout