Every day, Filipino health-care workers exert tremendous physical effort in the medical trenches to care for new coronavirus disease (COVID-19) patients. The public, meanwhile, has nobly contributed to providing for needs like food, shelter and transport.
So who takes care of their minds?
Psychiatrists have been mobilizing to support medical front-liners since the start of quarantine. In a meeting of clinical department heads of The Medical City (TMC) on March 13, Dr. Imelda Batar, chair of the Department of Psychiatry, brought up the idea of psychosocial support. “In any crisis, psychological issues will come up and will have to be appropriately dealt with. My anticipation is born of our work as mental health professionals in previous disasters and emergencies.”
Batar is also a trained trainer in psychosocial response to disaster and psychosocial processing as intervention.
The first support group created at TMC was for quarantined health-care workers, followed by two other support groups: one for doctors and nurses of the emergency room (ER) and of the intensive care unit (ICU), and another for doctors and nurses attending to noncritical patients with COVID-19, persons under investigation (PUIs) and persons under monitoring (PUMs).
There was already a felt need to support medical front-liners even before the lockdown, says Dr. Daryl Lindo-Calleja, consultant director of TMC’s Center for Behavioral Health. “We saw a sudden surge in the number of patients in the ER. There were also problems with manpower, because some of our health-care workers were in quarantine.” Fortunately, hospital management has long recognized the importance of mental health, Calleja notes; psychiatric consultations at the Center for Behavioral Health for TMC employees are among their health benefits.
Psychological first aid
What constitutes psychosocial support?
“Psychological first aid, processing, crisis intervention, medication and other group and individual therapies,” says Dr. Norieta Balderrama, chair of the Department of Psychiatry at the University of the East-Ramon Magsaysay Memorial Medical Center (UERMMMC), where a program for front-liners was in place and disseminated to different departments two days after lockdown.
“One-on-one counseling is given by psychiatrists to front-liners who have been referred by their supervisors, and lately, even by co-staff members,” says Batar. “We reach out to them via ‘#UsapTayo,’ a psychosocial support kamustahan.”
The kamustahan is how peers check on an assigned health-care worker through Viber or SMS, adds Calleja. “We ask how they are doing, their current stresses, their ways of coping. We open lines of communication with assigned front-liners and let them know they can talk to us about daily struggles they are unable to relay to their usual sources of support, such as family, because they do not want to make them worry.”
TMC’s Department of Psychiatry has partnered with psychologists from the Emmaus Center for Psycho-Spiritual Formation to provide counseling and emotional support to families of front-liners, as well.
“Support groups also have as participants representatives of the Human Capital Management Group, known as the Human Resource Department in other organizations,” says Batar. “So, if a quarantined personnel is worried about her leave credits or getting clearance to go back to work, someone in the group can answer her query.”
Worst fears
There’s a lot going through the minds of front-liners. “Among their worst fears are contracting COVID-19, and confusion about protocols and adjusting to their roles since they have to do other procedures,” says Balderrama. “Professionally, they worry about expectations, and that they are being sent to the COVID area unprepared. Personally, they fear being alone during quarantine and not being able to see family.”
Quarantine itself is another challenge, says Calleja. “There is that loss of normal routine. They become frustrated, bored and helpless with the limitations in activities. We encourage them to try and make a daily routine to give them that sense of ‘normalcy.’
“They have accepted the fact that as health-care professionals, they are exposed to diseases, but most of them fear that they can be carriers and transmit the virus to their families,” adds Calleja. “Most are mothers, daughters or sons to senior citizen parents. That is why to ensure that their families aren’t exposed, many choose to stay in the hospital. It is a great sacrifice, so we encourage them to stay connected to their families, their emotional anchors, through technology. Although there is physical distance, it doesn’t mean we cannot be emotionally connected.”
Batar says, “Being confronted with death and dying on a day-to-day basis and feeling a loss of control are, I think, the most difficult challenges faced by the health-care system today.”
Demoralizing
Batar brings up “a very important mental health issue” that plagues these workers: discrimination. “They are sent out of their apartments, ostracized by their community, and even literally socially isolated by families. This, regardless of whether these workers have been tested or not.”
Then, in some hospitals, there is the utter, demoralizing lack of management support, Batar notes. “There are stories from our colleagues in one government hospital of how the staff sourced PPE (personal protective equipment) on their own, because of an inability of management to respond appropriately to their needs. This is a failure of psychosocial intervention in this pandemic crisis. Anxieties are escalating there, possibly leading to anger.”
Yet, despite obstacles, health-care workers have soldiered on, finding hope when there seems to be little left. In Batar’s opinion, what has kept them productive and effective is a combination of management support, as they have to be assured of adequate protection and benefits; staff support, where “they work as a team, and they have each other’s backs”; family support; a clear set of priorities and sense of responsibility; true altruism in service; and finally, essentially, “a belief in God, the hope and faith that all this will pass.”
“They are more resilient if they have the capacity to think of solutions to their problems,” says Balderrama. “What keeps them going is related to the profession, the reason they became nurses and doctors: an intrinsic dedication and wanting to heal and help others. They find hope when patients get well.”
“Resilience in individuals can be explained with a balance scale,” says Calleja. “On one end of the scale are strengths, while on the other end are negative experiences. Crisis situations make the negative end heavier and may cause imbalance. But in some individuals, inner strength, skills, social support and spirituality do help counterbalance the negative end.”
Extension of the ICU
Things come into greater play in the ER, which, at TMC, Batar recounts, “has become an extension of our ICU. Critically ill patients who cannot be transferred to our filled-up ICU, and whose families refuse to transfer to another hospital, stay in the ER—many, for several days. The staff have to care for these patients beyond their usual competencies. As one front-liner says, ‘Mga code, sanay naman kami dyan. Pero ’yung sunod-sunod, araw-araw . . . ’
(A code is an alarm sounded when a patient shows a flat line on an ECG.)
“More and more ERs in the country are being taught to think and anticipate COVID rather than non-COVID, however,” says Batar, “so anyone who comes through that sliding door is potentially infected with this virus—this enemy, a lethal, uncompromising yet largely misunderstood enemy.”
The reality, however, is that front-liners who survive the Philippines’ COVID-19 crisis will need to process what happened long after the virus has been controlled, and this nightmare ends. “There will be people who may need further support or a formal psychiatric consult, depending on the impact of their experiences during this crisis,” says Calleja.
“We still do not know the full intensity of this pandemic’s long-term impact on our health-care workers.”
“We have to reach out to them,” insists Balderrama.
“Every one of us will need to find internal and external support after this crisis, but most especially, those who have come face-to-face with death,” concludes Batar. “This has become more than just biological warfare. It has shattered our lives and brought us to our knees, in more ways than one.”
“Some people did not initially understand what mental health professionals do in crisis situations. Now, many of them do.”