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DR. JAN NEWMAN
Every day holds more questions. What is happening with quarantine protocols? Why are some people following them while others are not? Will there be a vaccine or a treatment? What’s happening with schools, childcare, graduations, and summer camps? Am I selfish for worrying about these kinds of things when people are getting sick? It’s no wonder we are all so stressed out.
But what about those of working on the front lines?
Healthcare providers on the front lines of the Coronavirus pandemic are experiencing extremely high levels of stress.
Healthcare providers and other hospital and clinical staff on the front lines are experiencing stress and anxiety that is truly next level. Hospital workers are witnessing poor facility protocols and training. There are shortages in critical supplies and staff. Of course, they are at an extremely high risk to contract and transmit COVID-19 due to exposure. Every day many of us on the front lines are living in fear of hurting those they love while trying to manage obligations like childcare.
Although those of us who can do teleheath don’t have the constant threat of exposure, we have other challenges. We may struggle to find the line between work and life because there no longer seems to be one. And yet every day, we are still dealing with people who are experiencing pain and trauma.
Not surprisingly, healthcare providers are experiencing burnout at alarming rates. Burnout occurs when you reach a state of emotional, physical, and mental exhaustion caused by intense and prolonged stress. There are other terms that are often used to describe the unintended psychological harm that occurs when working with clinical populations. These terms include secondary traumatic stress, vicarious trauma, and compassion fatigue.
At the core of this problem is our difficulty in being able to manage our human stress response. To prevent and manage burnout, vicarious trauma, and compassion fatigue, it is critical to understand our stress response and how to regulate it effectively.
In the Empire Strikes Back, Yoda famously tells Luke, “you must unlearn what you have learned.” Yoda’s point is that some of the knowledge you have learned may be getting in your way.
Most healthcare professionals have learned that the root of many medical and mental health disorders is the inability to regulate the brain’s stress response through the autonomic nervous system. We can see these signs of stress easily in others.
But when it comes to ourselves, we often forget that it is not the stress response that causes us so much harm. It’s our attempts to avoid or “get rid of” stress. This is an extremely common but unhelpful response to stress – even for healthcare professionals.
Logically, we also often believe that root of our stress in caring for people in pain is “caring too much.” So, as healthcare professionals, we’re often advised by well-intentioned colleagues to “not get emotionally involved.”
Yet current research shows that empathic engagement with our patients and colleagues is actually the antidote to burnout. It is associated with higher levels of job satisfaction and tenure. Isolation and avoidance actually predict burnout in many health professionals.
Of course, we must be able to regulate our emotions in the face of someone who can’t regulate theirs, but that doesn’t mean we have to emotionally numb out.
At first glance, these two concepts seem paradoxical. First, that more stress and suffering is caused by our attempts to get rid of it and avoid it. Second, that to improve stress and burnout we need to engage empathetically.
Our brains are hardwired for survival. The brain’s autonomic nervous system contains two parts: the sympathetic nervous system (SNS) often called the “fight-or-flight” response that activates us to stuff that matters, and the parasympathetic nervous system (PNS) often called the “relax and digest” response that deactivates this response. The SNS gets a bad rap as being solely for the purpose of threat detection and lions, and tigers, and bears, oh my. It also helps us perform athletically and is involved in sexual arousal. And the PNS isn’t all flowers and rainbows. The PNS is involved in our “freeze” or immobilization response to extreme threat or danger.
When there is a true emergency in our environment, our brain reacts to survive. The first signal is usually these uncomfortable physiological sensations of stress.
Healthcare professionals are still human. We all find these sensations uncomfortable. And the pull to avoid these uncomfortable sensations is actually stronger than our desire for pleasure or happiness.
These sensations may include:
rapid heart rate,
dilation of pupils
tingling in hands and feet
tunnel or portrait vision (background fades away)
muscle tension
“butterflies” and gastrointestinal discomfort,
and many more.
Most of us also react to them by trying to suppress them. Some people will call this “compartmentalization.”
Ironically, when we do this, we can actually trigger a response called amplification. By trying to suppress these sensations, we actually amplify them! Our survival-thinking is not the best, so this is why we overtrain for emergencies and crisis situations to follow protocols.
What happens to our brains when we aren’t certain of what to do or what will happen? Above all else, our brain hates uncertainty and things that are not clear. Our brains would rather know the enemy, so to speak. It is always trying to solve problems, make predictions, and create order.
When things are unclear, uncertain, or unstructured, we often start to ruminate.
A stress response is like a fire. If an unhealthy stress response were a full-blown fire, the fight-or-flight response is the heat. Survival-based rumination is the so-called oxygen for stress response fire.
The technical definition of rumination is the mental process of reimagining past events (e.g., what would have happened if I would have done X?) and projecting future concerns and behaviors (e.g., what if this happens in the future?) This rumination typically takes the form of increased worry and dread.
When we start this worry train, it is hard to stop. Rumination can lead to increased distress.
As the heat sources continues to burn (SNS response) and the oxygen (ruminative thoughts) keep circulating, the fire grows out of control.
This can eventually lead to a “freeze” response triggered by PNS involving the dorsal vagus nerve. It actually causes us to then isolate ourselves or become less physically active. This creates a negative feedback loop that makes it difficult to regulate the stress response or rumination. Again, although many healthcare workers know this science, it’s hard to remember it when you’re stress levels are so intense and chronic.
HERE ARE 7 SPECIFIC STRATEGIES TO HELP YOU MANAGE STRESS
The first step in managing stress is to acknowledge what’s actually happening.
I often describe this as “name it to tame it.” For example, simply observing, “I’m noticing that my heart rate is increasing and I’m feeling tightness in my chest” is important. Then, remembering your training about these physiological reactions (e.g., “This is SNS activation. This is a normal response to stress and certainly a pandemic”) is critical to combatting your stress response. Without awareness, you cannot regulate stress.
Breathing deeply is a key part of parasympathetic recovery or triggering your “relax and digest” response. There are many different techniques to help you do this. Mindful breathing basically means that you take several deep breaths focusing on the physical sensations in your chest and completing the breath—not your to-do list.
A quick and easy breathing technique that you can do anywhere is called the physiological sigh. You do a double inhale with two in breaths in through your nose, followed by a 5-count, longer exhale. Teh short inhales increase the surface area of the lungs and remove CO2 from the body much more efficiently. The long exhale the receptors in the heart sense the increase in pressure, this sends signals to the brain to slow down the heart rate.
This creates a relaxed feeling.
Of course, even with all of this feel-good relaxation, your mind will wander—that is completely normal (more on this below with the default mode network). Mindfulness is a process of focusing and refocusing. So, just gently acknowledge that “I’m noticing my mind wandering” and intentionally shift your focus back to your breath. Repeat as necessary.
Other breathing methods such as Wim Hof breathing, box breathing, or 4-7-8 breathing are often used by athletes for performance.
Consider bringing lunch to work or prioritizing meals at work. Some of my busy clients have started ordering meals from companies like Factor 75 or Hello Fresh. Prioritize daily sunlight exposure and regular bed and wake times. Trade your wine or beer for another option to limit alcohol consumption. Alcohol can cause inflammation, which slows down parasympathetic recovery.
Could it really be as easy as the Nike slogan? JUST DO IT. Well almost.
Rumination, or the oxygen of the stress response, often occurs when we are not focused on a task or activity. This inactive mind-wandering state of the brain has also been described as the default mode network. This network is a set of neural regions that activate during off-task were resting states of the brain. This network is very active during rumination. It’s linked to poor emotional regulation.
Focused, goal-directed activity, or put more simply, doing stuff that matters to you with intention, is the enemy of rumination. It shifts the brain from the ruminative default mode network to the focused task-positive network. This requires shifting from ruminating about the past to focusing on the present moment. It means focusing on here-and-now awareness. (Check out this quick video by Dan Harris discussing the difference between these two networks).
To hack the task-positive network, you don’t need to meditate like a Buddhist monk or go all Eat. Pray. Love. Simply choose some type of action that engages your five senses in the present moment. An action that is not focused on your thoughts about yourself, your work, your problems, or the pandemic.
Instead, it would be your breath, your physiological sensations, or the sounds of nature or the city. Things that are right here, right now, not back there or up ahead. A recent research paper suggested that just 20 minutes of focused, goal-directed activity per day could engage the task-positive network and reduce rumination.
Although it’s beyond the scope of this article, on my podcast, Mastering Momentum, I discuss different types of awareness – exteroception (five senses awareness), interoception (internal or felt sense awareness of autonomic signals, hunger, etc.), and proprioception (awareness of body location in space) and techniques to engage them. Note that if you’re in your head too much with thoughts that exteroception tends to work better while if you’re overwhelmed by your environment. I’ll note which is which below.
Here are some possible focus breaks to trigger the task-positive network:
Take a shower and focus on the sense of touch, shifting back to these when you start making your to-do list and forget if you’ve shampooed or not (exteroception) and if you notice the impact on your heart rate or vision (interoception)
Engage your sense of temperature by drinking a cold glass of water slowly or if you are really stressed, holding ice cubes (exteroception)
Walk outside and try to focus on some sensory aspect of your environment (e.g., identifying trees or flowers, identifying instruments from musical piece playing on your phone) (exteroception and proprioception)
When you do have time, engage in a hobby or activity that requires focus and presence that you enjoy (all three)
Name your five favorite books or movies of all time and your favorite character from each (interoceptive)
Do a body scan starting from your head to your toes noticing internal sensations only (interoception)
I tell my clients when they encounter a distressed patient or colleague that it’s the evolutionary equivalent of our ancestors being faced with a bear or other wild animal trying to kill them. Your SNS doesn’t “see” like that.
I guess the catch here is that we care deeply about these bears. Yet no matter how much you care, you’re not going to feel better if you just sit there and let it eat you. So, it shouldn’t be a surprise that you’re brain recovers from stress easier when you TAKE ACTION. Recent medical research has also suggested that the more you sit the less healthy you are.
Because many healthcare professionals are often required to sit for long periods, here are some ideas to help you fight stress:
You could try standing when you are returning phone calls or doing any clinical documentation.
You could also schedule five-minute breaks between appointments.
Recent research has also found that being outdoors also reduces our stress response. Stepping outside for breaks or enjoying the outdoors before or after work can boost the effects of exercise.
You could take the stairs. When I worked in an academic medical center, I took the stairs instead of the elevators all the time and tried to get my “steps” in. It really helped.
When we feel stressed out, it is normal to have the urge to isolate or disconnect from others. But, it is the last thing we should do. Social isolation is ineffective because it creates a closed-loop system for the professional. Without connection, it is difficult for you to break the cycle. Connecting with family and friends can also calm your neurological responses through the release of oxytocin.
Research has also shown that seeking out social connection at work in the form of work friendships but also in the form of professional consultation can help alleviate burnout and compassion fatigue. Yet be aware of the old adage: misery loves company. To help, social connection should focus on the relationship between two people and not the events which are causing stress. So talking to a colleague or family member about the pandemic at length is actually going to make you feel worse. This happens because you’re now ruminating together. Like COVID, rumination is contagious.
Rumination can also happen en masse. Many of my clients have recently found it helpful to disable notifications from social media and news sources. They are often introducing more uncertainty about the situation. Instead, they are opting to use Google Hangouts, Face Time, and Zoom for face-to-face conversations, card, and board games, and connection with others. (If you’re interested in reading some tips on setting boundaries at work – here’s an article on why they’re important and one on how to say it.)
I’ve just given you some concrete skills for managing the stress that can lead to burnout, vicarious traumatization, and compassion fatigue. But, there are plenty of others.
And, there are also research-based methods for preventing and reducing burnout in physicians, mental healthcare providers, and other healthcare professionals. If you’re a healthcare professional who often deals with traumatized populations, you may be experiencing signs of vicarious traumatization.
Seek help from a trusted supervisor or colleague. If you are noticing symptoms of depression, anxiety, or vicarious trauma, please consider talking to a mental health care professional trained in one of these research-based models.
You are caring for human lives every day. There is no greater calling. You are precious and important as well. Thank you for what you do!
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References
Miller, B., & Sprang, G. (2017). A components-based practice and supervision model for reducing compassion fatigue by affecting clinician experience. Traumatology, 23(2), 153.
West, C. P., Dyrbye, L. N., Erwin, P. J., & Shanafelt, T. D. (2016). Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet, 388(10057), 2272-2281.
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