The context of the COVID-19 pandemic places us in unique circumstances that call for flexible and creative ways to help ourselves and each other. Nearly half of Americans polled by Kaiser recently reported that the coronavirus crisis was harming their mental health, the disaster distress hotline had a 1,000% increase in number of calls in April compared with the same time last year, and the online therapy service Talkspace reported a 65% jump in clients, mostly dominated by COVID-19 anxiety (Wan, 2020). Medical practitioners and first responders are particularly expected to face higher rates of posttraumatic stress disorder (PTSD), depression, anxiety, moral distress and burnout (Aghili & Arbabi, 2020).
For existing clients of trauma specialists, the context of an extended pandemic can create a greater risk of anxiety, sense of helplessness, isolation, depression, substance abuse and increases in PTSD symptoms. Quarantine has been shown to result in increased risk of developing mental health problems, particularly when associated with inadequate supplies; boredom; frustration; and a sense of isolation, insufficient or conflicting public health information, fears about personal health or infecting others, and socioeconomic distress or loss (Brooks et al., 2020). Exposure to the virus creates additional potential for grief and risk of stigmatization and rejection by others (Logie & Turan, 2020). Of those who contracted SARS in Asia, PTSD was the most common mental disorder in one study, occurring in 54% (Lam et al., 2009), and in another study, occurred in around 40% of those surveyed almost four years after discharge (Hong et al., 2009). There is also a link between economic upheaval and mental health issues such as suicide and substance use.
The pandemic is already creating significant changes in the lives of mental health providers. For instance, a recent survey of mental health providers by Rutgers University indicated that many are delivering telehealth but with varying degrees of success due to limits in their organizational infrastructure; existing technology; a lack of expertise in staff for more in-demand services; and lack of client access to smartphones, computers or conventional phones. Expenses have increased for staff overtime and purchases of technology, software, apps and PPE, and there is lack of clarity in regulations regarding what is permissible and reimbursable (Rutgers, 2020).
The Cynefin model of complexity and organizational change has informed our thoughts about self-care and coworker support in the context of this pandemic (Snowden, 2010). Its author, David Snowden, has recommended taking a “lessons learning” approach and engaging in “sensemaking” as we proceed in this pandemic to make contextually appropriate decisions and give meaning to our experiences (Snowden, 2020). From the perspective of this model, whereas research findings are useful for navigating simple challenges in a stable environment, when a disaster occurs it creates chaos where those in charge act to establish order and experiment with new solutions. Right answers can be hard to identify as circumstances then move into the complex domain, where cause and effect can change from day to day. Patterns can only emerge with the freedom to try creative attempts at solving problems, accompanied by making sense of rapidly gathered feedback which can inform new responses. This domain can move with time into the complicated domain when analysis of patterns and expertise can be brought in to help leaders navigate complicated challenges. The ability to sense, analyze, respond and act correctly to the presenting environment lessens mistakes and helps guide decision-making. Eventually, the context can return to the simple domain.
In the context of the COVID-19 pandemic, well-being will require us to make sense of, and respond to, the ever-changing contexts in which we find ourselves while at the same time building a capacity to stay present, centered and grounded in fluid conditions where some things are guaranteed and others are not. We will have to experiment, be tolerant of trying new strategies and be willing to falter in informing new choices. There will be situations where decision-making is not based on there being a “right answer” and times when one can only monitor to make fast decisions about necessary next steps from moment to moment. There can be coherent messages, but ones that allow for individual differences. For instance, rather than explicitly and prescriptively telling people how they should support each other, we should instead highlight the importance of coworker support, which can often only arise in the unspoken understandings that result from working together. It is frequently only in moment-to-moment encounters that the right support can happen, if we are aware of its importance and open to being creative in accessing and giving that support.
This model recommends that theory-informed practice is the only way we can cope with uncertainty, in that it can guide actions but still allow for creativity and individual choice. The Stress First Aid Model is an example of such a framework for self-care and coworker support. Its inception occurred at an ISTSS meeting in New Orleans in 2004, where 50 researchers and practitioners gathered to discuss recommended approaches to responding to disasters and public health crises that presented an ongoing threat. As a result, five “essential elements” were identified that seem to be related to better recovery for people in different types of ongoing adverse situations: a) Promoting a psychological sense of safety can reduce biological aspects of posttraumatic stress reactions, positively affect cognitive processes that inhibit recovery, and reduce exaggerations of future risk; b) Promoting calming can reduce anxiety that may generalize to other situations, increase risk for mental health disorders, and interfere with sleep, eating, hydration, decision-making and performance of life tasks; c) Promoting sense of self-efficacy increases a person’s belief in their ability to manage distressing events, principally through self-regulating thought, emotions and behavior; d) Social connectedness is related to better emotional well-being and recovery in many adverse circumstances. It increases opportunities to exchange knowledge essential to disaster response and provides opportunities for a wide range of social support activities; e) Instilling hope including increasing positive expectancy, a feeling of confidence that life and self are predictable, or other hopeful beliefs, is related to more favorable outcomes in a variety of adverse circumstances (Hobfoll et al., 2007).
These five essential elements have since been used to guide a self-care and coworker support model called Stress First Aid, for use in high-stress, service-oriented professions where selflessness, loyalty, a strong moral code and excellence both give one strength and create vulnerabilities such as prioritizing other’s need above one’s own. It uses a stress continuum as its foundation to help reduce stigma, create a common language about stress reactions, and to help recognize when and what actions would be most appropriate as well as how to use the SFA framework over time. SFA renamed the five elements to start with the letter “C” so they would be easier to remember and added two elements to map onto ongoing peer support. The seven actions of the model are: (1) Check: assess and reassess; (2) Coordinate: inform others and refer for additional care, as needed; (3) Cover: get to safety and keep safe; (4) Calm: reduce physiological and emotional arousal; (5) Connect: ensure or restore social support from peers and family; (6) Competence: restore self-efficacy as well as occupational and social competence; and (7) Confidence: restore self-esteem and hope. It has been adapted for military, fire and rescue, public safety, pretrial and probation, rail work and health care settings (Nash et al., 2011; Watson et al, 2013, 2017, 2019, 2020; Westphal, Watson, et al., 2015).
The Stress First Aid model includes supportive or preventive actions and is based on multiple focus groups across different work cultures with those who were identified as good leaders or supportive peers. Their recommended actions were then distilled into strategies within each of the core actions with the goals of prompting people to act or to keep doing what they are already doing. The actions constitute a compendium of helpful self-care, coworker and leadership strategies guided by individual personality style, circumstances and capacity to respond helpfully to others or self. It is not meant to address all ranges of issues, so one of its goals is to help to bridge people to higher care when indicated. It has been well received, with personnel reporting that they feel that both they and their departments are more prepared to provide support for coworkers (Jahnke et al., in preparation). There is also a public-facing version to help reduce stress reactions in patients, clients and customers who are faced with trauma, loss, morally injurious situations or accumulated stress (Gist et al., 2013).
Most of us who are in helping professions get depleted from time to time. We also know that stigma is an obstacle to asking for help, and sometimes mental health providers are the worst at this; we feel like we already have all the tools for taking care of ourselves, so we don't reach out to others. So, in times of extended public health crisis, reaching out to your colleagues to check in and engage in a conversation about potential stress can often be very helpful. We also know it's important to do this over time and not assume that when somebody tells you they are fine that they are going to continue to be fine. Many things can affect stress levels over time, so keep checking in with your colleagues. But the SFA model would endorse supporting coworkers as you can while also pacing yourself. If you can clearly see places where you can make a difference, or you have an opportunity to support others, then take it. But it’s important to also use the model for self-care. If it's not a good time for you to be supporting others because you need a break, think in terms of that balance point. Reach out to others and have conversations but also remember that the dance of self-care versus supporting others is unique to everyone. In the context of the pandemic, it may involve having to structure our lives around the reality of the situation we find ourselves in. It may mean accepting the possibility that things could involve future pain or that things could get much worse. It may involve a “way-finding process” that may include a cycling back and forth between what feels like overreacting and underreacting, and not being sure which you are doing at any given moment.
When it comes to self-care, none of us are experts at managing the stress of an ongoing public health crisis as wide-ranging and severe as this pandemic. Some situations will require problem-solving and finding solutions to emerging situations; some will necessitate seeking guidance and mentoring from others; and some will require seeking comfort in reconnecting with your values, focusing on things you can be grateful for, or connecting with philosophical or faith practices. A long-term approach is required. Check in with yourself regularly to make sure you aren’t taking on too much, ignoring changes in your functioning, changing your expectations for yourself and others, or checking in with others while underestimating your own needs.
Your self-care strategies will likely require adjustment from time to time. You may be dropping your self-care strategies rather than modifying them to fit the current context. You may be ignoring others telling you to slow down or increasing self-medication with alcohol, substances, food or other distractions. Maybe you are starting to get into unhelpful thoughts and habits and not modifying those early enough, or maybe a sense of stigma is blocking you from reaching out to others. When you start to see these behaviors increasing to the point where they are causing problems, pay attention. These are things that can contribute to people having more significant stress reactions. Getting stuck in unhelpful patterns, becoming more disengaged from yourself and others, and continuing to over-work or under-do things that can balance that work might push you further into stress reactions, and if you are not seeking help or expertise at that time you are more likely to stay in a state of high stress.
The strategies that have been gathered by those in high-stress occupations for the SFA model can apply to the current pandemic. For instance, gather as much information as you can about your situation, and be adaptive and flexible based on what’s happening each moment. Be realistic about your goals and be content with just being in the process of building healthy habits and setting necessary boundaries. A part of the process is sharing and learning from each other, consulting with those you respect, creating stability and ways to better imagine a future, finding routines that are feasible and enjoyable within our current circumstances, accepting help when needed, gaining a helpful perspective when we can, being patient with ourselves and others on days when we don’t feel strong, and being strong when we can. It can help to be more disciplined about taking breaks. Seek support from a colleague or friend to help with specific things you may be having trouble with. Start to build your skills a little bit at a time. Make time for the things that help keep you grounded. Make time to think through those values that support you in this specific circumstance and seek mentoring as needed. Adaptation and adjustment will be a moving target whereby we will all adjust to living with uncertainty.
As many trauma clinicians know, it can help to pay closer attention to our own unhelpful thoughts where they potentially keep us stuck or immobilized and start practicing more helpful thoughts. Advice from those who have survived life-threatening situations highlights the importance of cultivating a positive mental attitude that involves improving fortitude, patience and the will, in the worst of situations, to do one’s best. They recommend celebrating your successes, counting your blessings, keeping the mind occupied, searching for meaning and acting upon those things you prioritize carefully, joyfully and decisively. Accept that the environment is constantly changing, and if you encounter setbacks pick yourself up and start the entire process over again, if necessary, in manageable steps (Gonzales, 2003).
If you are experiencing higher levels of stress reactions, it is recommended that you be more disciplined in prioritizing the use of your preferred coping strategies. Identify the places where you are stuck and start to build little toe holds or tiny habits towards greater healthy practices. We all set ourselves up for failure when we try to do too much too soon, so small changes are recommended until you get momentum to make bigger changes. You may need help to find ways to regain lost ground and may also need to consider making bigger life changes, including potential job changes or shifting other things in your life so you can get back to where you need to be. If you find that you have moved into more significant, persistent stress reactions, more formal treatment or mentorship might be necessary. An analogy is physical rehabilitation after an injury, which requires professional guidance and disciplined action on a strict schedule to get back to full functioning.
There is more information about this model on the U.S. Department of Veterans Affairs’ National Center for PTSD website as well as a toolkit of training materials should you choose to use this model for coworker support. There is also guidance for mental health providers about working with clients that can help support you in your work with traumatized individuals. We have a companion helpful thinking table that focuses on how to change potentially unhelpful pandemic-related thoughts into more helpful ones. There is also guidance for families, health care workers and leaders about supporting others during the COVID-19 pandemic, as well as information about supporting others who are grieving. We have a consultation line to help with specific questions, a COVID-related mobile app, the PTSD coach online toolkit and an online course for Skills for Psychological Recovery, a flexible, modular course designed for working with people in adverse situations.
About the Author:
Patricia Watson, PhD, is a psychologist at the U.S. Department of Veterans Affairs’ National Center for PTSD. She has co-authored the Psychological First Aid (PFA) Field Guide, the Skills for Psychological Recovery (SPR) Manual, the Combat Operational Stress First Aid (COSFA) Field Guide and Curbside Manner and Stress First Aid for Firefighters and Emergency Services Personnel, as well as co-edited three books on disaster behavioral health interventions and numerous articles, guidance documents and chapters on disaster mental health, combat and operational stress, early intervention and resilience.
References
Aghili, S. M., & Arbabi, M. (2020). The COVID-19 pandemic and the health care providers: What does it mean psychologically? Advanced Journal of Emergency Medicine, 4(2s).
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet.
Gist, R., Watson, P., Taylor, V Evlander, E., Leto, F., Martin, R., &Vaught, D. (2013). Curbside Manner: Stress First Aid for the Street. National Fallen Firefighters Foundation.
Gonzales, G. (2003). Deep survival. Who lives, who dies, and why. True stories of miraculous endurance and sudden death. W.W. Norton & Company. New York.
Hobfoll, S. E., Watson, P. J., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283-315.
Hong, X., Currier, G. W., Zhao, X., Jiang, Y., Zhou, W., & Wei, J. (2009). Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study. General Hospital Psychiatry, 31(6), 546-554.
Jahnke, S.A., Jitnarin, N., Kaipust, C., Hollerbach, B., Haddock, C.K. & Poston, W.S.C. (in preparation). Evaluation of the Stress First Aid Intervention of Firefighters.
Lam, M. H. B., Wing, Y. K., Yu, M. W. M., Leung, C. M., Ma, R. C., Kong, A. P., ... & Lam, S.P. (2009). Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up. Archives of Internal Medicine, 169(22), 2142-2147.
Logie, C. H., & Turan, J. M. (2020). How do we balance tensions between COVID-19 public health responses and stigma mitigation? Learning from HIV research. AIDS and Behavior, 1.
Nash, W. P., Westphal, R. J., Watson, P. J., & Litz, B. T. (2011). Combat and Operational Stress First Aid: Responder Training Manual. Washington, DC: U.S. Navy, Bureau of Medicine and Surgery.
Rutgers School of Health Professionals. (2020, April 8). Survey of NJ mental health provider challenges and adaptations to COVID-19 pandemic. Retrieved from: https://shp.rutgers.edu/blog/2020/04/29/covid-19-study-of-mental-health-providers/
Snowden, D. (2010) The Cynefin Framework, CognitiveEdge. Available at: https://cognitive-edge.com/videos/cynefin-framework-introduction/ (Accessed: 7 Apr 2020).
Snowden, D. (2020, April 2). Applying Cynefin® and complexity thinking to navigate the COVID-19 crisis. Cognitive Edge Webinar. Accessed at: https://cognitive-edge.com/events/applying-cynefin-complexity-thinking-navigate-covid-19-crisis/
Wan, William (2020, May 4). The coronavirus pandemic is pushing America into a mental health crisis. Washington Post. Retrieved from: https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/
Watson, P., Taylor, V., Alexander, M., et al., (2020). Stress First Aid for Patients and Families. National Center for PTSD.
Watson, P., Taylor, V., Alexander, M., et al., (2020). Stress First Aid for Health Care Workers. National Center for PTSD.
Watson, P., Taylor, V., Alexander, M., et al., (2019). Stress First Aid for Pretrial and Probation Settings. U.S. Probation Office, Federal Law Center.
Watson, P., Lightley, K., Gist, R., Taylor, V., Evlander, E., Leto, F., Martin, R., Vaught, D., Nash, W.P., Westphal, R., & Litz, B. (2017). Stress First Aid for Wildland Firefighters and Emergency Services Personnel. Department of Forestry.
Watson, P., Gist, R., Taylor, V. Evlander, E., Leto, F., Martin, R., Vaught, D., Nash, W.P., Westphal, R., & Litz, B. (2013). Stress First Aid for Firefighters and Emergency Services Personnel. National Fallen Firefighters Foundation.
Watson, PJ., & Gist, Richard. (2015). Stress First Aid for Railworkers. Amtrak Employee Assistance Program Publication.
Westphal, R., Watson, P., Gist, R., Taylor, V. Evlander, E., Leto, F., Martin, R., Vaught, D., Nash, W.P., & Litz, B. (2014). Stress First Aid for Law Enforcement Personnel Instructor’s Manual. Oregon Department of Public Safety Standards & Training.