ASSESSMENT & TREATMENT OF PANDEMIC BURNOUT &

KATHY HOPPE, LMFT Participants will be able to: OBJECTIVES § Re-conceptualize clients' issues related to pandemic burnout and compassion fatigue. § Explore diagnostic dilemmas in the identification of burnout, compassion fatigue, and moral distress occurring in the professional lives of people in the medical, educational, behavioral health, and other industries impacted by a pandemic. § Identify the differences in theoretical approaches to the treatment of collective pandemic burnout and compassion fatigue. § Outline a treatment protocol that addresses the unique factors that interfere with functioning. THE IMPACT

“With its lack of unpredictability and the need for distance and isolation, COVID-19 is tearing at the fabric of our most basic methods of , and calls for new ways of adapting to and thinking about crisis.”

Horesh & Brown, 2020 TERMS USED

Epidemic Collective Collective Pandemic Toxic positivity trauma stress virus

Post-COVID COVID-19 Caution Epidemic Compassion Stress stress fatigue fatigue Syndrome Fatigue

Peri Trauma Pandemic Burnout Stress fatigue ELIZABETH STUART, PHD, THE JOHNS HOPKINS BLOOMBURG SCHOOL OF HEALTH PEW RESEARCH CENTER'S AMERICAN TRENDS PANEL (ATP)

¡ n = 9687 ¡ March 19– 24, 2020 ¡ CES-D, GAD-7, & IES-R HOW ARE PEOPLE DOING? China • • • • • n 45% 49 72% distress 34% insomnia = 2700 - 59% dep. sx anx. sx

Italy • • PTSS 29.5%

Spain • • • 21.6% anxiety depression 18.7% 15.8% PTSD

Ireland • • • • 49.5% anxiety depression 53.8% 17.7% PTSD n = 1041 HOW ARE PEOPLE DOING?

CDC HOUSEHOLD PULSE SURVEY - ANXIETY SYMPTOMS 50

45

40

35

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25

20

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5

0 4/23 - 5/5 5/7 - 5/12 5/14 - 5/21 - 5/28 - 6/2 6/4 - 6/9 6/11 - 6/18 - 6/25 - 7/2 - 7/7 7/9 - 7/14 7/16 - 8/19 - 9/2 - 9/14 9/16 - 9/30 - 10/14 - 10/28 - 11/11 - 11/25 - 12/9 - 5/19 5/26 6/16 6/23 6/30 7/21 8/31 9/28 10/12 10/26 11/9 11/23 12/7 12/21

National Oklahoma HOW ARE PEOPLE DOING?

CDC HOUSEHOLD PULSE SURVEY - DEPRESSIVE SYMPTOMS 40

35

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25

20

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5

0 4/23 - 5/7 - 5/14 - 5/21 - 5/28 - 6/4 - 6/9 6/11 - 6/18 - 6/25 - 7/2 - 7/7 7/9 - 7/16 - 8/19 - 9/2 - 9/16 - 9/30 - 10/14 - 10/28 - 11/11 - 11/25 - 12/9 - 5/5 5/12 5/19 5/26 6/2 6/16 6/23 6/30 7/14 7/21 8/31 9/14 9/28 10/12 10/26 11/9 11/23 12/7 12/21

National Oklahoma Severe stress Stressors Witnessing Protective death Factors Having COVID/ Family/friend s Exposure Financial Quarantine/ stability Isolation Employment Income/job Safe place loss Wellness Work/kids/ checks school

BALANCE OF PROTECTIVE FACTORS VS. STRESSORS OCCUPATIONS IMPACTED

§ Medical professionals § Emergency responders § Healthcare workers § Community workers § Hospital industry § Ministry leaders § Education § Other “There’s a big difference between ‘staying positive’ and being generative. The first disregards hard truths and the THE DILEMMA second is the fruit of composting them.” Toka-Pa Turner

THE DILEMMA WHAT ARE WE TREATING? LAMENT OF A HOSPITAL CHAPLAIN

We the Hospital – We exist for hard times. We are seasoned professionals. We walk through hard truths and handle heavy situations. Enter Covid-19 stage right seeping into our lives, our work, our hospitals, our homes, our schools, our houses of worship, our gyms, our relationships. So, we buckle down and buckle up. We shore ourselves up for the long haul. And the long-haul, hauls on… We discover that the long haul is too long…We haven’t shored up enough. We haven’t stored for the hurricane. We haven’t stocked for the famine. We haven’t hoarded enough to sustain body, mind, spirit. Out of gas, Out of positivity, Out of energy, Out of wellness resilience, Out of coping strategies… Is this sustainable?Are WE sustainable? And still Covid-19 seeps and merges. Seeps into our hearts and souls and minds, Seeps into and merges until all are diseased by apathies. The virus of our apathies become more dangerous than any Covid-19 or Ebola or Bubonic Plague. Apathy seeps into our identity, into the tasks of our work. Help us, O God! Eventually, may we have some generative fruit from composting these hard truths and realities in which we live. FROM AN ICU COVID NURSE

Have you ever sat with yourself alone, still and quiet like a mountain and then gone deep inside far below the surface until you are under it all alone with just you, the you that has always been you? Have you ever looked up from that space into a universe of tears, yours and others, held back by a fragile membrane – the relentless density of , grief and loss, heavy, smothering, immense, afraid to reach up and touch it for fear of drowning in the emotion as an ocean erupts through the pin hole? Have you ever found the courage to touch it, yet it doesn’t break, and you are left with the crushing pressure bearing down on your soul. You push and prod – nothing. You yearn for release, better to drown than be crushed. Sill nothing but to hold this previous suffering like Atlas? This is this moment. AUDREY – SPECIALTY RN

§ RN in step-down unit turned into COVID-19 unit § Approximately 20 patients § Average deaths 2 - 4 per week § Family disallowed § Slow deaths with breathing difficulties § Complains of anxiety & stress CONNIE – COMMUNITY WORKER

§ Community worker in non-profit agency § Responsible for discharging resources to homeless § Limited resources § Making decisions: who gets resources or not § Exhausted § Complains of depression BRIAN – HIGH SCHOOL TEACHER

§ Administration ambiguity § Teaching online & in school § Science class – involves lots of “handling items” § Complains of fear § Obsessive about cleaning things § Requires entire family to wear masks § Visitors in home must wear masks LIMITATIONS TO CURRENT DIAGNOSTICS: 1. MASS TRAUMA 2. METHODOLOGICAL

Danny Horesh, NYU School of Medicine Adam D. Brown, NYU School of Medicine THE NEW ENEMY: COVID FATIGUE WHAT IF? changed the lenses? Lucy Johnstone, UK Consultant Clinical Psychologist, author of Users and Abusers of , Formulation in Psychology and , and a Straight-Talking Guide to Psychiatric Diagnoses “The single most damaging effect of psychiatric diagnosis is loss of meaning. CONSTRUCTIVIST By divesting people’s experiences of their personal, social, and cultural significance, APPROACH diagnosis turns ”people with problems” into “patients with illnesses.”

Lucy Johnstone, PhD, UK Consultant “What we’re experiencing here is a collective trauma. If we treat this the way psychologists have in the past – as individual patients with trauma – then we’ve missed the boat. The collective problem calls for a collective solution. It’s not just about getting rid of symptoms; it’s about helping people make meaning out of what happened.”

Nadine Kaslow, PhD, ABPP Director of Postdoctoral Residency Training in Health Service Psychology Emory University School of Medicine

COLLECTIVE TRAUMA COLLECTIVE TRAUMA

Collective trauma is a cataclysmic ¡ Psychological reaction event that shatters to societal tragedy the basic fabric of society. ¡ Potentiality of Aside from the horrific loss of life, cascading crises collective trauma is also ¡ Risk & uncertainty a crisis of meaning. Hirschberger, 2018. FACTORS THAT INFLUENCE COLLECTIVE TRAUMA

¡ Timing – continual triggering ¡ Mass-mediated responses representations ¡ Political context ¡ Carrier groups ¡ Public authorities ¡ Collective memory Major events in 2020 - 21 Pandemic • Isolation, Masks, Vaccines, economic uncertainty, massive loss of life Recognition of Personal crises systemic racism • Brutal slayings

Weather events Unstable politic • hurricanes, system heatwaves, wildfires • Attack on Capitol

Extensive media coverage

CASE CONCEPTUALIZATION

¡ Etiology “Since the posttraumatic phase of the COVID-19 crisis is likely ¡ Symptoms to be rather long, ¡ treating people for Severity of impact on acute stress disorder and/or initial functioning posttraumatic symptoms, which has not yet crystalized into full- ¡ Duration blown PTSD may be of particular importance.” ¡ Prognosis ¡ Formulate diagnosis Horesh & Brown, 2020 ¡ Define treatment plan SIMILARITIES TO PTSD & ASD

§ Hypervigilance § Avoidance § Negative mood and cognitions § Intrusive thoughts related to health and death § But . . . not quite a good fit for all “Well-established models of secondary traumatization, compassion fatigue, moral injury, and burnout should be applied and used to assist these workers in their daily effort to cope with massive amounts of work and stress.”

Horesh & Brown, 2020

COMPASSION FATIGUE = BURNOUT = COVID FATIGUE? COMPASSION FATIGUE OR BURNOUT?

BURNOUT COMPASSION FATIGUE § § Burnout symptoms § Cynicism or § Secondary traumatic depersonalization stress symptoms § Reduced efficacy § Mitigated by compassion satisfaction CONTRIBUTING FACTORS

Burnout Compassion Fatigue

¡ Job Demands-Resources – Perceived ¡ Burnout demands > perceived resources ¡ Direct or indirect exposure to trauma ¡ Conservation of Resources – basic ¡ Moral distress motivational theory – arises due to persistent threats to available resources ¡ Areas of Worklife – person-job imbalance or mismatch: workload, control, reward, community, fairness & values (COVID-19)

A DIFFERENT PERSPECTIVE A TRAUMA-INFORMED APPROACH

Recent research suggests that traumatic stress reactions during the pandemic – including intrusive re-experiencing and heightened arousal – are particularly prevalent.

Bridgland, et al., 2021 FORWARD-FACING RESILIENCE PROGRAM (POLYVAGAL THEORY + CBT/CPT + NET) CE-CERT (CBT + MBSR + NARRATIVE) COMPASSION CULTIVATION TRAINING

COMPASSION FATIGUE & BURNOUT + TRAUMA INFORMED FORWARD- FACING Coaching RESILIENCE • Confront threats THERAPY • Identify breaches Intentionality • Values/Code of honor • Purpose/Meaning

Education • Tools for hope • Self-regulation

https://www.facebook.com/groups/448297342837555 SKILLS NEEDED

¡ Skill 1. Self–Regulation ¡ Skill 2. Intentionality ¡ Skill 3. Perceptual Maturation ¡ Skill 4. Connection and Support ¡ Skill 5. Self–Care and Revitalization SKILL #1: SELF REGULATION

DR. STEPHEN PORGES ON POLYVAGAL THEORY SELF-REGULATION SKILLS

Polyvagal theory ¡ Hierarchy ¡ Neuroception ¡ Co-regulation SELF-REGULATION ACTIVITIES

¡ Body scan – wet noodle “According to the theory of ¡ Muscular to skeletal reciprocal inhibition (Wolpe), awareness stress, fear, and anxiety cannot ¡ Peripheral vision be felt in a relaxed body.” ¡ Core relaxation J. Eric Gentry ¡ The Yawn DR. ERIC GENTRY ON SELF-REGULATION SKILL #2: INTENTIONALITY

¡ Value exercise “Human beings cannot live in ¡ Code of honor habitual & willful violation of their integrity without getting sick.” ¡ Mission statement or covenant J. Eric Gentry TRIGGERS

• Words, • Actions, actions, words, situations emotions

Reaction Triggers to triggers

Current Past impact hurts

• How do • What did these breach they teach your code of you? honor? DR. ERIC GENTRY ON THREAT PERCEPTION This is who I want to be. SKILL #3: PERCEPTUAL MATURATION

¡ Real danger versus Perceived threat ¡ Demand versus Choice – nothing is demanded of you ¡ Outcome-Driven versus Principle-Based ¡ Relinquishing Entitlement ¡ Acceptance of a Chaotic System SELF- COMPASSION SCALE

https://self-compassion.org/self- compassion-scales-for-researchers/ SKILL #4: CONNECTION & SUPPORT SKILL #5: SELF-CARE & REVITALIZATION J. Eric Gentry’s works Faith-Based (Christian)

THESE MAY HELP WRITING A STORY

References

Alharbi, J., Jackson, D., & Usher, K. (2020). The potential for COVID-19 to contribute to compassion fatigue in critical care nurses. Journal of Clinical , 29(15–16), 2762–2764. https://doi.org/10.1111/jocn.15314 Al-Masaeed, M., Al-Soud, M., Alkhlaifat, E., Alsababha, R., Ismail, K., Alhabashneh, N., Abu Tapanjeh, S., Alqudah, M., & Rasdi, I. B. (2020, Dec). An investigation of the impacts of Covid- 19 pandemic spread on nurses fatigue: An integrated literature review. World Journal of Innovative Research, 9(6), 20–24. https://www.researchgate.net/publication/348167412_An_Investigation_of_the_Impacts_of_Covid-19_Pandemic_Spread_on_Nurses_Fatigue_An_Integrated_Literature_Review American Psychological Association. (2019). Clinical practice guidelines for the treatment of depression across three age cohorts [pdf]. https://www.apa.org/depression-guideline/guideline.pdf American Psychological Association. (2017). Clinical practice guideline for the treatment of PTSD. https://www.apa.org/ptsd-guideline/ptsd.pdf Australian Psychological Society. (2018). Evidence-based psychological interventions in the treatment of mental disorders: A review of the literature (4th ed.). https://www.psychology.org.au/getmedia/23c6a11b-2600-4e19-9a1d-6ff9c2f26fae/Evidence-based-psych-interventions.pdf Bridgland, V., Moeck, E. K., Green, D. M., Swain, T. L., Nayda, D. M., Matson, L. A., Hutchison, N. P., & Takarangi, M. (2021). Why the COVID-19 pandemic is a traumatic stressor. PLoS One, 16(1): e0240146. https://doi.org/10.1371/journal.pone.0240146 Centers for Disease Control and Prevention (2021). Anxiety and depression: Household Pulse Survey. https://www.cdc.gov/nchs/covid19/health-care-access-and-mental-health.htm Clay, R. A. (2020, Jun 11). Are you experiencing compassion fatigue? American Psychological Association. https://www.apa.org/topics/covid-19/compassion-fatigue COVID-19 impact on behavioral health: Essential focus on the frontline worker. https://www.chartis.com/behav-health-3 Demertzis, N., & Eyerman, R. (2020). Covid-19 as cultural trauma. American Journal of Cultural Sociology, 1–23. https://doi.org/10.1057/s41290-020-00112-z Department of Veterans Affairs/Department of Defense. (2016). VA/DoD clinical practice guidelines for the management of major depressive disorder. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf Department of Veterans Administration/Department of Defense. (2017). VA/DoD practice guidelines for the management of posttraumatic stress disorder and acute stress disorder. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal.pdf Fish, J. N., & Mittal, M. (2020). providers during COVID-19: Essential to the US public health workforce and in need of support. Public Health Reports, 136(1), 14–17. https://journals.sagepub.com/doi/pdf/10.1177/0033354920965266 Gentry, J. E., & Dietz, J. J. (2020). Forward-Facing professional resilience: Prevention and resolution of burnout, toxic stress and compassion fatigue. Outskirts Press. He, Q., Fan, B., Xie, B., Liao, Y., Han, X., Chen, Y., Lu, L, Guo, C., & McIntyre, R. S. (2020). Mental health conditions among the general population, healthcare workers and quarantined population during the coronavirus disease 2019 (COVID-19) pandemic. Psychology, Health & Medicine. https://doi.org/10.1080/13548506.2020.1867320\ Holingue, C., Badillo-Goicoechea, E., Riehm, K. E., Veldhuis, C. B., Thrul, J., Johnson, R. M., Fallin, M. D., Kreuter, F., Stuart, E. A., & Kalb, L. G. (2020, Oct). Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey. Preventive Medicine, 139, 106231, 1–8. https://doi.org/10.1016/j.ypmed.2020.106231 Horesh, D., & Brown, A. D. (2020). Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. : Theory, Research, Practice, and Policy, 12(4), 331-335. http://dx.doi.org/10.1037/tra0000592 Hyland, P., Karatzias, T., Shevlin, M., McElroy, E., Ben-Ezra, M., Cloitre, M., & Brewin, C. R. (2020). Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM-5. Psychological Trauma: Theory, Research, Practice, and Policy. Johnstone, L. (2018). Psychological Formulation as an Alternative to Psychiatric Diagnosis. Journal of Humanistic Psychology, 58(1), 30–46. https://doi.org/10.1177/0022167817722230 References Karatzias, T., Shevlin, M., Murphy, J., McBride, O., Ben-Ezra, M., Bentall, R. P., Vallières, F., & Hyland, P. (2020, Jul). Posttraumatic stress symptoms and associated comorbidity during the COVID-19 pandemic in Ireland: A population-based study. Journal of Traumatic Stress, 33(4). https://www.researchgate.net/publication/342928255_Posttraumatic_Stress_Symptoms_and_Associated_Comorbidity_During_the_COVID-19_Pandemic_in_Ireland_A_Population- Based_Study Kirzinger, A., Kearney, A., Hamel, L., & Brodie, M. (2020). KFF Health Tracking Poll – early April 2020: The impact of coronavirus on life in America. https://www.kff.org/report-section/kff-health-tracking-poll-early-april-2020-the-impact-of-coronavirus-on-life-in-america-coronavirus-findings/ Liebman, G., & Pendegar, E. (2020). Responding to COVID-19 collective trauma: Legislative issue brief [pdf file]. https://mhanys.org/wp -content/uploads/2020/05/POL_20200429_LegIssue-CollectiveTrauma.pdf Maslach, C. (2017). Finding solutions to the problem of burnout. Consulting Psychology Journal: Practice and Research, 69(2), 143–152. http://dx.doi.org/10.1037/cpb0000090 Miller, B., & Sprang, G. (2017). A components-based practice and supervision model for reducing compassion fatigue by affecting clinician experience. Traumatology, 23(2), 153–164. http://dx.doi.org/10.1037/trm0000058 Moreno, C., Wykes, T., Galderisi, S., Nordentoft, M., Crossley, N., Jones, N., Cannon, M., Correll, C., Byrne, L., Carr, S., Chen, E., Gorwood, P., Johnson, S., Kärkkäinen, H., Krystal, Lee, J., Lieberman, J., López-Jaramillo, C., Mäannikkö, M., Phillips, M. R., Uchida, H., Vieta, E., Vita, A., & Arango, C. (2020, Sep). How mental should change as a consequence of the COVID-19 pandemic. The Lancet Psychiatry, 7(9), 813–824. https://www.sciencedirect.com/science/article/pii/S2215036620303072 North, C. S., Surís, A. M., & Pollio, D. E. (2021). A nosological exploration of PTSD and trauma in disaster mental health and implications for the COVID-19 pandemic. Behavioral Sciences, 11(7), 1–14. https://doi.org/doi:10.3390/bs11010007 Panchai, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., Muñana, & Chidambaram, P. (2020). The implications of COVID-19 for mental health and substance use. https://www.kff.org/health-reform/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/ Sasangohar, F., Jones, S. L., Masud, F. N., Vahidy, F. S., & Kash, B. A. (2020). Provider burnout and fatigue during the COVID-19 pandemic: Lessons learned from a high-volume intensive care unit. Anesthesia and Analgesia, 131(1)106 – 111. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173087/ Shevlin, M., Hyland, P., & Karatzias, T. (2020, Oct). Is posttraumatic stress disorder meaningful in the context of the COVID-19 pandemic? A response to Van Overmeire’s commentary on Karatzias et al. (2020). Journal of Traumatic Stress, 33(5), 866–868. https://doi.org/10.1002/jts.22592 Silver, R. C., Holman, E. A., & Garfin, D. R. (2021). Coping with cascading collective traumas in the United States. Nature Human Behaviour, 5(4-6). https://doi.org/10.1038/s41562-020 -00981-x Tahara, M., Mashizume, Y, & Takahashi, K. (2021). Coping mechanisms: Exploring strategies utilized by Japanese healthcare workers to reduce stress and improve mental health during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 18(1), 131. https://doi.org/10.3390/ijerph18010131 Taylor, S., Landry, C. A., Paluszek, M. M., Fergus, T. A., McKay, D., & Asmundson, G. J. G. (2020, May). Development and initial validation of the COVID Stress Scales. Journal of Anxiety Disorders, 72, 102232. https://doi.org/10.1016./j.janxdis.2020.102232 Tucker, P. M., & Czapla, C. S. (2020, Oct 5). Post-COVID stress disorder: Another emerging consequence of the global pandemic. https://www.psychiatrictimes.com/view/post-covid-stress-disorder-emerging-consequence-global-pandemic World Health Organization. (2020). ICD-11 for mortality and morbidity statistics (Version: 09/2020): QD85 Burnout. https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f129180281