The health care fight against COVID was couched in the language of war from the start of the pandemic. Health care workers were “on the front lines.” Practitioners and staff were “redeployed” from regular duties to COVID work. Front-line workers in major cities were treated to nightly outpourings of support from their communities—pots banging, hoots and hollers, sirens blaring—like mini ticker tape parades.
The similarities go even deeper. Warfare and COVID present complex challenges and stressors, known intimately by those fighting and often unknown to—or unknowable by—those outside the fight. These challenges are ever-changing and unpredictable, yet require full attention and ability. There exists the risk of witnessing pain, suffering, and death, and having to make difficult choices in the face of those hardships.
Despite these parallels, the line between the psychological tolls of war on soldiers and those of the pandemic on doctors and nurses has been less clearly drawn. Health care workers—doctors, nurses, techs, support staff—are leaving the field in record numbers, with nearly 1 in 5 workers quitting their jobs. A main explanation offered is burnout, which was already afflicting healthcare workers in concerning numbers prior to the pandemic. The most recent pre-COVID assessment reported physician and nurse rates of burnout as high as 54 percent. Health care was hard; COVID made it even harder, this explanation goes.
We think a broader, more insidious stress is at play, making the crisis worse not just in degree, but in definition. While this stress does not align perfectly with that experienced on a more literal battlefield, what health care workers are now suffering from is in many ways akin in key ways to what soldiers experience. Importantly, we can take lessons from the support systems set up for soldiers and set them up for healthcare workers, too. The stakes are high: failing to address the experience of doctors and nurses in the pandemic properly will risk the continued suffering of our health care workforce.
The mental health toll of the pandemic on health care workers has been hard to properly define because it does not fit neatly into any one box. Naming what is unique about the experience of fighting COVID—unique from standard health care work, and unique from military duty—is a step towards understanding it. First, practicing under disaster circumstances, forced to ration resources and break the usual bonds of caregiving, can cause moral injury, a sense of failing caused by dissonance between one’s idealized and actual roles. Second, ever-changing conditions, due partly to variability in crisis standards of care between hospitals, create a perpetual sense of insecurity. Third, going home from battle every night and returning the next day, jumping back and forth between realities, can lead people to cope by pushing away or ignoring one reality. Fourth, health care workers have acted as de facto mental health providers, offering a new, and sometimes sole, outlet for their patients’ mental health needs, without the typical safeguards of mental health professionals—process groups, one’s own mental health provider—leaving them less capable of processing their own reactions to the pandemic.
These experiences taken together form a type of trauma. In this sense, it is more accurate to think of health care workers in the pandemic as prone to the immense mental health toll that soldiers are—rather than as simply a burned-out workforce. The comparison isn’t perfect: The familiar meaning of “trauma” often used in the context of the military is the type of acute trauma that leads to Post-Traumatic Stress Disorder, that is, a single terrifying or life-threatening event that produces lasting psychological aftereffects. While health care workers are certainly prone to PTSD—think of the doctor who experiences a traumatic event, like an unexpected patient death—the experience of COVID hews more closely to a different trauma paradigm, the phenomenon of complex trauma.
Complex trauma is a term typically applied to people who experience chronic, unpredictably stressful environments, that is, not one life-threatening event, but multiple events or chronic feelings of being unsafe. Examples include children in abusive homes, or people living through civil conflict. Although our mind and body’s responses to stressful situations are adaptive, a flight-or-fight response meant to protect us in the moment, we are not meant to live with alarm bells constantly blaring. Doing so has long-term psychosocial, interpersonal, and even biological consequences; we can lose our ability to regulate emotions, engage with others, and think clearly, while at the same time having our bodies physically depleted, further worsening our psychosocial experiences.
A portion of individuals in such conditions develop complex post-traumatic stress disorder, or c-PTSD. While “classic” PTSD is marked by reliving the event, avoidance of reminders, and hyperreactivity to common stressors, complex PTSD is characterized in adults by dissociation, difficulty in relationships, destructive behaviors (e.g., substance use), difficulty controlling emotions, and feelings of shame and guilt. For health care workers, it is no leap of the imagination to view the uncertainty, exhaustion, stress, grief, and lack of support as forms of complex trauma. Nor is it a leap to view the resulting dissonance, instability, avoidant coping, disorientation, and dissociation as responses to this complex trauma.
While conceptions of trauma have evolved to include chronic and complex stresses—experiences similar to the fight against COVID—what is happening with health care workers is nevertheless poorly understood because it has been poorly studied. It is therefore truthful to say it is not clear exactly what label best applies. What is clear is that acknowledging this experience as a form of trauma, and beginning to frame our aid for health care workers through a trauma lens, will make more headway than continuing to speak only of burnout and its usual bedfellows.
We can take cues from the military on how to proceed next. The military has evolved tremendously in its thinking on mental health from an era of significant stigma around the topic to now, where mental health is front and center. This was in large part catalyzed by World War II. Anticipating the psychosocial needs of 20 million veterans, the Public Health Service and Veterans Administration grew a formal mental health workforce where there had been none. The resulting system of care is now one of the best mental health service systems in the country. Currently, assessment and treatment of mental health issues are folded into military service. Psychological screening is a routine part of the return from deployment, and treatment of psychological trauma, specifically, begins in the field at the time of injury; both of these are standard of care.
In health care, by contrast, a stigma around mental health persists. Hardship, including psychological hardship, has traditionally been a cultural expectation of the profession, so much so that it is often venerated; a thick skin allows us to navigate caring for the ill and keep providing care. This stigma is one reason mental health needs go undertreated, as health care workers are less likely to seek help. The nature of the stress of COVID only adds to the problem: While a doctor losing a patient unexpectedly is a moment that signals the potential need for help, COVID’s chronic insidious stressors do not necessarily attract attention the same way.
For those fighting COVID, we need an overwhelming response. Having missed the window to be proactive about our health care workers’ mental health needs, now is the time to react. In keeping with the military’s precedent, we propose a national expanded mental health workforce, to be formed by mobilizing a large cohort of existing practitioners and training new practitioners. The hallmarks of care would include: a trauma-informed approach; an emphasis on interpersonal, family-based care; standardized criteria for recognizing those at risk; and more universal mental health screening. Screening and treatment should operate through state or federal means to increase coordination, minimize confusion between different approaches, and avoid exacerbating inequities between higher- and lower-resource systems; an example would be for licensing boards or professional organizations to mediate outreach and treatment initiation. Additionally, a broad investment in research is needed to better characterize the psychological effects of such experiences.
Improving the mental health of health care workers extends far beyond addressing the trauma of the pandemic. A systemic reckoning is needed regarding the known dissatisfiers of health care work—student loan debt, long hours, insufficient pay and time off. Because once we begin to heal the trauma of our health care workers, we may be back where we started: a chronically dissatisfied workforce, prone to high burnout. Ultimately, we owe it to our health care workers to do better than this.
The authors would like to thank Shannon Washburn, Samuel Matias, Jillian Rork, Brad Wolcott, and Chad Emrick for their various forms of service to our country, and for their contributions to this piece. The opinions in this piece are those of the authors and are not expressed on behalf of their respective institutions.
State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.