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David Hao, MD, wasn’t emotionally prepared for the crush of severely ill patients with coronavirus disease 2019 (COVID-19) who came under his care in March 2020. Many were young, sedated, and dying alone. Sometimes while FaceTiming with their families, Hao saw very young children on the screen.
“It was frightening,” Hao, an anesthesia resident at Massachusetts General Hospital in Boston, said in an interview. “A lot of the things that we typically see in the intensive care unit with passing [away]—in terms of people being able to chat with their family members, being able to understand and communicate with clinicians about what exactly is going on—was taken away from them.”
To talk through his experiences, Hao reached out to a therapist. But he didn’t use the hospital’s employee assistance program or its peer support system. Instead, he contacted The Emotional PPE Project, one of at least 3 volunteer organizations that sprang up early in the pandemic to link health care workers with licensed mental health practitioners who were willing to counsel them for free.
The Emotional PPE Project was attractive because its therapists made sessions easily available via Zoom—something his hospital’s programs were not doing at the time, Hao said. The project was also separate from the hospital. Although Hao has been candid about his recent contact with a therapist, he said seeking assistance within the institution “feels taboo to a lot of people. They're afraid that their name is going to be listed somewhere.”
The pandemic’s myriad stressors—loss of life, safety fears, supply shortages, long hours, isolation—have raised alarms about the psychological toll on health care workers. Although many hospitals offer mental health services for employees, those on the front lines may fear being viewed as weak or incompetent if they use them.
“The culture of medicine tells you, suck it up,” Jessica Gold, MD, an assistant professor of psychiatry at Washington University in St Louis, Missouri, said in an interview. Gold wrote an editorial in the BMJ about the pandemic’s psychological risks to health care workers, including posttraumatic stress disorder, depression, and substance use disorder. The editorial accompanied a meta-analysis of research on the psychological responses of health care workers during virus outbreaks. Among the findings: access to psychological interventions can help protect health care personnel from emotional distress.
That’s where The Emotional PPE Project and 2 other groups, Project Parachute (now part of Therapy Aid Coalition) and Caring for Caregivers NYC, have stepped in. They’ve aimed to make it easier for health care workers to obtain mental health services—a mission that’s grown during the second wave of the pandemic and could linger even after the public health crisis subsides.
A Wellspring of Goodwill
When the pandemic began, support for frontline health care workers was widespread. Among their advocates was Ariel Brown, PhD, a neuroscientist at Sage Therapeutics, a Cambridge, Massachusetts–based company that develops medications for brain disorders. As COVID-19 case numbers climbed in March, she reached out to her friend and neighbor, Daniel Saddawi-Konefka, MD, MBA, Massachusetts General’s anesthesia residency program director, with an offer of help.
Before the pandemic, Saddawi-Konefka had told Brown of his concern for his trainees’ emotional needs. With COVID-19, those young physicians faced even more daunting job demands as well as stress on their personal lives, Saddawi-Konefka said in an interview. He asked Brown to consider ways to get them support.
Brown notified therapist friends on Facebook. Within a few hours, nearly 70 of them agreed to volunteer to counsel residents, including Hao. The project grew quickly in scope. Soon, The Emotional PPE Project website contained a directory of 500 mental health practitioners in every state. “It was this self-driving force,” Brown said. “Every time we'd put something new out there, we got feedback that it was a good idea. And so, we just kept building.”
Similarly, Project Parachute started as a “tiny local effort” to link health care workers to private practice psychologists and social workers, founder Stephanie Zerwas, PhD, a clinical psychologist, said in an interview. In addition to her private practice, Zerwas is an associate professor and clinical director of the Center of Excellence for Eating Disorders at the University of North Carolina in Chapel Hill.
Her initial call for help drew 90 volunteers statewide, but requests to expand into other states poured in. Eleos Health, a Boston-based company that provides digital tools for behavioral health, built a website for Project Parachute that attracted 600 therapists nationally.
In December 2020 Project Parachute became part of Therapy Aid Coalition, a larger relief organization that provides free or low-cost therapy to all essential workers.
Both The Emotional PPE Project and Project Parachute have welcomed all health care workers, even those not involved in direct patient care. “We wanted to serve anybody who works in a central position in the hospital, like in sanitation,” Zerwas said. The pandemic, she added, “is affecting everybody.”
Before the merger, Project Parachute collected workers’ personal information so that a volunteer could personally match them to a therapist. In contrast, Therapy Aid Coalition uses an algorithm to match each worker to 5 mental health professionals, founder Jennifer Silacci, LCSW, a trauma therapist in Boulder, Colorado, said in an interview.
Similarly, The Emotional PPE Project provides workers with a list of mental health practitioners in their state. A worker simply calls or emails a provider on the list. Other than the therapist, Brown said, “No one knows they’re reaching out.”
A Targeted Approach
Caring for Caregivers NYC took a more targeted approach, serving mostly emergency physicians in New York City. Fear of professional repercussions presents a tremendous barrier to physicians seeking mental health treatment, one of the founders, private practice psychiatrist Lori Plutchik, MD, noted in an interview.
Both Plutchik and her cofounder, licensed clinical psychologist Marianna Strongin, PsyD, counseled survivors of the September 11, 2001, World Trade Center attacks. Spotting another need for crisis intervention as the pandemic took root, they recruited about 60 volunteer therapists from their professional network—“people we’ve worked with and trust,” Plutchik said.
Awareness of the need grew with the suicide in April of Lorna Breen, MD, clinical director of the emergency department at NewYork-Presbyterian Allen Hospital in Manhattan. Breen had contracted COVID-19 herself, and her death, which the media widely reported, “really hit the medical community in New York City,” Strongin said in an interview. “We realized we were onto something even bigger, that maybe COVID was having neurological issues and causing depression, anxiety, all kinds of things.”
Plutchik and Strongin publicized their service by reaching out to people they know in the medical community and posting on Twitter. Plutchik interviews physicians briefly before matching them with a therapist. She said physicians can be particularly discerning about the quality of their own care providers and may find it daunting to locate a good therapist. “They simply don’t know where to start,” she said.
Over the Edge
For some health care workers, contacting one of these services is their first encounter with mental health care. The exhaustion and trauma of dealing with patients with COVID-19, along with fear of infecting family members, have “pushed them over the edge to seek out treatment,” Plutchik said.
Not only is it upsetting to see so many patients dying, “It’s the way that patients are sick,” she added. “It’s the gasping for air, the not having enough resources to take care of people.”
Difficulty sleeping—an early sign of depression and anxiety—is common. “After working a 12-hour shift, they just cannot put away what they’ve seen, and these are ER doctors who are used to seeing really gory stuff and still coming home and going to sleep,” Strongin said. Nine months into the pandemic, she sees a lot of burnout—a state of mental and emotional exhaustion brought on by long-term stress.
Resentment is common, too. Some workers feel let down by their employers, which contributes to the awkwardness of seeking counseling through work. Especially early in the pandemic, inadequate personal protective equipment (PPE) triggered feelings of helplessness for workers who felt duty bound to stay on the job despite risks to their own and their family’s safety. Strongin said she advised a physician on how to demand frequent replacement of her N95 respirator as a condition of doing her job.
Then there’s the public’s failure to grasp the gravity of the situation, which has given rise to unsafe behavior. “A post on Instagram of people flying places or traveling, or seeing people sort of disregard public health advice—it’s hard [for health care workers] not to take that personally sometimes,” Zerwas said. Nurses in Texas and South Dakota have written viral Twitter posts in which they expressed frustration over treating very ill patients who denied the severity or even the existence of COVID-19.
Silver linings are rare in a pandemic, but advocates hope this one accelerates a movement to normalize health care workers’ mental health needs. In fact, some prominent physicians have opened up about their own experiences. For example, Esther Choo, MD, MPH, a professor of emergency medicine at Oregon Health & Science University who is an outspoken advocate for diversity in medicine, started a Twitter conversation in July by revealing that she had seen a therapist and taken antidepressant medication. In a subsequent column for The Washington Post, Choo described how she initially hid a bout of depression during her residency that sapped even her interest in her own wedding plans.
Hao said such candor from health care leaders is “a big step toward creating a movement of change.” Personally, he said, he’s come to realize that seeking counseling should be considered mental health maintenance rather than a last resort during troubled times.
Meanwhile, some hospitals have expanded mental health services for staff and made it easier to reach out for help. For example, the 8-hospital Mount Sinai Health System in New York City in April created a Center for Stress, Resilience, and Personal Growth, which provides workshops, screening, and mental health care referrals to help frontline health care workers cope with the intense stress of providing COVID-19 care.
On a policy level, the bipartisan Dr. Lorna Breen Health Care Provider Protection Act, introduced in July 2020, proposed a grant program to support mental health care for health professionals involved in the COVID-19 response as well as research on preventing burnout, improving resilience, and reducing barriers to mental health treatment.
The Road Ahead
Still, there is a long road ahead. All of the projects’ leaders told JAMA of upticks in demand for their services as COVID-19 cases surged in December 2020, even as health care workers received the first COVID-19 vaccine doses in a mark of progress toward ending the pandemic. (Therapists with The Emotional PPE Project have voluntarily reported treating about 500 health care workers in 42 states as of early January, while Caring for Caregivers NYC treated about 50. Project Parachute provided counseling for about 500 before its merger.)
As sick patients once again filled hospital beds, many health care workers’ frustrations returned. Some still lacked PPE. “They are daunted, facing another surge, and they are fed up with political and social factors,” Strongin said via email. Mental health specialists aren’t certain what’s driving the increased requests for support—heightened stress due to a new surge in cases, more public awareness of services, or workers dealing with the effects of the first wave, Strongin cautioned. In fact, experts expect even more health care workers to seek treatment as the pandemic subsides. Generally speaking, Plutchik said, “There's a spike in people presenting for treatment about 12 months after” a trauma.
Anticipating that need, the founders of The Emotional PPE Project and Caring for Caregivers NYC expect to operate at least through 2021. Although launched during the pandemic, Therapy Aid Coalition has a permanent mission to make therapy accessible to all workers who need it. It’s already responded to emergencies such as the 2020 wildfire season and the Christmas 2020 bombing in Nashville.
The coalition has crafted partnerships with companies to help support its 3000 therapists, some of whom have already complained of burnout, Silacci said. For example, Austin, Texas–based VidHealth provides free telehealth platforms. A Boulder, Colorado–based not-for-profit, the Somatic Experiencing Trauma Institute, conducts training for therapists and assists with grant writing and publicity. Frontliners Med, a PPE company founded by 2 nurses, allocates a portion of its revenue to fund therapy for employees of hospitals that buy its products.
“One of the things we [at Project Parachute] were trying to figure out is, how do we have a sustainable mission? Are we just a COVID organization or is there a way to continue this work?” said Zerwas, who has joined the Therapy Aid Coalition’s board. After all, she added, “there will always be crises in the United States.”
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Jaklevic MC. Therapists Donate Their Time to Counsel Distressed Health Care Workers. JAMA. 2021;325(5):420–422. doi:10.1001/jama.2020.25689
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