Disaster Cascade: Behavioral Health Challenges for Health Care Providers During the COVID-19 Pandemic

Educational Objectives

The goal of this program is to improve behavioral health challenges for health care providers during the COVID-19 pandemic. After hearing and assimilating this program, the clinician will be better able to:

1. Summarize resilience as a product of disaster cascade.
2. Identify neurologic consequences of disaster cascade.
3. List stress-related concerns associated with disaster cascade.

Summary

Disaster cascade: multiple impact events in a large scale occurring within the same window in which individuals recover from the initial impact; from the standpoint of behavioral health, this restarts the disaster cycle, albeit with a lower baseline because a disaster has already been experienced; eventual result of all large-scale events, including disaster cascades, is resilience

Resilience: it is the most common outcome of any kind of human suffering; the prevalence of posttraumatic stress disorder and major depression vary greatly depending on the type of disaster; this can also lead to cognitive issues like attention-deficit/hyperactivity disorder or dementia; the impact of COVID-19 on the brain is a long-term disaster response of increased cortisol level; cognitive symptoms include distraction and inability to focus; physical symptoms are also notable; bimodal responses based on personality traits are very common in disasters in terms of behavior; people may tend to act out (eg, hostility, aggression, possibly substance abuse, unlawful activity) to show their distress; inaction manifests as isolation, disengagement, and not engaging even when allowed

Neurologic consequence: the limbic system and the prefrontal cortex are the systems most strongly impacted by large-scale disasters; the limbic system's purpose in a disaster is to keep people alive and safe; serotonin, dopamine, oxytocin, endorphins, and other chemicals that contribute to good feelings decline slowly, contributing to widespread burnout; the limbic system also constantly scans for threats; a consequence is misperception of others' intention; the activated limbic system is more likely to perceive interaction (eg, receiving text, being cut off on the road) as negative, threatening, or hostile in attempts to keep an individual safe; the prefrontal cortex is not as necessary for survival from an evolutionary standpoint; it does not contribute to logical thought and the limbic system is influential and controls a lot of actions; recommendations include slowing down and taking more time; this might lead to accurate interpretations of others’ actions and regulate response to others (eg, consider consequences and word choice); this helps to regulate and integrate the 2 systems

Impact of COVID-19: subconsciously, people are seeking increased levels of dopamine and serotonin, as well as endorphins and oxytocin; this can lead to actions considered out of character; substance abuse and reckless driving increase with large-scale disaster; nationally an increase of 20% in vehicular deaths have been seen since the beginning of the pandemic; people are gambling and shopping and spending impulsively; people are attempting to feel better about circumstances, but they frequently choose compromising methods; the speaker recommends appropriate techniques that do not have negative consequences

Stress-related concerns: burnout — is a consequence of imbalance; burnout occurs when too much mental, emotional, and physical energy is spent and less is received; compassion fatigue — loss of empathy; secondary traumatic stress contributes to compassion fatigue; it is a significant issue for health care workers, as they are constantly exposed to end-of-life and COVID-related impacts; moral injury — a term originally used to describe war-time field hospital triage situations; it now more widely refers to intense feelings of guilt, shame, or anger caused by a lack of resources necessary to accomplish a job; this applies to, eg, educators

Mitigating the impact: the most effective way to reduce burnout is to set and maintain healthy boundaries; free-time activities should be unrelated to work; compassion rewards are the antidote to compassion fatigue; people lose a bit of the ability to attend to and internalize compassion rewards when the limbic system is focused on threat scanning; expressions of gratitude are not threatening and consequently not recognized; as a result, people focus on the negative and ignore the positive work they are doing; the speaker encourages people to overexpress gratitude to mitigate this; environmental factors induce moral injury; it is not a personal failure; draw attention to all the work on any scale that has significant impact; with moral injury, people become overwhelmed by the challenges

Grief and loss: there have been direct and acute losses linked with COVID-19; it is likely to be emotionally more acute because of the way it affects the profound experience of loss over the last 2 yr; it is part of this large-scale disaster; most individuals mistakenly attempt to make others feel better when experiencing grief and loss but people respond most positively to being understood

Problem-solving communication: the brain is able to focus and be more engaged in learning and problem solving when neurologic integration occurs; physical movement (eg, getting up out of a chair) helps; it is important to be cognizant of adrenaline (ie, fight or flight response); when people are emotionally overwhelmed, it takes 30 to 60 min for adrenaline to be reabsorbed and for people to adapt; thinking about time and space is critical; continuing to pursue an issue when people have an activated limbic system is unlikely to be effective

Active listening: this is not problem-solving interaction; start with open-ended questions to learn more about someone's experience; in a disaster, it enhances speaker-listener connection; problem solving tends to increase disconnection; increasing connection enhances resilience; active listening helps the speaker process emotions and heal psychologically; this is not an attempt to help but to understand; active listening should be avoided in presence of compassion fatigue; it is necessary to recognize one's capacity limits and self-care before engaging in this type of support

Anger: anger shields individuals from experiencing more complicated feelings; anger is easier to access neurologically; the limbic system is prepared for it; it is more socially acceptable compared with fear or sadness; fear and sadness are internalized feelings; anger is an externalized feeling, directed toward an object; there is a great deal of anger related to feelings of powerlessness in the pandemic; these feelings are related to circumstances in general, being told what to do, and frustration over inability to solve the problem; these are fear responses that are expressed as anger

De-escalation techniques: an important element is self-awareness; nonverbal messages (eg, not crossing arms, keeping hands out of pockets) are important; slow down the speech, lower the voice, take a deep breath, and make it observable; mirror neurons encourage others to stay calm when the individual they interact with is calm; awareness of surroundings is important; do not block an angry person from access to exits; sitting next to or walking alongside someone demonstrates to them that someone is on their side; identify the root of anger through active listening; anger is a surface emotion and usually masks fear; ask open-ended questions (eg, who, what, where, when, why, and how); this model also includes self-support; do not ignore a high-intensity conflict situation (with a friend, family member, or patient); process through it and share it with someone else

The 4 ingredients of resilience: resilience is a process, not a goal; it is helpful to use a tree analogy to implement this; these 4 ingredients are highly impacted by disaster and individuals can use them to ground themselves moving forward into recovery in the next few years

Purpose: this is the fruit of the resilience tree; this is about motivation, what one is producing or doing; this is threatened in disasters, when external circumstances upturn them; focusing on the purpose with goals that are “the right size,” ie, narrowing the scope, increases the likelihood of achievement; success fosters self-efficacy and resilience; big goals always risk failure, which has negative consequences

Adaptability: it is the trunk of the tree that sways in the wind; a tree (or a person) that does not sway when necessary can break; this is the most challenging of the ingredients; human beings want to know what is coming and do not like change; adaptability involves becoming comfortable addressing unexpected negative events as challenges instead of threats; this requires the prefrontal cortex to remain involved in the response; with the sense of threat, the limbic system compels the individual to hide, fight, or run

Hope: there are opportunities to confront unexpected negative events; the course of action taken can increase adaptability; the byproduct of this is hope; optimism is not synonymous with hope; hope is reality based; hope is based on what can be achieved; individuals likely do not notice it during a disaster because of adverse events; the analogy is that hope is the moss growing on the north side of the tree; it is dark and cold but these conditions are suitable for hope

Connection: this is the root of the tree; according to the speaker, it was likely a semantic error early in the pandemic to refer to social rather than physical distancing; social connection is critical; eg, pets, a spiritual connection or relationship with a higher power, friends, family members, social groups, hobbies, are significant

Leadership considerations: important to realize the power of social learning and modeling; demonstrating to others the active ingredients of resilience and how to cope with things actively rather than avoiding them and model healthy boundaries can have a strong positive impact; it is important to realize actions are not designed to create more work; one should transform thinking and change emphasis; when considering modeling, simple and aggressive behaviors are more likely to be copied; it is essential to take a breath before responding; escalation is much faster than de-escalation; there is power in the opportunity to influence the behavior of others by simply pausing for 45 to 60 sec before responding, taking a noticeable deep breath, and then approaching a conversation

The elements of organizational culture: there is an opportunity in health care culture to leave behind unhealthy means of interaction used before the pandemic; core values should be identified and this should be followed up with action rather than discussion; this process includes 1) redefining what matters most, at the team, organization, or system level, 2) emphasizing these elements through communication, and 3) backing these elements up with resources

Behavioral health care elements: there are 4 elements; positive reinforcement — the most effective way to influence human behavior; individuals should choose rewards that are suitable to them; establish healthy boundaries — stick to them; share feelings and concerns — a big issue with health care workers is that others not in the field do not understand what the experience is like; establishing support networks is applicable to both sharing and trusting, ie, reaching out to trusted colleagues who share the individual’s perspective; debunk myth of indispensability — myth established in medical school in which a health care professional believes they are the only one who can follow their patient’s care from beginning to end; this is dangerous; it becomes important to be able to talk to a colleague, and get additional help or support when overwhelmed

Readings

Barzilay R, Moore TM, Greenberg DM, et al. Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry. 2020 Aug 20; 10(1):291; Haldane V, Foo CD, Abdalla SM, et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nature Medicine. 2021; volume 27:964–98; Mizrahi S. Cascading disasters, information cascades and continuous time models of domino effects. Int J Disaster Risk Reduct. 2020 Oct; 49:101672; Nawaz MW, Imtiaz S, Kausar E. Self-care of frontline health care workers: During COVID-19 pandemic. Psychiatr Danub. Autumn-Winter. 2020; 32(3–4):557-562; Russo SJ, Murrough JW, Han MH, et al. Neurobiology of resilience. Nat Neurosci. 2012 Nov; 15(11):1475–1484; Thomas DSK, Jang S, Scandlync J. The CHASMS conceptual model of cascading disasters and social vulnerability: The COVID-19 case example. Int J Disaster Risk Reduct. 2020 Dec; 51:101828.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mauseth was recorded at the 37th Annual Infectious Disease Conference, held in Seattle, WA, December 16-17, 2021, and presented by Providence Regional Medical Center Everett. For information on future CME activities from this presenter, please visit providence.org. Audio Digest thanks the speakers and presenter for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

IM691401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.