Mind and Body

‘We are human, battling an inhumane disease’

A reflection on the toll that the coronavirus is taking on health care workers on the front lines, battling despair over what seems to be never-ending death

Image courtesy of Margaret Howard

Margaret Howard, Ph.D., a psychologist at Care New England and former director of the Day Hospital program at Women & Infants Hospital.

By Richard Asinof
Posted 5/4/20
An in-depth interview with psychologist Margaret Howard, as she talks about the trauma for health care workers on the frontlines of treating coronavirus patients, and the urgent need to provide behavioral health services.
How many times have you ever heard a news reporter or commentator admit that they do not know the answer to a question? What happens when the President and his administration attempt to muzzle the Centers for Disease Control and Prevention and prevent the public from learning the truth about what is happening? What is the responsibility of large public corporations to return money from new federal loans that was supposed to go to small businesses? Will the R.I. Attorney General’s office investigate low reimbursement rates for behavioral health and mental health services that undercut existing parity laws?
When Vice President Pence showed up at the Mayo Clinic and refused to wear a mask, disregarding the Mayo Clinic’s policy and his own advance staff’s directive to reporters covering the event, it may prove to be the striking “empathic” break that ends up costing President Trump his re-election.
The stunning visual evidence of Pence’s arrogant disregard of protocols that everyone else in America is attempting to obey cannot be explained away. First, his wife attempted to say that her husband was "unaware" of the policy. Then, Pence himself tried to say that because he is being frequently tested for coronavirus and been found to be negative, there was no concern. Really?
Too many people across the U.S. know too many people who have been unable to obtain tests, whether it be nursing home workers, frontline health care workers, or meat-plant workers. Even the doctor in charge of health care for the U.S. Senate said that there were not enough tests available for the Senators to be tested.
Pence’s willful, arrogant behavior – his refusal to wear a mask while visiting the Mayo Clinic – cannot be justified or explained away. His inability to admit that he had made a mistake was even more telling. As the death toll mounts, such cavalier, reckless behavior will stand out as revealing the truth about the Trump administration’s lack of empathy and responsibility for their own inaction that led to tens of thousands of Americans losing their lives.

PROVIDENCE – Dr. Megan Ranney, an emergency room physician in Rhode Island, has been a constant outspoken source of truth telling, as she and her coworkers have confronted what seems to be a never-ending onslaught of patients sickened by the coronavirus. Her no-nonsense tone of voice is one of the reasons why Ranney has become a frequent “virtual” guest being interviewed on the cable news network shows on CNN and MSNBC.

Ranney’s most recent tweets on Saturday evening, May 2, had an alarming, worried tone of voice. “Observations from EDs across the county: non-COVID-19 volume is starting to pick up again in emergency depts. A large % of that volume is, sadly, trauma. A large % of that volume is, sadly, people who have stayed home for weeks and become REALLY SICK.” [1 of 6]

Ranney continued: “The system is still REALLY broken. Frontline workers still don’t have the tests, masks, or gowns they need. And they’re still understaffed. But consultants are still nicer than usual [thank you to ortho, ophtho, & everyone else who hates our ED phone calls!]” [2 of 6]

Further, Ranney wrote: “The strain is starting to show on nurses & docs & techs. The sadness & anger is seeping out. The larger community is starting to forget.” [3 of 6]

Ranney continued: “I hear people talking abt how we’re worried for when the other shoe is going to drop. The country ‘re-opens,’ but the virus is still here, & none of the underlying problems have been fixed. (PS: this discussion is occurring regardless of personal political beliefs)” [4 of 6]

Ranney then wrote: “Am an eternal optimist but let me be clear. The time is NOW to double down on science, staffing, and #GetMePPE. Opening haphazardly will only widen the cracks in the system. [5 of 6]

“And counting on a miracle doesn’t tend to end well.” [6 of 6]

Trauma in an age of pandemic
Ranney’s alarming tone of voice in her tweets offers a segue to another distressing story that emerged this past week: A medical doctor on the frontlines of New York City’s battle against the coronavirus pandemic committed suicide, her story making the front page of The New York Times. It was a tragic story that resonated with many across the health care system – an emergency room doctor who had been overcome by the experience of constant death and her own personal loss of hope.

In response, a member of the communications team at Care New England asked Margaret Howard, Ph.D., the executive director of Women’s Behavioral Health at Care New England, division director of Women’s Behavioral Health at Women & Infants Hospital, and Professor of Psychiatry and Human Behavior and Medicine at the Warren Alpert Medical School of Brown University, to write something.

What poured forth from Howard, a psychologist who helped to create the “Day Hospital” for mothers at Women & Infants, which offers intensive mental services for pregnant women and women with young children, were five paragraphs filled with an emotional intensity that even surprised Howard herself. She wrote:

“The compass of health care providers points toward understanding disease, ameliorating suffering, and providing hope. The coronavirus pandemic disregards the compass. It is a disease that is ferociously contagious, indiscriminate, and lethal.”

Howard continued: “For so many health care workers the sense of ‘failure,’ guilt, and ineffectiveness in treating the unrelenting flow of patient after patient, afflicted with the virus can become unbearable.”

Tragically, Howard said, “Some providers, overwhelmed, exhausted, and cut off from normalizing supports and routines fall into despair. They lose hope. For some, this loss of hope, coupled with despair, can lead to thoughts of suicide. Some, as we have heartbreakingly learned, succumb to these thoughts and take their own lives.”

Further, Howard wrote: “It is vitally important for health care workers who are experiencing psychic pain to remember that they are not alone. They must reach out, seek support, [and] seek help; because with help they will recover.”

Howard concluded: “What they are experiencing is not a moral, professional, or character failure. It simply means they are human, battling an inhumane disease.”

The missing part of the equation
Of all the words that have been written about the coronavirus pandemic and the reporting attempting to capture the unfolding tragedy, Howard’s words had an emotional resonance – something often missing from the daily news briefings and the coverage by the news media, focused on calibrating the numbers of how many have died, how many have been hospitalized or recovered, as metrics and benchmarks of explaining what has been happening and when the world will return to a semblance of normalcy.

ConvergenceRI spoke with Howard last week, to delve further into her thoughts about the long-term impact on health care workers and the future behavioral health consequences.

When ConvergenceRI asked Howard what question she would ask, if she could, of the Governor, at the daily news briefings, Howard responded with directness. The news media, she said, often tends to focus on the wrong things.

“My question would be: what kind of resources is the state going to bring to bear on insuring that the mental health needs of all affected will be addressed? This goes beyond the doctors and nurses. We don’t talk enough about the housekeeping staff, the CNAs and the dietary staff – all of the people who are working together behind the scenes, who have just as much risk of exposure. What are we doing for these people in the health care system?” Good question.

Here is the ConvergenceRI interview with Margaret Howard, Ph.D., a psychologist who offered her perspective on what is needed to address the behavioral and mental health needs of health care workers. She warned that the blunt force of the trauma experienced by health care workers will not be fully recognized until after the pandemic has receded.

ConvergenceRI: How involved have you become in working with health care workers who have been experiencing the psychic pain of the corona virus pandemic?
HOWARD:
I will be honest with you. I have not been that directly involved in terms of providing the care.

But rather, it swirls around me, while I have been taking care of other types of patients. I have been involved in some of the planning and actually taking shifts for the Care New England telephone program. The last four weekends I have been on call to be able to spend 30 minutes or so, talking to any health care worker who is experiencing emotional psychic stress because of their work in [treating patients during] the coronoavirus pandemic,

Interestingly, we have received minimal calls, We have received very few calls that get bumped to the level of talking to somebody like me.

And, when I talk with my colleagues at other health care systems around the country – just a few days ago, I was talking to a colleague in Los Angeles, who [works in] the USC system, she said the exact same thing is happening with them as well. Similarly, with Lifespan, too.

What we think is going to happen is that the proverbial you know what is going to hit the fan when this begins to die down, when health care workers have a chance to breathe and actually have some psychic space to experience the trauma and grief and whatever, all the emotions that come along with what they’ve been dealing with.

It’s at that point, I would hope that they would reach out to get the support they need, to get the validation they need.

ConvergenceRI: What you seem to be saying is: The immense pressure and demands that everyone is working without respite, in life and death situations, people are “protecting” themselves. But once you get that breathing space, the PTSD will really set in.
HOWARD:
I think it will.

My son and his girlfriend are critical care nurses in Seattle, Washington. They are normally neuro-ICU nurses, but because of COVID-19, which hit Seattle really hard early, they got retrained in medical critical care, So they’ve been taking care of these Covid patients.

Interestingly, I would talk to them and ask them how are you managing this? And, their attitude was: We are doing our job. We are just doing our job. When we come home, we self-quarantine, and we try and block it all out.

Because they are both young, fit and healthy, they are convinced that may be carriers of this [virus], asymptomatic. And, so they are most conscious that once they have left work, to not be near anyone, to self-quarantine.

Maybe it has helped that they live together, so they could offer each other mutual support, as opposed to a lot of health care workers who can’t be near anyone. You know, they are coming home to their families but they have to take off their clothes, go into the basement, shower, and stay there.

ConvergenceRI: Everyone speaks so highly of your work with young mothers and newborn infants. How your work has provided you with insights and influenced your approach? How did Care New England come to turn to you for a statement?
HOWARD:
[The communications team member] sent me an email yesterday and said, basically, can you make a comment?

I was just going to write one sentence, but then, I started, it really came from my heart. I just started writing.

Absolutely, [the coronavirus] has impacted the work we do here, of course, and it has impacted our patients in very profound ways.

Especially for new mothers who are newly post-partum. That in and of itself can be a very isolating experience, under the best of circumstances. And then, when you add the fear of coronavirus, it just amplifies it.

ConvergencRI: Can you explain what you mean?
HOWARD:
For some reason, the post-partum period is the most vulnerable time in any woman’s life, to come down with a depressive disorder or an anxiety disorder.

It’s just a really vulnerable time, we don’t know why; there are no exact answers. For so many women, it is a combination of genetic factors, psychological factors, [such as] sleep deprivation, and role transitions. And, a woman’s own psychological makeup.

Some women may have become symptomatic during pregnancy. And, there are women who say: I’ll feel better once the baby is born. But that doesn’t happen. In fact, they feel worse.

It can be women who have a family history of mood or anxiety disorders. There are women who are particularly vulnerable, along with women who have significant psycho-social stressors, i.e., poverty, lack of support, discrimination.

ConvergenceRI: Many of the workers on the front lines in battling the coronavirus in health care are women. Are there parallels that can be drawn from your work?
HOWARD:
Yes, excellent point.

ConvergenceRI: The health care workers are the ones that are providing care and hope. It can be a jarring experience to experience a great number of deaths.
HOWARD:
Fifty percent of medical providers are women. It could be even higher than that, because the percentage of women is even higher than other in some specialties.

Women are kind of groomed from birth to be nurturers. And then when you layer that with the grooming of a doctor – to be a caretaker and problem-solver and a fixer, I think for women physicians, dealing with these COVID patients who are so challenging, and the virus is so lethal and so capricious, and in some ways, unpredictable, it can be devastating for them.

Because they have this drive to nurture, they have this drive to solve the problem, they have the drive, as all physicians do, to offer hope, and to offer knowledge, you know, we are sorely lacking in the knowledge department at this point. And, we’re learning more every single day about this virus. But it is sort of like, the more that we know and understand, in so many ways, the scarier it is.

ConvergenceRI: It sounds like the old adage: the more you know, the worse things get.
HOWARD:
We need to ask: what are we doing for those people in the health care system [with behavioral health needs]? And what are we doing for family members? And what about the health needs of new moms who have may have an activation of previously treated anxiety disorders.

So many of our patients have anxiety disorders. Their obsessive compulsive disorders have come roaring back in the context of both new motherhood and the coronavirus.

And, what about all the people out there who are in recovery and who are isolated, who are stressed, who are cut off from their normal sources of support?

And what about those people who don’t have a laptop or they may not have a home to do the Zoom meetings.

I think people’s sobriety is at risk. I think people’s mental health is at risk. Everything is really precarious because the things that support and sustain good mental health in the best of times are social connectivity, and routines.

ConvergencRI: In talking with behavioral health and mental health service providers, they have voiced great worry about some of their frontline staff, because of the stress that they are under, saying that there was a lot of suicide ideation expressed by those frontline workers. Is that also one of the under-discussed, not really visible problems that also need to be addressed?
HOWARD:
Yes. Excellent point. I think that I mentioned that in my little blurb I wrote, Health care workers and providers are under tremendous pressure, and certainly behavioral health providers are under tremendous pressure to have it all together, to be taking care of the emotional needs of others.

[Frontline workers are expected] to be calming, to be soothing; to be strategizing with patients and protecting them from suicide ideation.

It begs the question: Who is taking care of the caretaker? Behavioral health people are holding a lot a trauma. So, what we worry about is vicarious “traumatization” that these frontline behavioral health providers are potentially experiencing.

I get this as a psychologist; it’s like there’s this expectation that somehow we have it all figured out, and we have it all together, that we are always calm under pressure. We exhibit grace under pressure. That we’re unflappable, that we have the answers, that we can hold everyone else’s pain and suffering. And not be affected by it. And it’s just not true.

We’re human, too. Yes, we have training. Yes, we have experience. But, for us, I think it is even more important to be tuned into our own self-care.

ConvergenceRI: Are there simple exercises, such as breathing exercises, that can relieve stress, that an actually help punctuate your day?
HOWARD:
Yes, absolutely. I think that there are things that people can do that make a difference. One is to start by attending to physical needs. And I would put at the top of that list: adequate sleep.

Healthy eating, and some form exercise. Movement, and even better, being outdoors.

Some sort of time to be outdoors, and walking, and being meditative when you walk, listening to birds, feeling the sun, or the rain, depending on the day, I think those sorts of activities are very important.

The other thing that is so important for people to do in terms of self-care is to stay connected, to share feelings, even if it is over Zoom, or over the telephone, I think that when people are burnt out [emotionally], and the natural reaction is to pull back and socially isolate.

But, even a 10-minute phone conversation, with a friend or a loved one can make a big difference in staying connected.

The other thing that people need to remember to do is to not compare themselves to others. Don’t judge yourself; don’t compare yourself to others, because everyone is doing the best they can.

Finally, finding time, even if it is for three minutes, a few times a day, to just sit, pause, and focus on breathing. Just put all of your mental focus on breathing in, to the count of four, holding it for a count of four, exhaling for the count of four.

That simple act of focusing on focusing on slow, intentional breathing can actually bring stress levels down.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
HOWARD:
I feel like I’ve done all the talking here. You’ve asked great questions. I just want to really push the mental health aspect.

What is the state going to do to ensure that everyone has access to mental health [services]?

Here in this division, Richard, we worked very quickly to adopt virtual visits for our patients, in fact we are running the whole Day Hospital program virtually now.

We felt we were on a burning platform: our patients could not have a disruption of care. We were fortunate in that we didn’t have to shut down, but that meant we had to be very nimble, and we had to learn quickly how to hold Zoom group therapy sessions, how to hold zoom psychotherapy sessions,

And it’s worked well; it’s hard, it’s worked well.

My biggest fear is that when things die down, the Office of the Health Insurance Commissioner is going to say: OK, it’s back to business as usual [and remove the emergency waivers authorizing payments for virtual visits].

I think it is so important for our patients to be able to continue, if they choose, to have virtual visits versus coming into the office. And, it sets up a conflict if the insurance company is saying, well, we are only going to pay 85 percent of the fee for a virtual visit, versus a 100 percent of the fee for a face-to-face [session].

I am hoping and praying that the Governor and the Health Insurance Commissioner will find a way to use this as platform for true parity and reimbursement, whether it is virtual or in person.

ConvergenceRI: Have you expressed that to Marie Ganim, the Health Commissioner, herself?
HOWARD:
Two days ago, I wrote a letter, an email to her, I especially talked about our Day Hospital program. I got a robo reply.

ConvergenceRI: I would be happy to try and facilitate a dialogue between you and Marie Ganim, because that is what “convergence” is all about.
HOWARD:
That would be so fabulous.

Editor’s Note: The next day, working through Cory King at the R.I. Office of the Health Insurance Commissioner, a conversation was arranged between Commissioner Marie Ganim and Margaret Howard. Stay tuned.

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