Omar Reda, MD

Even as a psychiatrist, this has been an extremely challenging quarantine season for me, not so much because of the restrictions posed by the mandate to stay home, as I am still privileged to be going to the hospital daily to do patient rounds, my biggest struggle has been watching the toxic effects of the 

 pandemic on many in my immediate social circle, my community, and my coworkers, I called that phenomenon “COVID-20” in my recent article in the 

To read the “Heros Work Here” sign displayed on the entrance of my hospital, then minutes later hear the news about one of my frontline colleagues, an emergency room physician, taking her own life, can throw anyone spinning down an emotional rollercoaster. The cause of death and suffering for the frontline staff is not always the physical complications of the virus, it is rather the toll that compassion fatigue and provider 

 take on their minds and souls, trauma can indeed suck the joy out of life, trauma can literally kill our heroes.

Is it really worth anything to cheer up someone who is visibly caught on fire? Isn’t it our duty as systems and individuals to lend a helping hand to someone who is drowning and ease their burden? This social distancing thing is a very destructive, lonely, and isolating experience if we continue to treat it as a social death sentence rather than what it was intended to mean, a safety measure through keeping some physical distance from others-I am afraid that we have been silent bystanders while this psychological pandemic is killing our heroes. Growing up I was always taught that heros survive until the end and they defeat the “enemy.” I always thought that heros were not supposed to die.

The concept of the wounded healer is very much an unacknowledged reality in the medical field, our invisible wounds are the big elephant in the room that we tend to consciously and subconsciously ignore. The bad news is that ignoring something does not make it go away, if we don’t pay attention to the psychosocial effects of COVID-19, we will spend lots of time cleaning up its messy and heavy legacy.

Early prevention is always better and cheaper than late intervention, those on the frontlines are humans too, even machines need breaks or they will break down. They are family members and have loved ones who they might have sent away or haven’t touched in many weeks for their own protection. It is wonderful that these superheroes who are wearing masks not capes are receiving accolades, gifts, and discounts, but what they might be missing is the human bond that makes all the difference.

 survivor who decided to jump because no one cared to keep eye contact with him, smile at him, or ask why he was on the bridge that day. Let us pay attention to each other, because a small act of kindness can literally save lives.

When a superhero dies, the town turns into a ghost city and the “bad guys” start to spread corruption, when our frontline staff who are the walking wounded and profusely bleeding, physically, emotionally, or spiritually die, we lose as a society, and it is a shame on all of us. The cause of death is for the most part preventable and the remedy is simple, it is human connection, our heroes deserve every drop of it, heroes are not supposed to die.

Dr Reda is a Practicing Psychiatrist, Providence Healthcare System, Portland, OR. He reports no conflicts of interest concerning the subject matter of this article.

Articles

This has been an extremely challenging quarantine season for me, not so much because of the restrictions posed by the mandate to stay home, as I am still going to the hospital daily for patient rounds; my biggest struggle has been watching the toxic effects of the COVID-19 pandemic on many in my immediate social circle.

Heroes Are Not Supposed to Die

I am neither a fear-monger nor a conspiracy-theorist, I am rather quite the optimist, yet I predict a second wave of the 

. COVID-20, if you like, will be a psychological crisis.

My move to “sound the alarm” is based on detecting lots of smoke, not only within my own practice and the sharp increase in the rates of anxiety, fear, depression, despair, anger, grief, substance use, family discord, child abuse, domestic violence, and even suicidal thoughts and behaviors that I see in my patients, but also in the amount of restless energy I feel within my small community, the general public, and the whole nation.

 is a complicating factor here, especially if the crisis continues to drag on with no end in sight. Dealing with protracted traumatic stress paired with the sense of uncertainty about the virus, jobs, schools, and what life and the “new norm” might look like as well as buying into the worst-case narrative depicted by the media, politicians, and “experts” could cast a heavy shadow on the long-term outcome. Trauma forces people into narrow corners of regression and dysfunction, some might shut down while others lash out. However, trauma is a communal affair, and we can and should go through it together, leaning on one another for support rather than judgment, hostility, and “othering.” As healers, we can normalize feelings and channel unhealthy coping: people can be sad but shouldn’t hurt themselves, they can be mad but shouldn’t hurt others.

Following are 19 ways I think, and hope, that if implemented might help us, psychiatrists, mitigate the current situation, then I boldly add a final theme as my conclusion.
	1. Taking the necessary precautions and adhering to the official safety protocols
	2. Reconnecting to oneself and our own version of a high power
	3. Reconnecting with family and loved ones
	4. Checking up on neighbors
	5. Looking after those otherwise forgotten
	6. Clear communication through large-scale 

 campaigns, both online and offline
	7. Supporting people on the frontlines
	8. Brainstorming short and long-term solutions, especially for basic needs in the here and now
	9. Paying special attention to the vulnerable
	10. Advocating for calmness and spreading the message of hope
	11. Focusing on unity and community service
	12. Finding opportunities in during these challenging times
	13. Being part of the solution, not the problem
	14. Focusing on emotional and spiritual needs that are commonly forgotten
	15. Encouraging sharing, rather than hoarding resources and essential items
	16. Collaborating rather than competing
	17. Using all available resources for healing
	18. Focusing heavily on the children and creating healthy and attractive ways for them to unwind
	19. Paying extra attention to self-care

Humanity, you don’t have to be a therapist to be therapeutic, serve wherever you are needed!

 is a Practicing Psychiatrist, Providence Healthcare System, Portland, OR. He reports no conflicts of interest concerning the subject matter of this article.

19 ways I think, and hope, that if implemented might help us, psychiatrists, mitigate the current situation.

COVID-20: A Psychological Crisis

Human suffering comes in many forms and shapes.

Working with interpersonal violence and man-made trauma is something that we as psychiatrists encounter on a regular basis, and we have the tools, confidence, and expertise to engage survivors in meaningful and effective interventions.

 and similar large-scale natural disasters, we have a unique opportunity to explore new territories and play vital roles in helping the public cope and heal.

The mental health consequences of trauma are more than “just PTSD,” and natural disasters come at a heavy psychosocial price. The 

 and mental scars of such experiences can go unnoticed and lead to long-term dysfunction and, at times, transgenerational transmission of trauma.

The suffering might extend beyond classical psychiatric symptoms to include somatic, academic, vocational, and relational struggles. And although most people who survive disasters usually completely recover, there are some that will have a persistent difficult time.

Disasters usually strike the least prepared areas and communities, but, as COVID-19 has proven, industrialized societies are not immune. Disasters tend to overwhelm the existing local resources and there is usually a need to find additional sources of assistance.

As psychiatrists, we can either regress, react in fear, anger, or despair and be part of the problem, or we can choose resilience and become an active part of the solution. But what can psychiatrists really and realistically do in response to incidents of such magnitude?

Using the COVID-19 crisis as an example, here are a few suggestions that can magnify our potential to help and heal ourselves and others.

Psychiatrists do not live in vacuum or behind fortress walls; we are part of communities and we need to be in the frontlines in responding. We should start with our families and expand to neighborhoods, schools, community centers, and places of worship.

 Psycho-education is very important in the aftermath of disasters. Survivors need to know that most of their symptoms are normal responses to an abnormal situation. Triage is also needed to maximize benefit and wisely allocate sparse resources. Psychiatrists can help first responders in differentiating medical and psychiatric symptoms. Psychotherapeutic skills-active listening, calm and non-judgmental approaches, trust-building, establishing rapport, compassion, coping skills, and grounding techniques-also can come in handy. Those skills may help in assessing risky behaviors and addressing unhealthy coping habits, including the use of alcohol and drugs and suicidal or violent thoughts or behaviors. As needed, comfort could be brought to grieving families through the ease with which psychiatrists talk about death and dying. And, in rare circumstances, psychiatrists can judiciously prescribe the use of psychotropics and referral to specialized services.

 Recovery time varies, not only among communities as they try to rebuild, but also among individuals as they try to piece together what happened and make a meaning out of their trauma stories. Recurrence of symptoms is possible at times of high stress; it is important to help survivors understand this so they can be better prepared to deal with symptom recurrences.

 Trauma shatters and confuses the core beliefs that the world is a safe place and that others can be trusted. In the aftermath of disasters, therefore, it is vital to regain the sense of safety and to establish routine, structure, and a semi-normal state so survivors feel they have some control. For example, random acts of beauty and kindness include offering to babysit for those working in hospitals and grocery shop for the elderly as well as sharing limited resources with neighbors. Similarly, helping survivors find their inner strength and pointing out available psychosocial resources, support networks, and their belief system and spirituality is of utmost importance.

To prevent or at least reduce the risk of vicarious trauma, provider burnout, and compassion fatigue, it is essential that we take care of ourselves and encourage other caregivers to do the same.
	Social distancing

To reduce the spread of COVID-19, we have been encouraged to use social distancing; even in our inpatient psychiatric unit we place folks on isolation precautions and limit staff contact. Social distancing, however, does not mean cutting the therapeutic alliance and human bonds. I am a strong believer that:

- The treatment of choice for human suffering is human connection;
	- Being in isolation is a very lonely experience;
	- Having the virus should not be a social death sentence;
	- We need to support rather than alienate; and
	- We need to reach out to our patients, co-workers and neighbors. 

These trying times can offer a golden opportunity to reconnect with our families and loved ones through quality time spent together, opening channels of communication, and building bridges of trust.

Yes, these are hard times, but they get a little easier when we make the decision to unite and go through them together.

is a psychiatrist at Providence Health & Services, Portland, OR.

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These are hard times, but they get a little easier when we make the decision to unite and go through them together.

Exploring the Role of Psychiatrists in Disasters

At the tender age of 6, after losing my 14-year-old sister to brain cancer, my dream was to become a neurosurgeon. I would, however, faint every time I entered the operating room, pushing me to my true calling-taking care of emotional needs. I was meant to work in psychiatry. It is my delicious cup of tea. There is nothing I love more than healing invisible wounds, mending broken hearts, wiping children’s tears, and helping families build bridges of trust, open channels of communication, to reconnect and heal. Here is how I got there.

In July of 1999, I was returning home from a typical day of work as an emergency department physician in my hometown of Benghazi, Libya. I found my father waiting at the front door. He handed me cash and urged me to flee the country immediately. He discovered that my name had ended up on the government’s “blacklist” because of my humanitarian activities and psychosocial work with trauma survivors and their families. Confused and heartbroken, I had only minutes to say goodbye to my family. I never thought it would take me 12 long years to return to my home country, under very different circumstances, trying to help heal the wounds of war and interpersonal violence.

I crossed the Mediterranean in a boat, eventually landing in the United Kingdom. The judge rejected my application for asylum due to “lack of evidence for physical torture.” That theme-to ignore the psychosocial impact of forced displacement-struck me as I continued my journey to the US and became a psychiatrist. Many people dismiss mental anguish and emotional pain as “real” out of ignorance and stigma. Stories of trauma are often hidden behind closed doors and eventually morph into the elephant in many of our rooms.

In February of 2011, I was horrified to learn of a bloody war on the streets of Benghazi. Unable to reach my family, I felt like I was losing my mind. When I finally got hold of my mother, she told me that “orders came to wipe out the city.” I was certain I would lose my whole family to genocide. Mom told me that she loved me and was proud of me-we would meet again in paradise. The voice of my mom and what I thought were her last words haunted me in my dreams-I understood what 

I asked my wife and three children to let me go on a medical mission. With heavy hearts we said our goodbyes, not knowing if we would ever see each other again. I was fortunate to connect with Medical Teams International, a nonprofit organization in Portland, Oregon, that provided me with about half a million-dollars’ worth of medications to take with me.

I took multiple flights and entered Libya through the border in Egypt. The minute Mom saw me, she almost fainted, I last saw her in 2006 in Egypt where she was undergoing treatment for a minor heart attack, and she now looked decades older-a result of the war. I delivered the medications and spent some time working on psychosocial education, training, and capacity-building. The physical wounds were prevalent, and there was too little attention paid to the emotional wounds of trauma and its impact.

Since then, I have been to Libya seven times, working on multiple healing and reconciliation projects. We have used dialogue to bring people on both sides of the conflict together, to grieve and to heal together. Play and art therapy with orphan and traumatized children was the most rewarding experience of my life.

Storytelling: a powerful therapeutic tool

Trauma survivors need to be heard. I was blessed to graduate from the 

 (HPRT) where I learned valuable skills on how to care for refugees and victims of violence. The sacred and private experience with traumatized individuals plays a major part in nursing wounds and mending hearts.

We can do a lot of damage if we fail to listen to patients’ stories. This brings to mind one young woman admitted to my unit who was prescribed antipsychotics for schizophrenia. When I asked her about the nature of the voices, it turned out that she was reliving the memory of “hearing” two women screaming as her father drove drunk and killed them in a car crash. At a young age, she told herself to find the families of these women and apologize on her father’s behalf. It turned out that the diagnosis was indeed PTSD. Ultimately, treatment of therapy combined with a short course of medication management significantly lessened the voices.

In another case, a Syrian boy witnessed his father shot by a sniper, rendering him quadriplegic. The young patient made progress in therapy but continued to fidget with his fingers. When I asked him about it, he shared that he feels like the man of the house now. He massaged his father’s hands every night, and the fidgeting ritual was his way of taking away his dad’s pain.

Most of my work focuses on family bonding and youth empowerment. A theme common to refugees is the family dysfunction caused by trauma and forced migration. Parents often work long hours and more than one job to provide for their children. A young Somali boy was extremely anxious because his father was leaving for work at 6 am and coming home at 12 midnight, seven days a week. Although he provided materialistically, his child’s emotional needs went unfulfilled (an example of losing the American dream while chasing it). These are but some cases of many.

Working with traumatized children and their families and caregivers is an extremely rewarding but emotionally laden and exhausting experience. Violence is ugly, and it leaves heavy and long-lasting imprints on the psyche. Many trauma survivors do not enjoy their life due to their daily struggles with memories in the aftermath. Wounded healers are no exception. For psychiatrists, self-care is vital to prevent vicarious trauma, commonly referred to as burnout or compassion fatigue. We cannot care for others unless we take care of ourselves first. Healers need to know their limits and be assertive and mindful not to carry a load heavier than what they can realistically handle.

In addition to my loving family I use academic writing as a means of catharsis, which helps me cope with the graphic stories I hear of atrocities and the dark side of humanity. My wife and three daughters are the driving force behind the work I do, and they are also heavily involved in the refugee cause.

In October of 2016, I was heartbroken as I flew to Benghazi to spend one final week with my mother in the ICU before she died. I was glad to be next to her in her last hours. I am very much a mama’s boy-she is the one who made me who I am today. She told me to stay busy mending broken hearts. If I cannot be the source of someone’s joy and delight, I should never be the cause of their pain and distress. Rest in peace Mom; I hope to make you proud.

My goal is to help untangle the deadly web of dysfunction and to break the cycle of trauma. I founded Project Untangled (

), a model of psychosocial care for refugees and trauma survivors to help families bond and empower the youth. The objective is to celebrate inner strength, culture, coping styles, and resilience, so they become an active part of the solution rather than part of the problem. Untangled helps heal traumatized individuals, families, and communities through education and training, providing access to safe spaces and culturally sensitive resources and clinical care.

Dr Reda is a psychiatrist at Providence Health & Services, Portland, Oregon.

Many trauma survivors do not enjoy their life due to their daily struggles with memories in the aftermath. Wounded healers are no exception. More in this Portrait of a Psychiatrist.

Author | Omar Reda, MD

Articles

Heroes Are Not Supposed to Die

COVID-20: A Psychological Crisis

Exploring the Role of Psychiatrists in Disasters

Project Untangled: A Journey of Hope and Healing