Past experiences should inform, but not determine, future action. This has been much on my mind as we bolstered outpatient psychiatric services in response to the COVID-19 crisis. The effort has felt deeply personal, as well as professionally imperative. Waiting now for my own COVID-19 test results, keeping physical distance from my family, I suddenly lost focus and momentum. For a fortnight, it seemed to take more energy to pause than to move forward in disaster response and planning. In the quiet moments, thoughts drifted back to a series of experiences that brought me to this moment, and the sense of urgency that has driven (and continues to drive) these efforts.
In 1997, I had the privilege of spending a few weeks in Bosnia doing site visits at Doctors Without Borders’ mental health programs following the genocidal war. One was in Pale, where a team was helping to rebuild a psychiatric hospital that had been abandoned during the war, its patients left to fend for themselves. In the quiet and unexpectedly beautiful remains of the place, two wards were rebuilt, staff rehired, and occupational therapy programs put in place. The vulnerability of this population was one I had never considered before, and it has stayed with me always – as has the evidence that focused attention on a psychosocial problem can change the lens through which both the situation and solution can be assessed. In Gorazde, there was a committed psychologist providing individual and family therapy home visit after home visit: he saw directly the way these engagements could help shift the frame or dynamics to something a bit more adaptive. In Sarajevo, many different types of programs were underway: from community-based efforts and radio shows to trauma-focused therapies. Each component was necessary and complementary. And there was genuine heroism in work done by individuals who stayed grounded in direct patient care.
I ended up in medical school at 31 years old, with the 9/11 disaster occurring on the heels of my white coat ceremony in NY. There was deep frustration in not being able to “really” help then; it obliged me to watch attentively from the sidelines until a decade later, I was immersed in addressing the complex downstream mental health effects of the 9/11 survivors. The medical sequelae of this environmental disaster compounded the intense experiences of lost control that can be central to trauma exposure, including a terrorist attack. And while navigating this program that straddled a public hospital system and the federal government, Hurricane Sandy hit, and we had to evacuate, managing through telephone outreach and a borrowed office or two within our network. A year in Rwanda suggested that approaching a population with complex, varied, but almost ubiquitous trauma exposure was best done through a resilience lens: recognizing how the brain, mind, and body adapted to survive adversity; and exploring what helped and hindered adapting yet again when the external threat abated.
Now in Boston, a new context presents: a pandemic that requires social distancing without social disintegration. Among the many lessons learned from these experiences, three have driven my approach to the response:
1. Prophylaxis may be less sexy but it can make a huge impact. The hardest part of responding to disruption is finding ways to offer our patients the message that they are not forgotten (or, better, proactively engaged in problem-solving). It takes great fortitude for clinicians and administrators to call hundreds of active and high-risk patients to let them know they could still expect a call (and eventually even a video session) with their psychiatrist, social worker, or psychologist at their appointment time. The relief at the outreach was as palpable as the anxiety about the many different ways in which shut-downs and shut-ins would impact everything from medication availability to wages. What does “shelter at home” mean for families struggling with domestic violence or food insecurity? For an individual living alone, whose contacts are primarily those around the neighborhood? Tackling that head-on is part of being in the trenches. Along with Friday afternoon urgent prior authorizations for medications that patients have been on for months. Seriously.
2. Psychological first aid and trauma-informed care remain salient frameworks for building a mental health support structure. Experience will inform our threat salience, capacity for contextual processing, balance of executive functioning, and emotional (dys)regulation. The goal is to foster a sense of intersecting communities while being clear-eyed about the dangers of COVID-19 exposure, infection, and the social disruption the public health response requires. Rapid triage and evaluations can help connect people with the right care earlier, avoiding an unraveling of their sense of self-efficacy and empowerment before getting appropriate treatment.
PTSD is not an inevitability, and post-traumatic growth is always a possibility. There are trauma-related symptoms – shock, disbelief, anger, hypervigilance – that may be a normal response to an abnormal situation: the impact on functioning is key. Few will come through this pandemic unimpacted by the disruptions it has wrought: many will need or benefit from mental health supports ranging from psychiatry to the therapeutic arts. Others may find a new or renewed sense of meaning and purpose in their relationships and work. For many of us, it will be both.
3. Our primary and secondary prevention efforts addressing mental health need to acknowledge that social determinants of health (financial, educational, social) – ones that are driven by policy and programming. These will be crucial in determining the long-term mental health impacts of this situation. We cannot conflate socioeconomic crisis with mental health distress, though they are bidirectional in their impact. We will need a surge in our psychiatric services – alongside crucial political leadership and economic reconstruction.
We already ignored warnings about the physical dangers of COVID, to our peril. We have an opportunity to get ahead of the curve in containing the mental health impacts in its midst (and in its wake). But first, I need my COVID test results.
Nomi C. Levy-Carrick is a psychiatrist.
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