During the COVID-19 pandemic, many healthcare workers are being pushed to their limits (and beyond) as they selflessly care for patients.
Not only are they under enormous strain at work, they also face the fear of bringing the virus home to their families.
So what can help providers who are feeling exhausted, overwhelmed, or afraid during these difficult times?
Ron Siegel, PsyD recently sat down with Ron Epstein, MD to get his take.
Dr. Epstein: I think there are several, and the big one is uncertainty. There are really two kinds of uncertainty, there is one that we call stochastic uncertainty, meaning you know that, for example, 70 percent of your patients are going to do well and 30 percent aren’t, and you just don’t know which category people are going to be in because it’s such a new situation. The other is called epistemic uncertainty, we just have no idea even what the parameters are. The disease is evolving before our eyes, we just don’t know. So those two kinds of uncertainty interact and really make it difficult for us to predict anything, to be able to understand what’s going to happen to people, to counsel patients, or to even feel like we’re experts. The second is fear, and the fear is for ourselves as well as for our families. Balancing that fear is really tricky because, on a personal level, I’m 65, I may be called in to go into the hospital to take care of people at the end of life with COVID and I am going to be putting myself at risk and not only myself, but also my family, and balancing that, I think for many clinicians is terrifying. The third is really the absence of connection, the fear of isolation, the fear that you’re going to be alone, both for health professionals as well as patients, it’s a fear that we share.
Dr. Siegel: Ron, let me ask you a little bit more about that second issue that you mentioned. I’ve seen this also in my patients who are healthcare providers, that they really want to do a good job, they want to be a good person, they want to address the needs out there, but it’s scary. How might they somehow wrestle with this tension between being the person they want to be, the professional they want to be, and also protecting themselves?
Dr. Epstein: I think, for one thing, you’re not alone, and we’re sharing those fears and dealing with them in a way that’s principled and rational. What I’ve done, personally, is relied on people at the institution to say, “Okay, how are you handling risk based on age of healthcare professionals?” It gets people thinking, and we’re thinking collectively how to do that and what a reasonable risk is and what an unreasonable risk is. The second is to talk with family and I’ve done that personally, I’ve spoken with my wife. We’re aware that I’ve got an aging mother who might need my help, and we’ve made a decision about where to draw the line, in terms of my involvement. The third piece is to really take your own emotional temperature. Like, we’re taking our physical temperature every day, but where are you emotionally and how are your emotions either guiding wise decisions or getting in the way of them?
Dr. Siegel: Do you have any tips for what providers might do when they’re in the midst of a busy day, they’re exhausted, there are all these challenges, and they’re starting to feel super stressed out and overwhelmed? What might providers do when they’re in the thick of things?
Dr. Epstein: Well, I think the first thing is to figure out what you need to do to be physically safe, given the parameters of what’s possible. The second is, when feeling afraid, recognize that we not only have a fearful self, but we also have a robust and resilient self. If you survived medical school, if you survived medical training, you are, by definition, resilient, and we often forget that. The third thing is don’t worry alone. If you’re afraid of something, clearly there’s someone else who’s afraid of the same thing. Decrease your social isolation, even if you’re physically distant. So, call a colleague, call a friend, email a family member, but just try to create a web of connections so that you don’t actually feel alone. Think about ways that you can deal with uncertainty in a healthy way. First of all, don’t deny it. Second, recognize that there are limits to what you know and also what can be known, and try to be comfortable with that, because we’re all in the same boat. Sometimes compartmentalization is good, especially when you’re in the in the thick of things. But that only works in the short term, so we all need to find some way of integrating the horror and difficulty that we’re finding ourselves immersed in each day. A couple of very simple things you can do is find ways of taking brief pauses during the workday. So, when you’re between patients, what do you do mentally? Can you take a breath, can you stop and mentally set aside what’s just happened with a previous patient, so that you can be more aware attentive and present with a patient you’re about to see?
There are also some ways in which you can make a connection with colleagues and patients. Even before this crisis, I counseled physicians to spend the first 60 seconds of any encounter just listening. Just listen to what that other person’s experience is. Take it in, you don’t have to fix it, you don’t have to do anything, but it will enrich your understanding of that person, enable you to be more helpful, and also feel that you’ve made a human connection. Do that with family, do that with colleagues. It may sound paradoxical that when you need things the most, that listening is the thing that you can do the best. But, I would say try it on, see if it works for you. Finally, there are some breathing exercises that can be of help. One is what I call a vagal breathing exercise. It seems to raise parasympathetic tone and lower sympathetic tone. You inhale for a count of four: 1 2 3 4, hold your breath for a count of four, and then exhale for a count of four. It sounds almost too simple, but if you do that repeatedly a few times during the day, it may actually enable you to be your more calm, resourceful, and robust self, as opposed to just experiencing the fear, uncertainty, and vulnerability.
Dr. Siegel: Do you recommend trying that kind of vagal breathing in the midst of things, when you find your heart racing and you start to feel panicky about how to handle a situation?
Dr. Epstein: I would suggest starting in less acute circumstances, so you kind of get the hang of it. But it’s really useful to employ when you feel that the stress level is beginning to go up. And in that context, it’s good to have a little internal “stress meter” so that you don’t start to employ these strategies when the stress is 11 out of 10, you begin to employ them when it gets to about 5 or 6 out of 10. That’s a habit of mind that I think is pretty helpful. A lot of us develop that habit, I mean, surgeons in the operating room, anesthesiologists, ICU doctors, you can’t survive in environments like those without figuring out some way to manage your stress reactions. But you’ve also seen people who’ve managed those situations well and those who haven’t, and you want to be one of those who’s managing it well. I think this is just one simple exercise that you can do. Don’t just either take my word for it or limit yourself to that; think about ways in which you’ve dealt with stress and adversity in the past and bring those to bear. Sometimes, you know more than you think you know, it’s just a question of bringing to awareness those strategies which have been tried and true for you.
Dr. Siegel: Thank you. You mentioned that compartmentalization has a role, that there’s a time to put aside thoughts and feelings. But I’m assuming that self-care, particularly the self-care that we might do after work, when we’re not under the gun, when we’re trying in some way to work with the thoughts and the feelings and the images of the day that maybe were overwhelming at the time, I’m imagining that compartmentalization might not be the optimal strategy then, or is it? How do you advise folks to somehow process what’s happened during the day when they have a few minutes of relative peace at home?
Dr. Epstein: I can tell you what works for me, and I think we all have to discover that. In terms of talking things through, I would be judicious about with whom you do that. So, if your spouse is someone who’s ready to hear those stories from your day, maybe that’s the person, but maybe it’s not. Maybe it’s a phone call to a colleague or just a text message saying, “I had a tough day, just so at least you’re aware of that.” That kind of storytelling can be really useful but I think you need to decide who is the person who’s going to really be present and help you the best with that. For me, I’m a musician, I like playing music – that’s one way of connecting to something bigger than I am. For some people, that might be going out for a run, for some people, that might be hugging their kids. But in terms of the actual impact, there’s both a cognitive impact that is telling the story, what is it that happened, and also the emotional impact. The emotional piece can often be dealt with through social connection and through connecting to something that’s bigger than you are. The storytelling piece, maybe you need to write something, maybe you need to talk to somebody. But again, choose the right person at the right time.
Dr. Siegel: Thank you so much for sharing your insights, this is such a hard time for so many people, for patients, for providers, and I think these tips are wonderful beacons for how we might direct ourselves in these moments of stress. So, thanks so much for sharing them.
Dr. Epstein: Thank you.
Now we’d like to hear from you. How are you helping patients manage their stress and fear during the pandemic?
Please let us know in the comments below.
I clicked on this article only to find it was talking specifically about healthcare workers. Healthcare workers are not the only ones working on the frontline..they are not the only ones pushed to their limits and burnt out during this pandemic. Matter of fact two of my sisters and first cousin who are RNs are on vacation right now enjoying life, living, while me and my fellow work crew have not managed to get more than a day off through this.. we are the restaurant crew. We have been overworked and under appreciated throughout this pandemic. Every single one of us breaking our backs and losing our minds trying to keep up with the turn over this pandemic brought. We have not been given a raise or incentive throughout this and have been dealing with nothing but disrespect from entitled people and customers. Its like people have been calling/coming to our establishment just to take their anger out on us. The majority of our staff including myself have been employed there at least 8yrs and every single one of us are uncertain if we can take another day working through this. It’s also sad that us waitresses who wage $3hr are putting together $100 lunch orders for the nurses at our near by hospital and they tip us Nothing.. Nothing against nurses or healthcare, just stating my current/ personal work experience. Every essential worker at this time is burnt out and being pushed to their limit. Speaking for store clerks, and everyone. People are very mean these days and it’s sad. As an essential worker.. I work everyday until my body hurts, I am mentally being beat up by customers over pandemic rules that I didn’t create, or because wait times are longer than normal, while many of my neighbors and friends are collecting more money and income being unemployed right now. Sorry I’m venting, but hopefully people can take these thoughts under consideration when your in a store or eating out these days.. we are in this together.
I am sorry about your situation
While your sisters who are nurses are vacationing at this time, please remember there are a large amount of us in the medical field who are working night and day and day and night since March to care for these very sick people.
I’m a respiratory therapist. On the front line. In a covid unit. I have worked up to 11 strait 12 hour shifts with one night off, back again to a minimum of 6 start 12 hour shifts back again, 1 night off. We are tired.
My question is this to you…your sisters who are nurses , who are vacationing at this time, what sort of nurse are they, like what department? I know in my medical facility a number of nurses were laid off like in same day elective surgery, that sort of thing….those of us who are in critical care, pulmonary, icu… i can guarantee you we have not seen a total of more than 1 to 2 nights if were lucky off in a row since this began.
Please don’t lump us all together. We are exhausted. Physically exhausted, mentally exhausted…and not just because of the self quarantine restraints that we are under as you mentioned above. Most of us workers who are in the front line would trade ourselves with your situation gleefully for a week.
I’m not trying to lessen what you are experiencing. This is no fun for anyone. But, for a Frontline emergency covid medical professionals like myself, I do believe we have every right to have a writer address my profession, and my colleagues, who have been workinv non stop and who are exhausted in an article.
Also, I would just like to add that those 100 dollar orders that you are putting together for nurses? I can almost guarantee you that that item you are are preparing for them to eat, will probably be the only thing that they eat that day. If they even get to sit down to eat that.
I’m sorry that our extra pay has angered you. While we are all at risk it is not in the same capacity. As a respiratory therapist i am actively intubating these covid patients, putting tubes down their airways, they are coughing all over me, these very positive covid patients. If my epersonal protection equipment were to fail, or the seal broken at any given time in this we are exposed. We are exposed to sick people who we know for a fact have covid.
After our shift; God willing if we don’t happen to have an exposure, we shower, change our clothes, come come shower again and pray to God were not bringing anything home to our family.
I’m sorry our extra hazzard pay does not seem merited to you.
appreciate how to deal with self-proclaimed front-liners who escape the work and left you alone in a situation esp. in COVID times
I think it is so important that the people that we look up to like Dr. Siegel and Dr. Epstein allow themselves to present their unique human vulnerability and share that with everyone. Kudos to both.
We are teaching medical students to interview patients and understand the patient voice — incorporating mindful practice and best practice from the Academy of Communication in Health Care with them.
And trying to build humor into our days with a daily “COVID” joke…
I work in a Canadian mens prison in Spiritual Health. In order to facilitate an environment of calmness, I put together a package with prayers, coloring pages for adults, reflections, colorful photos of nature and Indigenous teachings. Each inmate who wishes to take a package is welcome to whether they are Indigenous or not.
M.M. Indigenous Elder
I like how the professors at Harvard use strengths based theory and feedback theory rather than static “evidence based” theory. Seriously.. It’s very affirming of social work and also of the leadership of Scott Miller who emphasised the importance of soliciting feedback: what works for you? (strengths) What worked for you? (feedback)
Absolutely refreshing! I agree!
Some great ideas thank you
Thank you!! That 11 minute conversation was an packed. We may know many of these ideas, but under stress find it difficult to know where the toes holds are on the wall! Thank you for this guidance. Without having said a word, I’m sure the listener (as myself) felt the listening to the reality we are facing had already been accomplished!
Excellent short interview – focusing on resilience
Helping patients and myself one step at a time.
I do the pause between the patients – it’s when I finish the complete on the note or dictation . I move on to call a colleague who consulted me for palliative care. Share what I learn with them.
I also when possible offer to do FaceTime with families, some do refuse for various reasons, sadly. Others do- brings some closure and peace to me and to them.
It’s hard for me to see families who think covid is a death sentence – they want me to “do nothing” but start morphine
They mean well. I explain the uncertainty to them about who will take what course, who will get sicker .
I see the nurses struggling dealing with moral distress as do I with some families that are struggling with decline but care is clearly futile
It’s sadness filled day at times
There are good moments
Then i come home to my family – I want to perform well here the most. But I can’t , sometimes I need 2-3hrs to unwind.
I meditate , do yoga 2-3 times a week
Not sure how long I can carry on, I feel guilty about the prospect of a mental health day
Dear Vik Sha, You should not feel guilty for needing to take time to look after your mental health. Everyone needs what you have to give right now, your skill, your perspective, your presence, your reassurance. These all shine through in your post.
You could perhaps reframe guilt at taking time to nurture yourself in the midst of this crisis as wise preservation of a precious resource – You.
Everyone working along side you will be feeling the same need to restore themselves, there’s courage in taking time to do this and giving others permission to do the same.
I’m writing from a very different position to yours at the moment. My heart goes out to you, your patients and your family. You are doing great work, please be kind to yourself and don’t add self reproach to your substantial burdens.
Step out, recharge, recommit, feel your own suffering and allow those who love you to bring you comfort as you clearly do for so many.
Emma.
Having worked in the Dept. of Psychiatry at the University of Rochester for a couple of decades before year 2000, it was refreshing to hear Dr. Epstein speak and realize that the biopsychosocial model of medical education is still alive and well there. The U of R is a very special medical institution.
Thank you for sharing important strategies and making people aware of the importance of taking their own inner emotional temperature.
I am one of a group of therapists who are available for front line doctors and nurses to talk to and even give therapy sessions to if needed. Your tips are important for us to remember and to share.
Invaluable! Thank you both!
I have a dilemma. It is that I want to SHARE this video with front line (and other) workers that I know. I am retired and am not in a work group anymore. I know several old friends from my old front line who are not connected to nicabm. I do not know how to share this freely with them.
Can you help? Or is it so easy I have missed it??
Many Thanks,
Cherie Rawlins
Watch on Youtube and press the share button.
Invaluable! Thank you both!
I have a dilemma. It is that I want to distribute this video with front line (and other) workers that I know. I am retired and am not in a work group anymore. I know several old friends from my old front line life that are not connected to nicabm. I do not know how to share this freely with them.
Can you help? Or is it so easy I have missed it??
Many Thanks,
Cherie Rawlins
I have converted all planned in-office appointments into telephone conferences, which are actually being requested at closer intervals than office visits. As my usual appointments are 2 hours, every 2 weeks; these are now weekly, one hour appointments. Understandably, my clients are unusually tense and worried. I find us often reviewing previously given self-care to them, for venting their tensions with big muscle activities, especially throwing….something hard, like a real rock (especially into the water as we live on the coast) and as they throw it, to label it what it is they are needing to get rid of within, at that moment.
They can also utilize a sandy beach if they have one, to draw a circle and put into it some object or word which represents their fear….then get close to the sand (or pillow if that is being used instead) and repeatedly pound it with big muscle strength. As these are elementary ways to release tension, their very familiarity seems to comfort them as they commonly say,,,,”Oh yes….I remember that one!”
I have found similar needs. Several of my weekly clients, are 2x week for shorter check ins. Or I offered texting/messaging daily with set times I would reply back. Using lots of movement.
Thank you both!
Taking this 11 minutes for myself to listen and connect with colleagues was the best thing I have done for myself today.
I treat many patients during this pandemic and need to remember to take care of myself and have just scheduled a therapy appointment with my therapist for later in the week.
O appreciate what Dr Epstein had to offer. I know from experience that those who have undergone or are still undergoing stress need not just what he suggests, they also need a time to totally let go. To relax deeply and regenerate and recuperate from the stresses. Yes the four in and out breaths can be helpful now and then. They certainly help to get some temporary relief. However the subconscious mind and brain also need some time to be relieved of the accumulation of stress and all its effects. So does the body. So I would be most happy to send to those in the medical field who need a therapeutic respite my Relaxation audio. It has been scientifically proven to be effective. It has two types of relaxation experiences to be enjoyed.
khypno@aol.com to ask for the download.
Thank you Ruth for this platform to stay connected with professionals.
I practice an ancient technique for boosting energy, stamina, and immunity for grounding and a sense of peace within. With breath and conscious alignment of soul, heart, mind and body, my clients experience instant transformation and a greater sense of peace. I also offer TAO HANDS, a powerful transmission of frequency to transform fear, uncertainty, and a sense of isolation into connection with greater universal powers. Please join a FREE INTRODUCTION TO TAO HANDS for Professionals, April 21, 7 – 8:30 pm PT.
Please email me for registration at mgiard@shaw.ca
Tao Hands trainings April 24-26 and July 9-11. Take care of yourself.
Dr. Monique Giard, PhD
Thank you for providing this short video packed with useful tips during this unprecedented time. I really appreciate all of the information you send out. In addition to healthcare workers managing their own fear, I am hearing that they are having a difficult time when returning home after a long, hard, emotionally draining day, and their family does not want them to walk through the door, as they fear all the germs from the hospital or healthcare facility are being brought into their home, putting their health at risk. Healthcare workers have to decide how much risk they are willing to take themselves, with the need for income being factored in, but their decision doesn’t always match up with the risk their spouse or older children are willing to take. Some healthcare workers are living in hotels to protect their families. As frontline workers do their best to protect their loved ones, they may be experiencing resentment and abandonment at a time when they need a great deal of support. These feelings can be more overwhelming than what they are experiencing at work. Any additional information you can provide addressing this issue would be really helpful.
I’ve been using rhythmic breathing with my counselling clients since we moved to online therapy. As I normally work F2F with clients I’m seeing a huge increase in anxiety about COVID and also the uncertainty aspect from care workers, midwives and clients in general. Much of this video content was helpful, acknowledging my own feelings and fears means I can be authentic with my clients as it is such an unprecedented situation. Getting them in touch with their own inner strength is also helping using grounding techniques and somatic body work. Thank you for posting.
there are heroes, heroines, survivors, thrivers, victims, casualties, orphans, compromised, etc etc in this challenge. positions will shift, flip, flow, and halt. seeking recognition for what “they”are “doing” or comparing value of this or that service…? perhaps take a personal inventory? there is no one on earth who wont be affected, suffered or changed. this is the time to do the best you can. wherever, whomever, whenever, however.
I have noticed this as well and have been distressed because the exhaustion from a full teletherapy work day makes me less excited to get on a FaceTime or Zoom visit with friends/family. Vicious cycle.
Thank you for these helpful insights & tips on how to cope & be more effective in being with our clients. However, there is a technical question I would like to submit that pertains to the adjustment many of us are going through in adapting to therapy via tele-health, remote video. I find that after a number of such sessions, I feel an increase of fatigue and some increased difficulty in focusing on cognitive tasks. I thought it was just me until a recent tele-conference with a group of my therapist colleagues, several of whom voiced similar feelings. Also, our son who is not a therapist, but who has been working from home via video connection, says he is more exhausted than when he used to go to his office. Is this experience common ? If so, is there any research to explain why ? It has caused me to alter my scheduling such that I insure that I have frequent breaks during my day. That seems to help somewhat.
find a method of grounding yourself. stretching, walking, shaking it off, take fresh air break from the electronics, technology. often.
Hi John, I hear the same thing from many of my collegues and experienced it myself. As if having just a face to connect to is more intens, or perhaps the absence of a body is.
Would it be possible to get a transcript of this? Thanks.
The realization that we do not all deal with uncertainty the same way and figuring out what works for us and not necessarily for others . Creating a safe environment for everyone and trusting the science of propagation and self protection
The unsung and under publicized heroes are the mental health techs working in drug rehabs. Most have no PPE at all and are working face to face in close proximity to people who have just come off the streets or out of the jails. I never see any mention of them. They also deserve attention at this particularly stressful time.
Great advice and very helpful reminders. Diaphragm breathing always works for me and my clients, along with someone you trust to share your fears and uncertainty with.
Thank you so much!
Please don’t forget healthcare workers and staff of nursing homes and assisted living facilities. They are in lockdown with residents who are confused by their loss of routine and not being able to see family. This will not change until there is a viable vaccine which means their stress will continue indefinitely
Thanks for this. I think I want to use the word mystery… we are learning to live with the mystery as Scott Peck wrote about.
I’ve found the classic prayer of 12 Step Programs (Alcoholics Anonymous, etc.) useful in helping me to keep all the uncertainties in perspective. “God grant me the Serenity to accept the things I cannot change; the Courage to change the things that I can; and the Wisdom to know the difference.”
I am a Psychologist married to an MD. I utilize your resources often and appreciate them. However, I am very disappointed you failed to include those of us in mental health, working alone from home with people who are in a lot of pain. This is very taxing and exhausting I hope you remedy this quickly as my web of connection of other therapists indicate this is a real need… now! Thank you.
Hi Pamela, As a clinical social worker using tele health daily to support clients I would just offer that I am with you, and recognize that we are holding increased stress while at the same time lacking the face to face connection that is so essential to our energy and ability to connect and help clients. It is exhausting. I am up at night worried about my clients who are not doing well and feeling so far away from them. I will use the above strategies to help several health care providers I see who are on the front lines caring for Covid patients, but some can also be used for us – increasing virtual connection to colleagues, taking breaks, breathing and mindfulness. Every therapist I know who is using tele health is reporting this increased stress so you are not alone!
I got some great tools out of this, and agree there is more to say. Thank you for bringing up the systemic aspects of disparities in risk, and uncertainty. I am a mental health nurse, and have been told by my employer that I can’t work from home answering crisis calls as most others in my department have been afforded, due to a lack of computers. I may also be redeployed with very little choice in what position I end up in. The stress of being expected to abdicate my agency and choice, and take on more risk for the benefit of others has made me think a lot about the importance of systemic advocacy for all healthcare workers. I don’t think it is healthy to expect the assumption of disproportionate risk by people without hazard pay and adequate ppe- this expectation amounts to sacrificing a certain sector of workers for the well-being of others, and is a reflection of systemic disparities, not a reflection of personal choice.
Hi, Pamela,
We actually did a program for mental health professionals a couple of weeks ago, and produced this one to address the needs of our front-line medical colleagues.
— Ron Siegel
Love the suggestion to just listen for a minute when first connecting!
I also would invite people to sense the support of the feet far from the head – solidly supported feet. And to focus on the sensations of the expansion of the in-breath on the sides of the torso & and to also sense the air bathing the skin. Noticing sensations of feet & breath expanding connects us to what is supporting us to listen! Mindfulness of sensations also enhances PNS activity and this also supports us in listening openly!
Thanks. Very helpful. Appreciate the fact that Dr. Epstein is speaking from direct experience as a doctor caring for sick patients and living with a multi-generational family. His tips are practical and useful, too. Would love to hear more from him and others on the frontline.
W.H. Utz, LCPC
Geneva, IL
I sent this to my grandaughter in 3rd year medical school.
the Vagal breathing was very useful to be used with client
thnak you.
Thank you so much, this is useful information for everyone, in- and outside medical care area
Thank you so much, this is useful information for everyone, in- and outside medical care area
This is an excellent presentation. The list of tips can, not only be employed in this pandemic crisis, but can equally apply in other stressful situations. I am thinking of adults who grew up with parents who have a serious mental illness (diagnosed or not), the topic of my research and who for some reason need to visit, live with them or be with them. The tips offered by Dr Ron Epstein can be applied in such scenarios. If people are interested in my (easy to read) research on an Unacknoweldged Trauma and Grief or the brief articles I’ve been invited to write by a psychiatrist for an e-publication (which I then put on for free in medium.com), they just need to google my name: Suzette Misrachi.
Thanks Dr Epstein for a terrific encapsulation of what to do and not do.
Stay safe! Suzette
I am having a number of politicians reaching out because they have similar concerns. They are listening to constituents tell their stories of loss, relate their anger, their conspiracy theories and so much more. They are overwhelmed emotionally.
Thank you. Love the reminder that people can be BOTH afraid & resilient at the same time. There are two parts to acknowledge not an either /or. Appreciate the pieces you are putting out for us during COVID. Helps us to help our people. Blessings!!!