Caring for the carers: EMDR in the context of a pandemic
As a Clinical Psychologist working with staff in one of the acute hospital trusts in the Northeast of England and responding to COVID-19, Amie Smith agreed with Professor Brandon Hamber’s keynote address to the EMDR Europe conference which drew parallels between the impacts of COVID-19 and those experienced in conflict. Hamber provided a conceptual framework for thinking about political conflict and mental health.
In his keynote address, Professor Brandon Hamber advocated that therapists take a broad view of trauma and emphasised the need to understand the bigger picture: “when thinking about individual wellness, context matters”, he said. The conceptual framework he provided for thinking about political conflict and mental health chimed with my own experiences and has given me much to reflect on concerning the individual and institutional provision of care to frontline staff.
The psychological offering for staff in acute Trusts is either through in-house psychological support or, more frequently, Occupational Health access to counselling. In my hospital, the Medical Psychology team had sufficient staff to be able to redeploy a team of more than 20 in-house psychologists to provide specialist psychological support to staff as part of the Trust’s Emergency Preparedness Resilience and Response (EPRR) plan during the first wave of COVID-19. Psychological input is provided systemically; psychologists have been recruited to committees that influence plans and policies. For example, they have made recommendations to redeploy staff in teams rather than as individuals and to carry out environmental audits to ensure that the workplace promotes wellbeing. In addition, psychologists offer support on COVID wards and in theatres and critical care departments. They have created and maintain staff “wobble rooms”, dedicated spaces for staff to take time out to look after themselves.
Our work has focused on a three-tiered approach to support the Trust’s 9000 employees, with EMDR woven into each tier. Tier one aims to promote wellbeing and prevent distress through offering psychological first aid. There is, for example, a dedicated helpline and scheduled and ad-hoc drop-ins offering one-to-one and team-talking sessions. We train staff to become Wellbeing Coordinators and Empathic Listeners who can offer a psychologically informed listening ear to their peers. The ‘Handwashing for the Mind’ campaign was rolled out at this level to encourage all staff to use the Butterfly Hug and Four Elements stabilisation exercises. We have uploaded recorded animations of these exercises to the staff intranet, website and YouTube channel and we promote the exercises in posters and screensavers.
Tier two is enhanced psychological first aid to those showing signs of burnout and distress; brief interventions are offered. At Tier two, we implement G-TEP in a three-session format titled 3P: Pause, Process and Prevent.
Tier three comprises specialist psychological support. Staff have access to one-to-one EMDR sessions or referral onward to appropriate mental health services. The Trust has recognised the benefit of psychology input through the pandemic and two permanent dedicated Staff Psychology positions were commissioned before the start of the second wave.
In January 2021, NHS England launched 40 dedicated Staff Mental Health and Wellbeing Hubs, modelled on the Greater Manchester Resilience Hub that was set up to treat those affected by the Manchester terrorist attack in 2017. They facilitate access to mental and physical wellbeing support for health and care staff, including NHS, social care, and care home staff when they need it. Provision varies for each hub but more information can be found here: https://www.england.nhs.uk/supporting-our-nhs-people/support-now/staff-mental-health-and-wellbeing-hubs/
Impact of COVID-19
Healthcare professionals are at high risk of contracting COVID-19. More than 850 UK healthcare workers are believed to have died from COVID-19 between March and December 2020 (ONS, January 2021). Staff reported that the increased requirement for PPE brought challenges such as dehydration, insufficient time for toilet breaks, feelings of constraint, claustrophobia and panic. Moreover, staff were under a constant threat of infection or of representing a source of infection. As a result, many isolated themselves from family or had to cope with feelings of guilt on returning home after shifts. It is estimated that at least 122,000 health service staff currently suffer from symptoms of Long Covid (ONS, April 2021) and are on sick leave.
Although Hamber’s framework was presented in relation to political conflict, the framework is applicable to the context of the COVID-19 pandemic. He stated that “in political conflict, infrastructure has been destroyed, individuals have been physically harmed and suffer psychological impact as a result of conflict. Before violence there was a community, sense of belonging, and a sense of place. At the heart of conflict is the destruction of a community of bonds, of social norms and interactions”. If “political conflict” is replaced by ‘the COVID-19 pandemic’, this statement still holds. Hamber detailed five types of dynamic that interact with each other in political conflict: structural factors, direct injustices/harm, psychological, language, and social ties.
Hospitals are organisations with inherent structures that are fractured by specialty, occupational groupings, professional hierarchies, and service lines (Mannion & Davies, 2018). Research conducted prior to COVID-19 found that healthcare workers are at a higher risk of developing PTSD (Skogstad et al., 2013) and personal and organisational factors contribute to the process of developing secondary traumatic stress in healthcare professionals (Ratrout & Hamdan-Mansour, 2020). Across studies with nurses and medical doctors, personal factors have been shown to include age, gender, years of working experience, education level, amount of trauma training and social support received, personal trauma history, coping strategies, and personality factors (Bock et al., 2020; Bhugra et al., 2019). Organisational factors include job characteristics, working hours, high work demands in combination with limited autonomy and support (Demerouti et al., 2001), peer and organisational support and clinical supervision.
Health Care Assistants
We are now seeing Healthcare Assistants (HCAs) presenting with some of the highest level of symptoms recorded by secondary and primary trauma-screening measures. The vulnerability to stress and trauma is likely to be higher in HCAs due to their age, the nature of their role, the lack of support networks and the lack of training and experience. Many HCAs start their role after finishing school aged 18 or 19 years and a lot of their learning and training happens on the job. They are subject to pressure to act as nurse substitutes at busy times, often without the necessary training (Unison, 2018). It is noted that they enter their jobs with dedication, enthusiasm and with a positive perspective of “doing whatever it takes” to help the patient (Wallang & Ellis, 2017). Healthcare Assistants take direction from qualified staff and their role is defined as “to make sure the patient experience is as comfortable and stress-free as possible” (healthcareers.nhs.uk).
It is likely that this role brings the least power and control over decisions whilst providing a lot of hands-on care. Furthermore, young HCAs have reported that most of their peers and social support networks cannot understand their work experiences, and this has increased feelings of isolation. The severity of illness and the level of grief and death they have been exposed to in the pandemic is unlike anything they have ever experienced or expected to experience in their role. The uptake in staff support from HCAs along with general support and administrative staff has not been as high as those in the nursing profession. Alongside this, these professionals do not have formal training, supervision or structured reflective space to process distressing experiences. We find ourselves having to state explicitly that our staff support is available to all staff and not, as some assume, just to nurses and doctors.
Staff who have been shielding represent yet another vulnerable population, unique to COVID-19. We heard in a recent Schwartz round we arranged for this group about their feelings of isolation, helplessness, guilt at leaving colleagues exposed and feelings of being forgotten. Schwartz rounds are structured forums where all staff come can together regularly to discuss the emotional and social aspects of working in healthcare. We have offered Schwartz rounds virtually and face to face and they have been well attended by hospital staff.
Hospitals as safe places?
Hamber described psychological harm from political conflict due to a distortion of psychological reality. A hospital, he said, was a place you felt safe but, in war, it is no longer a safe place. In COVID-19 the hospital was a place where staff felt most exposed. Staff describe feeling responsible to prevent spread of the virus in the workplace, and the uncertainty and loss of control due to the unpredictability of the virus. They report thoughts such as: “I am here to help people, yet I could be harming them by being a carrier”. Moral injury, defined as psychological distress derived from actions (or the impossibility of implementing actions) that violate personal, ethical and moral codes (Williamson et al., 2020) is a common occurrence. Patients having to die alone without staff or family by their bedsides, staff having to make decisions about which patients access critical care input, are examples of events causing moral distress. Reduction in feelings of psychological safety were also reported, influenced by staff having to change team or work location, often at short notice, due to redeployment.
Hamber also discussed the power of language in conflict. We have heard two dominant discourses threaded throughout the pandemic: conflict and comparison. Conflict of ‘fighting this disease, fighting for resources, fighting for patients’. Comparisons are made of who suffered the most, whose role was harder (ward staff vs critical care staff). Through staff support, these words have been broken down to remove shame and promote compassion, self-care and healing.
The NHS moved ‘recovery plans’, the label of ‘recovery’ was evidence of the expectation that services would revert to normal running after the second wave. This word evoked strong reactions among staff (including members of our psychology team). It seemed too soon to talk about recovery, the word dismissing the pain and losses the hospital had suffered: “we can never recover from this”. Alternative words that sat more comfortably included ‘rehabilitation’ or ‘repair’. In our work we have sought to privilege the voice of the staff wherever possible, we have found Schwartz rounds to be valuable spaces for staff to share their own COVID stories in a contained way. Other ways of sharing stories include writing letters to COVID-19 as part of the 3P programme and a video project for staff to tell their COVID stories to others.
Hamber described how conflict destroys a sense of belonging, a sense of citizenship. At the start of the pandemic, NHS staff were billed as heroes, clapped and celebrated. Donations arrived at hospitals, offers of help and support were plenty as emotions rose. But over time, particularly as a second wave gained force, staff reported feelings forgotten, unrecognized and abandoned by society.
COVID-19 was first framed as a medical problem (helped by a vaccine), Hamber reminded us. Second, it was a behavioural problem (keep your distance, wear a mask); third, psychologically (how you cope matters) and only fourth was it framed as a social, environmental and political problem. He reminded us that when addressing survivors’ needs, therapy will only work when we address the social and political legacies. “By adding to their therapeutic practice a greater exploration of the political and social understanding of the context, therapists added a real enrichment of those therapies. The description of the context and how that context changes is part of how you can conceptualise work with the individual.”
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