Circling in the news recently and being shared widely on social media is the story of Dr. Lorna Breen, a New York ER doctor who died by suicide after having served in the frontlines in treating cases of COVID-19. While Dr. Breen was not a therapist, any member of our healthcare community that dies by suicide is a warning sign to us all about the roles of health care workers at this time. We’ve addressed death by suicide before on our podcast and have openly applauded nurses who are leaving their jobs when not being provided the appropriate personal protective equipment as safeguards in making sure that health care workers are afforded the opportunity to be protected, too. Pointing out these tough decisions that the individuals face continues to focus on making systemic problems be answered by the individuals who work in those systems, and that stems from an absence of quality leadership.
Students of history know there are plenty of examples to show how poorly workers are being managed, whether in physical or mental health care. We don’t want to be hyperbolic in creating a metaphor here by comparing our work to being on the front lines of actual military battle, so we are emphasizing the leadership decisions and not the soldier’s plights highlighted in Dan Carlin’s “Hardcore History” podcast series on the “Blueprints for Armageddon”. In these episodes, Carlin describes the battles at the Somme and Verdun, which are generally considered the two bloodiest battles in the history of mankind. Early in these battles, commanding leadership failed to understand the need to rotate their personnel off of the front lines for mandated reassignment to other duties away from witnessing the atrocities of war. It wasn’t until these rotations were in place that incidences of soldiers with shell shock (the early name for what eventually became post-traumatic stress disorder) went down. With less afflicted personnel, the better that the overall job could be completed.
There are parallels to the current health care industry, and specific concerns to the front line workers in both physical and mental health. This article highlights many of the concerns that we have all been recognizing as important to our field even before COVID-19, and the situation has brought about many of the concerns in relation to COVID-19. But there is a vacuum in recognizing that health care workers of all kinds don’t do very well: take care of themselves first. We all know that we should take care of ourselves, but that doesn’t stop us from not doing it. There are people to take care of; people in need. The article about Dr. Lorna Breen linked above discusses that healthcare workers were working 18 hour shifts and sleeping in the hallways at the hospitals. When left to their own devices, these are the kind of people that will sacrifice themselves to help others—and they need leadership to recognize that they need to have structural stops to prevent them from burning out and dying in this way.
When we present on structural self-care, we talk about the importance of not only providing trauma-informed care, but also having in place trauma-informed leadership. Trauma-informed leadership recognizes that health care workers will not necessarily take advantage of “freely available mental health care service”. There is sometimes stigma for taking advantage of these services, such as being passed over for promotions, as discussed in our episode with Yael Shuman on working with first responders. In addition, there is also the self-sacrificing that health care workers with these mentalities do not readily approach these services. Why spend an hour of my off time talking to a therapist when that could go to sleeping to get ready for the next shift? Trauma-informed leadership recognizes that workers in these positions need to be prevented from making these decisions on their own. Until then, offering services gives the air of being trauma informed without actually being trauma informed.
In SAMHSA’s Trauma Informed Care in Behavioral Services, one of the key components of dealing with trauma is to committing to prevention and treatment of secondary trauma of behavioral health professionals within the organization. Amongst the ways of implementing this kind of workplace environment is to normalize the ideas that secondary trauma happens AND it must be dealt with on a systemic level. This incorporates ideas on implementing regular, consistent trauma informed supervision for all members of the department, but also on having interventions in place to deal with workers. These interventions can be as simple as mandatory paid days off to rotate workers out of constant front line work environments, open staff discussions that foster an agency or hospital-wide culture around secondary trauma, and reduction in work spillover to home or off-duty time by providing check-ins with staff in addition to making mental health counseling an option. Reductions in workloads and being adequately staffed are systemic steps to take, but have thus far been poorly implemented as volunteer nurses and doctors have been waiting around while regular doctors are completing 18 hour shifts. But, as time will tell, these expensive options may be cheaper than replacing burnt out staff members that quit or die.
These problems are already evident in the medical profession dealing with COVID-19 and have been present in both the medical and mental health fields for many years. But like so many other things, these two professions are showing just how fragile the infrastructure actually is right now. If the crush of new cases on the mental health services is only just beginning, we have a rare and limited opportunity to begin these changes in the mental health sector now. Our fields are too busy scrambling to catch up with what we’ve already been unprepared for, we have to look ahead to what’s coming next. Otherwise we’ll see the same kinds of struggles by the individuals, the same kinds of “Oh, someone should do something about that’s” from managements, and rinse and repeat of avoidable tragedy.