Heading to War: COVID-19 Trauma Tutorial
I wasn’t planning to do this.
None of us were planning to do what we’re doing right now.
Yet, here we are. The COVID-19 virus is the biggest curveball most of us will face in our personal and professional lives. It’s going to be traumatic for many. We don’t yet know exactly how we will be affected, and that may be the hardest part at this moment.
This is war, and medical and direct service professionals are on the front line this time. Even if we’ve dealt with illness, death, and devastation, never have we been forced to so fully share in it or with so much uncertainty. Will we become ill ourselves, or need to treat our co-workers as patients? Are we putting our families at risk simply by coming to work? Will we need to make heart-rending decisions about who to care for with scarce resources? My colleagues at one of the best teaching hospitals in the United States are making up their own protocols for changing their clothes before entering their homes, isolating themselves from loved ones, creating ways to procure and optimize use of scarce PPE, readying contingency plans for their own children’s care in case they become ill among other tasks they didn’t learn in medical school or ever expect to need to know. There are so many unknowns, and we all realize that the stakes are high so we’re trying to do everything right without knowing how. It’s stressful, to say the least.
Meanwhile, we’re watching others flaunt the advice of public health officials, downplay the severity of the situation, and even sue elected officials for “restricting freedoms.” It’s been a popular tack to reject science, factual news, and academic “elitism” in recent times, and there is no amount of teaching that can penetrate “fact oblivion” for some. It’s incredibly frustrating for those who understand and believe in science and math, especially the medical community, who know that we will have to deal with the fallout of this dangerous rhetoric making a bad situation worse. It’s hard to go to work every day knowing that not everyone is doing everything they can to keep you safe. We are all trying to educate more now, so that we can hospitalize and bury fewer people later, and it’s not working well enough. Some of us will become ill or suffer unnecessary trauma because of our collective failure as a nation to believe in science and to elect leaders capable of understanding it. Worst of all, there’s little we can do about that in this moment because we are heading to war. We need to put our armor on and ready ourselves for a battle we are ill-equipped to fight but somehow must win. We’re marshalling all of our collective resources.
If you are among the essential workers who will be providing services or care to others during this crisis, first of all, let me say thank you. Thank you for showing up for a job so very different than you expected. Thank you for doing it anyway to the best of your ability despite the inherent anxiety and real risk involved. Thank you.
As a PTSD specialist who has dealt with many forms of trauma over a long career, I have some tips for preparing for, and surviving the traumatic experiences you are facing right now or may be about to face. They are simple and based on personal experience as much as professional exposure. Please accept them in that spirit — we all need to offer what we have, and this is what I have. As a psychologist, I’ve often been asked to help after the trauma. To repair the broken mind. That is not to say that exposure to trauma inevitably results in PTSD. It certainly does not, but it’s not an “all or none” scenario. Some people exposed to trauma experience long-lasting sequelae, while others do not. Most experience at least some symptoms for some amount of time. We have some knowledge of how to prevent acute stress from becoming PTSD, and how early intervention and prevention efforts can lessen the impact. Most of the time, we don’t get any warning that a traumatic event is coming, so we don’t get to use these tools. This situation is unique. We see the tsunami coming. We have a little time to prepare — just a little, but it’s better than none. Maybe — just maybe — we can prevent or mitigate some of its effects by thoughtful preparation now. Want to try?
First of all, a brief introduction. You’re probably wondering, if you’ve read this far, why the unplanned Trauma Tutorial? In these times, everyone needs to contribute what they can using the skills that they have, so I’m putting this together in case it’s helpful to those called to deal with trauma without enough training in it, especially those thrown on the front line — medical professionals, first responders, therapists suddenly faced with patients needing specialists in trauma triage and treatment, front line workers with no trauma training whatsoever — anyone who needs to know more about traumatic experiences, how to prepare for them, how to survive them, and how to treat them. These things I know well. I have a broad view of trauma and curveballs, with much experience. Maybe sharing it will help.
There’s not much time for formalities now, so just the important parts: when I was four years old, I went to sleep one night. When I awoke the next morning, my mother was gone and my life changed instantly from ordinary and orderly to a series of unknowns, instability, survival-level poverty, and subsequent traumas from lack of parental oversight, bonding, or predictability. My mother returned a year later with profound injury, to an aftermath of bankruptcy, divorce, and life as a quadriplegic single parent of four with extremely precarious health. Long story short — I survived and my family survived, both the initial trauma and all the subsequent ones along the way. I’ve published many of those stories elsewhere, and will happily share them with you when time permits. I mention this now only so that you’ll know where I’m coming from and possibly believe what I say. For now, suffice it to say that I’ve been developing and using skills for most of my life that can help others to survive and recover from traumatic experiences and those moments when their lives change overnight. They happen to most of us who have lived long enough, truth be told. Me too. You too. I know. None of us was expecting COVID-19. This is one of those moments. We are going to get through this, but it’s going to be rough for a little while.
My name is Melissa Jenkins, Ph.D. and I’ve been practicing as a clinical neuropsychologist and member of the clinical faculty at the Warren Alpert Medical School of Brown University for 25 years. I’ve treated thousands of patients as a specialist in PTSD and cognition, and provided expert opinions in disability and civil cases. My dissertation was on PTSD in rape survivors, and elucidated the cognitive sequelae of trauma in a non-veteran cohort. Professionally, I specialize in veterans’ disability appeals and policy consultation.
This is not, however, intended to be professional advice. I’m not an expert in curveballs or surviving traumatic events because I’ve seen a lot of patients, or read or written a lot of papers. I’ve lived these, and heard them from so many different angles and through the eyes of many different people in my clinical and research experience, creating a broad view that I’m sharing today in hopes that it may be helpful to you, or to anyone.
I’m especially sharing it now as we stand on the threshold of the unknown because we have a little time. Time to prepare ourselves for whatever unknown is to come. You can’t prepare for every eventuality, but you can prepare your mind to handle whatever comes. There are some concrete steps we can take right now to get ready. We have armor. Weapons. Tools.
This is personal advice, not a textbook. Take what’s useful and leave the rest. Whenever you have time, if ever, share back anything you’re finding useful. Maybe that will help others, including me. We’re all in this together, and it’s a work in progress. Don’t expect perfection.
Heading to Battle: Calm Preparedness
Time is of the essence right now, so we need to triage our preparation. What’s really critical to do right this moment? What will help us to get through this the most? These will vary, so remember to triage for yourself according to your own priorities but be open to the experience of others; perhaps there is something here that you don’t yet realize will be important for you later.
Imagine the Worst-Case Scenario: Believe it or not, this can actually help if you do it right. Most of us are engaged in low-level worry or rumination about that anyway, but instead of helping us to focus, our worry is distracting and unproductive. We spend a lot of energy trying to suppress those thoughts, and to diminish them with logic or defense mechanisms. Instead, try this if you can tolerate it, or to whatever extent you can. Think about the worst outcome full bore. Imagine the worst, whatever it is for you. Prepare for it in any concrete way that you can. Write down your wishes as a will or simply a directive for your family in case you become ill or incapacitated. Make a list of your accounts and passwords. Talk to your partner or family about “what if?” Write a sealed letter for young children to open later. This sounds incredibly grim, but — honestly, it can help to free up a section of your mind from worrying about the “worst outcome scenario.” It’s unlikely to happen, but you’re going to ruminate about it for weeks or months unless you take the bull by the horns and just let it take over for an hour. Imagine the worst. Do anything you can to make it easier for yourself and your loved ones. Do the tangible things you can do now. When you have finished, take a look at the very low probability that that will happen. It is exceedingly low-probability. It’s VERY unlikely that your worst-case scenario will come true. But even if it does, you’re as prepared as you can possibly be. No more rumination or low-level anxiety; these linger in the background, so when other anxiety-producing events occur, it takes less to push us into the critical zone where our functioning is negatively impacted. It’s important to take out the background worry as much as we can. Go to the dark place of your imaginings. Just don’t stay there for more than an hour. In, prepare, out, done.
Prepare to need and accept help. You are not superhuman. Prepare to be less superhuman. Also, do not go it alone. Line up your support network (physical and psychological) and shore up your resources. Think about the logistics of what you’ll need as if you were planning a camping trip; resources will be scarce there, and you need to pack what you need now. The resources that I am talking about are YOU — your time, energy, mental bandwidth, and the stark limitations of being human. Think logistically about what you can do now to save mental energy later.
If you have a moment, order groceries or household supplies ahead. Arrange a carpool to work. Create a group message or email list with family and close friends so you can share information readily. Put your house in order in the literal sense, making sure that you have essentials for survival and as much comfort as you can, will help you to focus on the task at hand in the coming weeks and months. If you have someone who can do this for you, it’s a great time to learn to delegate. Many of us are used to carrying burdens that could fall to others, so it’s a good time to think about what we can delegate and prepare for that. Kids like concrete, specific assignments in times of uncertainty, also. Maybe they don’t normally do laundry; can you teach them how today and ask them to do that every Wednesday? Or to cook a simple meal for themselves, even if it’s PB & J? Maybe you have a neighbor or relative who is suddenly out of work; can they shop for you or do a routine chore that you normally do yourself? Do you have a neighborhood association, Next Door or Facebook group organized by geography? Medical students at Brown are organizing to help front-line providers in this way during disruption of classes; perhaps you can access a similar network of mutual aid at your institution, or within your community. Find your local support streams, and line up the support you may need later. It’s better to have it and not need it than to need it and not have it, so line it up now if you can.
Stock your comfort closet. Comfort items do not need to be stereotypical; bubble bath or ice cream are fine if they make you feel better, but what comforts you? Think about what makes you feel better when you’re not feeling well: Furry slippers? Tequila? Playlists of favorite songs? Chicken soup? Ginger ale? Cigars? Comic books? Whatever comforts you when you don’t feel well, either physically or mentally, get some now. Scoop these up and treat them as just as necessary as toilet paper. Soon, they will be. Share what’s in your comfort closet, if you like. If it works for you, it might work for others. For me, I try to keep on hand a bag of frozen cherries and some peppermint tea because they always make me feel better. If things get really rough, I bake a pie. Really, really rough? Sing (and hope nobody’s listening!) Every marathon I’ve run has had a theme song well-practiced on long training runs. It’s good to have something ready to distract your mind from the pain, whenever that arrives. Long shifts can be a lot like marathons; try a theme song in any genre even if you have to hum it silently until the ride home. Get your physical and psychological “comfort closet” stocked. You’re looking at me funny right now, thinking that this is a “nice to have” but not a necessity. No. This is a necessity for endurance, sanity, and your eventual ability to keep functioning. Pace yourself and stay as comfortable as you can for as long as you can. Remember to use these at regular intervals, even if you have to program them into your calendar or Fitbit. Endurance is key here, and this is more than a marathon. Pockets of comfort are going to be necessities. Stock up the comfort closet as an essential tool to get to the finish line. If you burn out or fall apart along the way, you can’t take care of anyone else so practice self-care regularly.
Practice mental flexibility. Creative reframing. Wildly innovative lifestyle modifications. Coronavirus Life Hacks. Whatever you want to call it. “The way it’s always been done” will not necessarily work right now, but we’re smart, creative, adaptable people. Think broadly about how you can do things now to get the job done under unanticipated circumstances. Put a bureau of clothes in your garage if you’d like to change your clothes there before going in the house. Feed your kids pancakes for dinner once in a while to save on grocery shopping trips. Think about efficiency innovations at home and at work. Don’t worry if it’s unconventional; if it works, it’s acceptable. Share good ideas, we’ll all need them. The important part is to separate the way things are usually done with the way things HAVE to be done. Outside basic safety, there are a lot fewer “have tos” than you think. Be flexible. Prepare to adapt. Be imperfect.
Create an escape valve and practice using it. Do you have a place where you can escape alone for a few minutes? You’re probably going to need one. I recommend one inside your home and one outside but nearby for easy access. Do you have an unoccupied guest bedroom? Cellar workshop? She shed? Corner with a rocking chair? Just as many people need a designated workspace to be productive at home, a designated relaxation spot in your home can help to maintain the right mindset when the world starts spinning. If you can, also identify a spot outside your home that is accessible within a few minutes’ walk or drive. If you live near a public scenic overlook, park, or trail that is relatively unoccupied, scope out a spot that you can access, even if you have to sit in your car. Put a chair in a backyard corner if you can’t leave home easily, or on a balcony or roof. Whatever’s possible. Maybe you already have one. If not, try to visit one now. It helps if it’s familiar before it needs to be. Set this up before you think you need it. Spend a few minutes and get comfortable there before you “need to.” Relax there. Spend a few minutes doing muscle relaxation, meditation, or calm reflection. Pairing relaxation and peace of mind with specific environmental triggers is a useful way to train your brain to elicit that same response when it is most needed. I don’t mean to scare you, but there may be a moment when even familiar surroundings do not feel familiar any more. Having a designated “grounding” place that feels familiar and comfortable will be extremely valuable when that day arrives.
Create a communication network inside your circle of co-workers.
Your co-workers will directly share your experience, so they may be your best source of emotional and physical support but that doesn’t always happen spontaneously, or at all. Do you have a formal peer support network? Can you throw one together? Maybe HR is thinking about this already — or you could suggest it. Early intervention and social support are among the best ways to prevent PTSD after critical incidents. Firefighters do this well, with organized networks of peer support, as they always anticipate trauma. Perhaps some medical staff organizations do, as well. Maybe your employer already has a network; now is a good time to find out what is available, or at least to think about what your support network looks like, even if it’s very informal. This is not to provide mental health treatment; this is to serve as an early outlet for stress debriefing, mutual support, venting, sharing coping mechanisms and practical resources, and for referral to mental health networks if needed. Keep an eye on each other. Prepare to mutually help and be helped.
Create a communication network outside your circle of co-workers
Your co-workers might provide emotional and physical support, but this does not always happen. Even if it does, eventually you will leave work and go to your separate homes. The crisis will pass. Your family and friends outside of work will need to know where you are psychologically in order to be a good support network. This one is hard; I’m not going to sugarcoat this or anything else. What you’re probably thinking in this moment is that you’ll protect them as much as possible from your traumatic experience, especially if they are young, old, frail, stressed, or vulnerable in any way. It’s your usual M.O. to protect them as much as possible and carry the burden yourself, keeping it from them as much as possible. You need to, and I cannot emphasize this enough — NEED TO stop that line of thinking right now. That is noble and so are you, but it is not going to help you right now and it’s also not going to help them. That is not to say that you need to share all the gory details, but you need to share enough of your experience that they can go there with you psychologically. I’m sorry, that’s hard. But when you struggle later to communicate, to share the experience, to be in the same “mind space” with your partner, family, and friends, you won’t be able to do that unless you start now. Share as much as you can. Not necessarily all the details, but the essential gist of what it’s like for you. Create the habit of doing that.
How? Communication channels work best when regularly used, so set them up now and practice using them. A regular “around the table” dinner check in (even if you can’t always sit down together, it creates a habit to use at other times.) A check-in spot on your family calendar or scheduling board (visuals, emoticons or colors representing how they’re doing are good for kids and busy adults.) Start an email chain or group message to check in that you can use later, even if it’s as simple as “today was rough, but I’m still here.” Your outside-work support network, to some extent, will need to take the journey with you. I expect resistance to this idea in this form; “my family did not sign up for this. It’s on me to protect them.” True, but it’s not the case that an absence of information (even difficult information) is helpful to them. Often, the uncertainty about what “might” be happening and dark imaginings are worse than factual information about your experiences. Of course, you will want to present this at a level appropriate for their maturity and level of understanding, but truly — do not keep your family and friends in the dark about your experiences or your emotions. It will ultimately make it harder for them, and harder for you in the long run, to connect and help each other. It’s hard to prioritize this when time is scarce, but this is also something you can delegate to some extent. Ask your kids or partner to make a check-in board or a list of family and friends to include on the email chain. Ask them to write some content about their own activities and feelings. Practice this connection and strengthen the communication channels as much as you can now. This will be critical later.
Feel your feelings.
Don’t let me tell you what to feel, but one common theme I’ve heard in recent days sounds a lot like bereavement. We’re experiencing many losses right now and anticipating more. We may lose patients and loved ones, but we’re also experiencing so many other losses in both collective and individual ways. Our trust in our government. Our well-thought out plans. Our economic security. The basic security of our own and our family’s health. Our social connectedness. Our carefully construed event calendars. Our career trajectories. Being able to plan ahead with a certain amount of confidence that our plan will occur. The ability to travel. The casual and not-so-casual hugs. The well-practiced routines we all have, and the freedom they create from having to plan each step. Our independence and ease to move about. Our sense of normalcy. Our peace of mind. The losses we anticipate within our communities. Our assumed responsibility for preventing such losses. Doing without much that we normally take for granted. Our usual priorities. Gravity.
Okay, maybe gravity is still working, but the world feels upside down in so many ways. It’s okay to feel whatever you’re feeling. If you’re worried, sad, bereaved, scared, terrified, numb…whatever you’re feeling…that’s a normal reaction to this abnormal event. We have a tendency to try to set our feelings aside and to focus on getting the job done, which is also okay, but it will be necessary to spend some time feeling amidst all the doing. As hard as this can be in the moment, suppressing feelings doesn’t make them go away. It just adds layers to their eventual processing. Try, as much as you can, to let yourself feel. It’s hard. It doesn’t feel good and you’re busy doing, but it is what makes us human and it is what will make us feel better in the eventual sense. Remember, this is temporary. Life will go on, and our lives will not be like this forever. Whatever feelings come up along the way, let’s feel them and go through them as we experience the very real losses in our lives that this crisis will create. We will be injured, but we will heal. It’s okay to feel the hurt. Just remember how resilient, adaptive, and strong the healing process is, and trust that it will kick in at the appropriate time. Life will go on.
I hope that these tips will be helpful in preparing for the battle ahead. I’ll be sharing more throughout this crisis about how to process traumatic experiences, and how to simply support others to deal with acute stressors more effectively. For now, love and solidarity for the battle ahead, and pure gratitude for the work you’re doing and the preparation you’re making to handle it. I hope that my personal experiences can help you to weather this storm, and I hope that we will all come out stronger, more resilient, and more connected on the other side. I look forward to seeing you there.