How can health care providers take care of themselves, their colleagues and their patients during this COVID-19 pandemic?
First and foremost is recognizing how the pandemic can stir up trauma from the past, said Dr. Alicia Lieberman, a psychologist specializing in trauma. “COVID19 is reawakening traumatic reminders in many of us and in the families we work with. And that often makes it difficult for parents to protect themselves and their children,” she noted.
Lieberman, the director of the Child Trauma Research Program at University of California, San Francisco Zuckerberg San Francisco General Hospital, was one of three panelists in a webinar on Wednesday, March 25, entitled Taking Care of Our Patients, Our Teams, and Ourselves: Trauma-Informed Practices to Address Stress Related to COVID-19. The webinar was organized by the ACEs Aware Initiative and the California Department of Health Care Services. Lieberman was joined by Dr. Edward Machtinger, the director of the Women's HIV Program at UCSF, and an expert in trauma-informed approaches to health care, and Dr. Brigid McCaw, a clinical advisor for the state’s ACEs Aware Initiative.
“In our work we find that if we listen with compassion to the ACEs in these parents’ lives, they gain a new empathy for their young children and they are able to stop the transmission of trauma from one generation to the next,” said Lieberman.
And now during the pandemic, Lieberman said that healthcare providers need to open up about how they, too, are affected by it. “Coronavirus is a new ACE for all of us,” said Lieberman. “We speak a lot about [coronavirus]. But what often remains unspoken in the effort to cope and to help is the fear that we experience and the emotional exhaustion that we can feel when we are driven to act without connection to our feelings. Our work shows us that when we give ourselves permission to feel our deepest fears, and give words to it with someone we trust, like our doctor, what we call speaking the unspeakable, that can heal trauma and promote health in all of us, healthcare providers and patients alike.”
The benefits of giving permission to feel fear and give words to it was illustrated in a recent virtual session that Lieberman had with a client who was stressed out by the behavior of her child as they sheltered in place. “One mother told me that her 5-year-old Kevin really annoyed her by playing again and again that he had the [COVID19] virus and died. He was lying on the floor stiffly, and this just terrified her and she responded by yelling at him and telling him to stop, But he did not stop,” said Lieberman. Lieberman asked the mother what she thought her son might be telling her. And the mother realized that he might be showing that he was scared of dying from the virus.
“While we spoke Kevin came up to the camera and cuddled against her and she asked him ‘are you scared that the virus will kill you?’” The child nodded his head yes. And, explains Lieberman, his mother reassured him by telling him that young children weren’t at risk and all of the precautions they were taking, like staying home, washing their hands to be safe.
“And the next week the mom told me that his play-acting about dying had almost disappeared,” said Lieberman.
Machtinger’s experience with patients – who are adult women with HIV -- has been entirely different. “ I'm seeing almost the exact opposite, like a cavalier attitude towards the virus and death and in some of my patients, and I think this comes from being totally overwhelmed, by their baseline life, which is already chaotic. And now this!. So with them, I try to use humor or I talk about something else for a little while, so they're less overwhelmed and less likely to totally dissociate. I ask very concrete questions about how I can be helpful,” he said.
And a “rule” that he's abided by since he started in medicine is making sure to take off the medical hat and say something to the patient that’s personal and positive. “The other day on a video call I said to my patient ‘that's a totally amazing tracksuit, because it was!’” said Machtinger. “So then regardless of what you accomplish in your visit with them, the interaction is at least positive for both of us. And then next time, they'd be maybe more comfortable revealing themselves, and something troubling or important that we need to talk about.”
The panelists reviewed:
How to recognize trauma — fight, flight and freeze, trauma triggers and how to diffuse them in patients.
How health care providers can break the barriers of physical distancing in their phone and telemedicine visits with patients, and address such challenging issues as domestic violence or coping with isolation.
Helpful resources and handouts to give out to patients for support such as materials from Futures Without Violence, The National Alliance for the Mentally Ill and a list of crisis hotlines, including the National Suicide Prevention Lifeline, the NAMI helpline, National Domestic Violence Hotline and the National Parent Helpline.
Several health care providers attending the webinar asked about strategies or resources to hand out for providers who work with high-risk and vulnerable populations like patients who are experiencing homelessness or domestic violence.
“The very act that they are telling us on the phone or on zoom about these events in their lives gives us a point of entry to ask about the specifics of the domestic violence, for example, or the specifics of their homelessness,” said. Lieberman, who said that during the pandemic access to domestic violence shelters may not be as accessible.
“And so what we have done--because there has been an increase in domestic violence -- has been to ask, and this seems a little daring, but it has worked in some situations, whether we can engage the partner in our conversation, given that they are living together. When we normalize the fact that everybody is so on overdrive as a result of stress, and one tends to react with anger and aggravation to even minor provocations, what we're finding is that often individual therapy becomes family therapy in the circumstances, and it can become an opportunity to create a safer environment for children and families.”