The covid-19 pandemic is likely to put healthcare professionals across the world in an unprecedented situation, having to make impossible decisions and work under extreme pressures. These decisions may include how to allocate scant resources to equally needy patients, how to balance their own physical and mental healthcare needs with those of patients, how to align their desire and duty to patients with those to family and friends, and how to provide care for all severely unwell patients with constrained or inadequate resources. This may cause some to experience moral injury or mental health problems.
This was the thrust of an analysis by Greenberg and colleagues considering the mental health challenges faced by healthcare workers during the covid-19 pandemic. However, taking into account psychosocial models of mental distress, it is arguably the case that the sections of society now most at risk of psychological injury are those deemed non-essential workers; those whose self-esteem will have taken a battering from being deemed not useful. Significant sections of society will be facing loss of self-worth on top of significant changes to their role in society and within their family context. They may also be facing actual loss of income, loss of social connections, loss of routine and access to their usual social supports. Work, for many, is a source of mental health maintenance. Working psychologically with these populations may be less glamorous than providing psychological support to the newly valorised NHS workers, but critically important for maintaining the psychological fabric of society. This raises the question of where psychological vulnerability in UK society rests now, and in the future, as well as questions about where and in what way the psychological workforce should be deployed.
This is not to say that NHS workers do not need and deserve support. But in doing so it seems important to consider carefully what type of support they might need rather than making assumptions about this. The Association of Clinical Psychologists UK are in the process of developing a response to the forthcoming NHS England vision for expanding the psychological workforce with a view to providing co-ordinated support for frontline NHS workers. Much of the current UK commentary is based on what is known about military personnel responses to disaster and conflict situations. While a useful comparison, it seems important not to assume that working in medical settings under extreme pressure is necessarily the same. Doctors are indeed likely to be at risk of psychological stress as indicated in a brief report from China. Yet, also coming from the Chinese experience, doctors appeared not to want the kind of psychological interventions on offer but indicated that what they really wanted was rest and protective equipment:
…the implementation of psychological intervention services encountered obstacles, as medical staff were reluctant to participate in the group or individual psychology interventions provided to them… Many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies.
If frontline medical staff are to be provided with psychological support it is therefore important to ensure this is responsive to needs and is based on learning from stress among medical staff working in emergency situations in the UK. Previous research I undertook with colleagues in 2003 examined stress in emergency senior house officers. The study found high levels of psychological stress in emergency doctors, levels that were higher than other types of doctor. The study also found that venting appeared to be an unhelpful coping style while active problem solving seemed to be a more helpful coping style to mitigate stress and anxiety.
At the same time as our 2003 study, a psychological group intervention was provided for senior house officers in three emergency wards in London using a psychodynamic consultancy framework. The findings were unpublished but now seem apt to provide some useful learning points for psychological practitioners considering providing support to frontline medical staff.
The psychological consultants delivering the intervention found that the sorts of stressors the doctors were reporting in sessions included lack of sufficient induction or education relating to the work they were being asked to do; they also reported stress arising from the fear of making mistakes, lack of social life as well as lack of recognition or respect felt to be accorded to doctors. The doctors also reported feeling abandoned by government with a sense of working in a crumbling NHS. This is very apt in the face of lack of protective equipment on top of a decade of disinvestment from government and major tensions between government and the NHS e.g. over junior doctors pay. However, public respect for doctors has become very evident in the last few weeks as the nation swelled in support for NHS staff through a national #ClapforNHS.
An issue that arose for the psychological consultants in our research was that the doctors tended to use strategies to protect themselves psychologically such as becoming hardened and cynical; becoming frustrated with patients seen to be time wasting; and objectifying patients. These may be natural responses to having to make hard decisions, relating to the ‘moral injury’ referred to by Greenberg et al. In our study, it seemed to be important for house officers to receive support from more experienced consultants and where there was felt to be a lack of support, belittling, lack of feedback or lack of a sense of team, this led to more stress. Thus, support for doctors needs as much as anything to be within the team or ward system rather than necessarily provided from the outside.
Another key findings was that the psychological consultants reported a general lack of engagement in sessions; they found the content brought by doctors was repetitive and gave the therapists a sense of hopelessness. The consultants reported some sense of mocking or pseudo-compliance with doctors, often using the time to complain and vent unconstructively. This is in line with the quantitative study, suggesting that venting was not associated with good psychological health. It seemed that the sessions were not being used effectively for in-depth reflection and it may even have been harmful to attempt to unravel some of the defences doctors used to manage the stress they were under. It seemed that perhaps doctors really wanted some time to rest rather than reflect along with some simple practical tips for stress management and problem solving.
To conclude, in considering the expansion of the UK psychological workforce in response to COVID-19, it would seem important to consider firstly where in society practitioners are most needed and whether the medical frontline is indeed the immediate priority. Secondly, if deciding to intervene with the medical frontline, it is important to consider what literature tells us about what would be welcome and useful. This may need to be light touch, responsive, and taking into account the whole ward and team system, offering ways to support practical problem solving or team issues with some simple and practical stress relief tips. No doubt later on, some individual medical staff may need more in-depth psychological support but this may not be their immediate priority.