How to Help Support Patients Who Are “Essential” Workers

In this podcast, Dr Andrew Brown, a member of the Group for the Advancement of Psychiatry, Work and Organizations Committee provides his views on how we – as psychiatrists – can help support those of our patients who have anxiety associated with the categorization as “essential.”

PSYCHPEARLS

Although states are relaxing their “stay at home” orders, the nature of work has fundamentally shifted since the beginning of COVID-19. Unemployment has skyrocketed. Those employees that have remained employed have been separated out into those who are doing “essential” and “non-essential” work. Working with the public and especially in “hot-spots,” can be an anxiety-producing prospect.

In this podcast, Dr Andrew Brown, a member of the Group for the Advancement of Psychiatry, provides his views on how we – as psychiatrists – can help support those of our patients who have anxiety associated with the categorization as “essential.”

Specifically, he discusses how we can: (1) normalize their fear and anxiety surrounding the risks of COVID-19; (2) provide supportive therapy that strengthens their confidence in their own decision-making ability; (3) employ self-disclosure, selectively, to humanize our self and emphasize the shared nature of the current crisis. 

Transcript:

Ashley VanDercar: This is Ashley VanDercar. I’m a psychiatry resident, and a fellow with the Group for the Advancement of Psychiatry. In today's episode I'll be interviewing Dr Andrew Brown. Dr Brown is the lead psychiatrist for the Boston Police Department. He'll be discussing how we, as psychiatrists, can help support our patients during COVID-19. Specifically, those patients who are essential workers.

Andrew Brown: This is Andrew Brown. I’m a psychiatrist with the Boston Police Department.

Ashley VanDercar: So, Dr Brown – how do you distinguish between fear and anxiety? Because, at least with the patients that I've seen they seem to be meshed together. There is such a pronounced feeling. These people, who have gone their whole lives to become what they are – whether that's in the tech sector, the health care sector, etcetera – are, many times, now afraid to go out and do their job.

They see their friends, who are “safe at home.” They're going out to provide an essential service. But - they feel, mixed together, a fear of going out, and anxiety. This is just overpowering for some of them.

Andrew Brown: Fear is often a very rational, reality-based response to a situation that is threatening or potentially threatening. It is important to be aware of one's fear. An appropriate idea for us to communicate is that we are glad that they're feeling fearful. We need to, in essence, normalize it.

A lot of the immediate aftermath of officer involved shootings tends to involve an enormous amount of overwhelming fear. One of the most important and therapeutic things that one can do is normalize the response. With COVID-19 I think that is also applicable. It's rational to have fear. We want to normalize that response.

Then, of course, there's anxiety. Which is really quite distinct from fear. I think most people, once their attention is called to the distinction, are fairly able to distinguish between the two.

Ashley VanDercar: So, I hear you distinguishing between fear and anxiety. It sounds a lot like the DSM distinction between the two. Fear, being the emotional response to the “now” threat. Whereas, anxiety is looking at - they refer to it in the DSM as anticipation - of the future threat.

This becomes challenging with COVID-19, because the fear is also anticipatory … it keeps going on and on. It has no end date in sight. Given that merging, of fear and anxiety – although they are distinguishable, there is also great overlap.

How do you suggest that we support our patients?

Andrew Brown: We need to play to the patient’s strengths. We need to ask, and know:

• How is it you got into this critically important field?

• What is it about your temperament, your talents, your makeup, your skills, your way of being in the world … that equips you so well to do this type of work?

If one listens carefully to that kind of orientation, you’ll get clued in pretty quickly about what interventions are needed…

Ashley VanDercar: So, what you're suggesting is almost like a psychodynamic guided intervention; looking at the patient’s strengths and why they got into their field in the first place, and then helping to guide them and provide support.

But let's back up. Give me something a little bit more basic. Some recommendations that we can give right at the “get go.”

Andrew Brown: Common sense basic mental hygiene: get plenty of exercise, take care of yourself, get plenty of sleep, meditate, pray, stay connected to other people, don't be overly concerned about asking for help. But, I think what's unique – that we as psychiatrists have to offer when folks come to us with concerns (e.g., “hey my friend gets to stay home safely, why do I have to go out and expose myself to this risk?”), is the ability to understand where this individual is coming from. In other words, to try and understand what this particular individual's concerns are right now.

What we do conforms more closely to what is called coaching.

Ashley VanDercar: That makes a lot of sense. I think the frame of coaching as opposed to therapy is really in line with a form of supportive therapy that we're doing. Being a coach is another way of viewing that type of therapy. 

But the line, between being a coach, and helping people to realize their strengths, can become a little bit esoteric. Especially with people who have family members at home; their anxiety and their fear are both very rational. They're trying to figure out how to deal with their desire to fulfill their professional obligations and expectations, and their fear and anxiety about bringing something home to their family. So, how do you help people process rational anxiety when it interferes with an essential service?

Andrew Brown: The first thing one does is essentially acknowledge the reality, the legitimacy, of many of the fears that they're having. Simply say to the person: “Yeah this is really a predicament that you're in … that we're all in right now. This is a really tough call. I understand why this is arousing so much anxiety in you. In a sense, I'd be more worried if you weren't anxious.”

The definition of anxiety, as opposed to fear, is that fear tends to be circumscribed – with a localized readily identifiable threat. So, as a result we can do things to neutralize the threat. Anxiety is usually just generalized and pervasive (like, the Greek God Pan). He was sort of omnipresent. We call it a pandemic because it's everywhere.

This is not the time to do exploratory therapy. Perhaps to explore a little, but the only reason we're exploring a little is so that we can support the troops in the field.

One thing that I do, that I think people feel is extremely helpful is, support people’s capacity to make good decisions. No one knows what's going on or what to make of this pandemic. We know a little bit, but we still don't know nearly enough. We don't know how to protect ourselves individually. We don't know how to protect ourselves as a society.

People feel very comforted when you learn enough about them to legitimately inform them that you're very impressed with their capacity to make good, reasoned, enlightened, decisions and judgements. I think that goes a long way.

A lot of what fuels anxiety at times like this are the thought of “what am I going to do?”. So, all we have to do, in our job, is give patients the level of self-confidence that they need; and acknowledge that it's an extremely difficult time for everybody. For ourselves as well as them. Because we're human beings in the same situation. Help them reason and figure out some type of compromise that they can live with, about their essential job.

Ashley VanDercar: It's not just the patients that are experiencing this, but it's us – as mental health professionals. How would you recommend that we handle our own countertransference, when we're in the same boat as many of our patients? How do we avoid letting our own anxiety infiltrate these sessions, when we're trying to be a neutral, supportive, coaching practitioners?

Andrew Brown: I'll tell you a little bit about my own personal experience working with police officers.

We learn very early in our training that self-disclosure is a very dicey kind of thing. We're told that you should only do it under a certain set of circumstances. You should never do it spontaneously without thinking about it. You should always explore why the patient is asking.

I took that to heart. I'd always done that. But … what I found in the police department, is that there's no way I can do the work I do with that kind of attitude (at least with police officers, at least with that culture).

I have had to completely put that notion away. Generally, when officers ask me about my personal life (which they do all the time), within reason, I simply tell them.

They knew they couldn't trust me as soon as I ask them something like: “Oh why are you so interested in where I went to medical school?” So I think it'll go a long way when you're working with patients in this crisis to simply acknowledge (as long as it's true): “Yeah it's totally normal, now, to feel a little scared … to feel a little bit indecisive … to really not know what the acceptable risk is.”

Ashley VanDercar: If you were to enumerate three things that psychiatrists should focus on when they're working with essential workers who have both fear and anxiety, about doing their job … what would those three things be?

Andrew Brown: One very important principle is normalization. It’s a very novel experience for just about everyone. Very few people have lived through anything remotely similar to what we're going through now. Normalize these reactions that are really quite appropriate and correspond to the reality of the situation.

The other thing to keep in mind, that's implicit in the first principle, is that in times like this we do a little bit of exploration of the particular individuals’ vulnerabilities. But the only reason we're exploring the individual’s history and specific situation is to figure out how they got to be where they are now (as an essential worker). Then we can help support the strengths that have enabled them to get through life quite successfully and adaptively.

Implicit in those two general principles is that I wouldn’t be overly reticent to self-disclose. (For instance: “When I came to work this morning, I didn't know … should I wear a mask? Should I not wear a mask? Is that just going to make people more panicked?”)

As psychiatrists, our role is to support those nascent or quite developed capacities.

Ashley VanDercar: So today, Dr Brown has discussed how we, as psychiatrists, can help support essential workers.

Dr Brown emphasized the importance of:

• Normalizing fear of an identifiable threat, and anxiety about generalized unknown threats;

• Providing supportive therapy in the midst of the acute crisis, meaning that we’re supporting a patient’s strengths, capability, and abilities as decision-makers; and,

• Loosening up restrictions on self-disclosure, as a way of humanizing ourselves to allow our patients to benefit the most they can from therapy, given the collective nature of the shared stress associated with COVID-19.

Transcript edited for clarity. -Ed