IT IS IMPOSSIBLE TO PREPARE FOR CES, BUT THEIR IMPACT CAN BE MITIGATED

A CE is a type of disaster event that is caused by and results in a complicated set of social, medical, and often political circumstances, usually leading to great human suffering and death, and requiring a broad and integrated response. ^{Reference Pakes3} Often, CEs occur in the context of war or epidemic; other examples include the Chernobyl disaster in 1986, the cholera epidemic in Haiti in 2010, Fukushima disaster in 2011, and the 2014-2016 Ebola epidemic in West Africa.

Although the scale of the system failure in low-resource settings that already struggle with lack of resources cannot be compared with the robust health-care systems in developed countries, conceptualizing the COVID-19 pandemic as a form of CE allows for placing the challenges of the response into a broader context. Various CEs share similar characteristics ^{Reference Cherepanov4} :

• It is impossible to be fully prepared for a CE.

• Its impact on the community and the responders is systemic and multilevel.

• It’s impact profoundly disrupts the fabric of social life.

• It overwhelms human resources, infrastructure, and logistic capability.

• Its responders can be the members of the same community and are subjected to the same ailments as their patients.

I further argue that, in the health-care system, CEs typically generate internal conflicts between

• the extensive needs and limited human and logistical resources;

• the emergency mode of operations and a heavily regulated health-care system;

• the needs for planning and preparedness and the demands of a rapidly changing situation; and

• having to provide patient care and not being able to ensure one’s own and family’s safety.

CEs REMIND HEALTH PROFESSIONALS ABOUT THEIR MISSION AND PURPOSE

Despite of all the hardship and confusion, work in a CE potentially can become a life-changing and rewarding experience. It underscores the value of camaraderie and strengthens peer bonding. For the mission-driven helping professions, it serves as a reminder of why we chose to do this work in the first place. CEs remind us of the fragility of what we took for granted, and teach us to appreciate what we have.

They also expand the understanding of the professional role to include fighting stigma, advocacy, and temoignage. Fighting stigma becomes an important component of community education because epidemics are often associated with stigmatization of the survivors. ^{Reference Abramowitz5,Reference Overholt, Wohl and Fischer6} Temoignage (or bearing witness) means that witnessing inequity and injustice in accessing health care adds more power to the advocacy. In this way, providers get the opportunity to use their experience to directly contribute to transformative change in the health-care system.

FRONTLINE WORKERS HAVE DIFFERENT PSYCHOLOGICAL NEEDS IN DIFFERENT PHASES OF THE EMERGENCY

The experience and psychological needs of the responders can be different at different stages of the disaster response, which are loosely based on Selye’s stress response classification ^{Reference Selye7} and is categorized as mobilization, resistance, and reentry. ^{Reference Cherepanov2}

SOME STRESSORS ARE WORSE THAN OTHERS: “DON’T CALL US HEROES”

It is important to keep in mind that the training and work experience have prepared first responders to manage routine job-related stresses and have allowed them to become aware of the limits of their endurance.

In CEs, the stresses can be extreme, and managing them remains a challenge. Overwhelming stresses make it more difficult to complete professional tasks and increase the probability of making mistakes. Even when responders rest, in their minds, they often still continue working and do not give themselves permission to de-stress.

In addition, some stressors carry a disproportional impact that leaves responders emotionally drained and physically exhausted. During CEs, most stresses come from the long work hours and not having enough time to recuperate, but they also come from uncertainty about the future, a sense of helplessness, and questioning the effectiveness of the work. Surprisingly, several responders told me that being called a hero made them uncomfortable because they believed that they were doing a job where they had to navigate moral dilemmas and make difficult decisions. In this context, being called a hero was experienced as a sort of dubious praise that only added additional pressure and expectations.

Imai et al. ^{Reference Imai, Matsuishi and Ito8} identified factors that influence health worker behavior during epidemics: fear of contagion, concern for family health, interpersonal isolation, quarantine, lack of trust in and support from their organization, information about risks and what is expected of them, and the stigma.

The most toxic stressor named by the trainees was “betrayal”—the belief that the organization, community, or family failed them when they needed their support the most. This feeling comes with the sense that the value of work has been minimized, discredited, or not acknowledged. Reduction in salary or inconsiderate words spoken by a superior or a community leader exponentially increase the potential for burnout.

The Substance Abuse and Mental Health Services Administration ⁹ has emphasized the importance of restoring predictability, control, and safety in coping with trauma.

During CEs, predictability is undermined by the rapidly changing and sometimes chaotic situation. Living in a “one day at a time” mode offers an alternative to long-term planning by focusing on what one does have control over. ^{Reference Cherepanov2}

In contrast to an unpredictable external reality, establishing routine in one’s personal life strengthens the sense of being in control. This can include small daily rituals before going to work and returning home: taking a few minutes for grounding or stretching to tune in. Taking time before going home helps to establish distance between work and personal life. This time allows the worker to decompress before seeing family members who expect a certain emotional presence from their loved ones.

Safety of responders is always the biggest concern in CEs. Although it is impossible to guarantee safety during an epidemic, diligently following safety precautions can increase the sense of control over the situation. ^{9,Reference Bickley10}

When not managed, chronic workplace stress can lead to the occupational phenomenon of burnout, which can significantly undermine professional and personal functioning, well-being, and health. The World Health Organization ¹¹ has identified the universal signs of burnout, such as feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism toward one’s job, and reduced professional efficacy.

PEER SUPPORT

Peer support is a critical component of managing psychological needs during a CE. Peer camaraderie and fellowship are all parts of the emergency response culture; first responders often believe that only their peers can fully understand them.

ANGER IS EVERYWHERE AND IT MASKS OTHER FEELINGS

Anger is probably the most common feeling reported during CEs; it is everywhere. Anger management becomes a priority, because when bottled up, suppressed, and unresolved, anger can escalate and be expressed in unsafe ways. It also can affect health. There is nothing cathartic about expressing anger, wrote Stokes, ^{Reference Stokes14} citing a Mistofsky study that linked angry outbursts to heart attacks and challenged the myth that expressing anger can be cathartic.

Based on my experience, anger often masks and substitutes other feelings that are far more difficult to acknowledge and express, such as fear, helplessness, sadness, and grief. Recognizing these underlying true feelings and expressing them for what they are can help to manage anger.

In addition, in a CE, the responders’ anger (that is often a façade covering helplessness) is sometimes directed at their institutions and the managers thereof, even though they, perhaps imperfectly, are part of the solution. This puts additional pressure on managers.

Providers can also become a target of the patients’ or their families’ misdirected anger, which can be emotionally difficult for the provider who believes that they have been doing everything they could. Here are some tips that can be helpful for managing anger in the workplace during CE:

• Identify the underlying feeling, eg, grief, fear, or sadness, and help to express it directly.

• Respond to feelings, not words.

• When anger is expressed at you, it does not mean it belongs to you, and you do not have to own it.

• Redirect if it gets out of control.

• Avoid placing yourself between a person and their anger, meaning that, if an individual is angry at the agency or someone else, reminding them that you are here in an attempt to help may defuse the situation.

• Chose words that sound both reassuring and grounding. For example, “I promise you that your loved one will get the best care possible.”

• Be mindful of your personal safety and the safety of others. It is important that a person can vent grievances in a way that is not harmful to themselves or others.

RECOGNIZING AND ADDRESSING FANTASIES

The mental state of extreme concentration in helping professions makes health providers prone to developing illusions and misperceptions. These cognitive aberrations that, in a predictable way, affect how an individual perceives oneself in relation to others are called fantasies. Acting out these fantasies threatens the integrity of care, carries the potential for boundary violation, and can lead to burnout; they also affect patient care and the safety of responders. ^{Reference Cherepanov2}

• The Rescuer fantasy

• The Superman complex

• The Helper’s fantasy.

The Rescuer fantasy is a subconscious belief that one must rescue or save another person from something bad, posited as a motive for certain actions or choices (Oxford Dictionary, s.v. “rescuer fantasy”). When acting upon this fantasy, a provider may feel that they alone are charged with the rescue mission and saving human lives.

Similarly, the Superman fantasy is based on the belief that Superman is the only one who can solve the problem. In reality, the “superman’s” interventions are not always wanted, and the superman does not take into consideration the natural path of coping with a situation: they offer quick fixes without taking responsibility for finding long-term solutions. It is not uncommon for a superman to actively seek out troubles to solve and thus “save the day.” Overestimating an individual provider’s role undermines collaborative efforts and is detrimental to the team’s work.

Both the Rescuer and the Superman fantasies come with the illusion of omnipotence, irreplaceability, and an inflated perception of one’s own role. They also are associated with perceiving other people as incapable of making decisions.

The Helper’s fantasy involves expecting appreciation and gratitude for one’s work. Finding meaning in their work through receiving appreciation makes providers vulnerable and dependent on external approval. Instead of approval, during an epidemic response, helpers may become targets of anger and hostility from those whom they are trying to help. ^{Reference Brueck15} This age-old phenomenon is reflected in the saying “No good deed goes unpunished!” Although the anger toward helpers is reflective of the whole larger situation, it can take them by surprise and leave them feeling disappointed and hurt. The ground assumption behind this fantasy is challenged by the realization that altruism and acts of kindness increase self-worth, and we do this work for our own self-satisfaction, to feel better about ourselves and fulfil our personal mission—in short, because it feels like the right thing to do.

SELF-AWARENESS OFFERS CHOICES

To counteract the detrimental impact of emotional over-engagement (common among helping professions in CEs), the self-awareness framework emphasizes the awareness of one’s own fantasies, countertransference, and biases, as well as existing choices in the areas of decision-making, risk assessment, and self-care. ^{Reference Cherepanov2} Introduction of this concept offers a different perspective on the self-care module, which was decreed an essential component of modern health-care systems governed by regulations and statutes. ^{Reference Kollack16} The self-care module has become the gold standard for helping professions, and includes recommendations about taking time for oneself through meditation, mindfulness, and grounding exercises. It has shown effectiveness in burnout prevention and has been credited with encouraging helpers to pay attention to their own personal needs.

However, it came as no surprise, that at least half of the trainees who spoke out, have previously pushed back at the offered self-care supports. Self-care, both as a philosophy and a tool, was perceived as a diversion from focusing on patients’ needs, and, most of all, it left the responders feeling like they were not trusted to make decisions about when and how to attend to their own needs. Other named concerns were:

• In the heat of the response, self-care may not be seen as a priority.

• Prioritizing self-care can be negatively perceived by the others, affect team dynamics, and put others at a disadvantage.

• Meditation, grounding, and mindfulness can make it difficult to remobilize and refocus on the work: “It makes me more vulnerable and weaker.”

Instead, in CEs, self-awareness becomes a particularly critical tool for ensuring quality and integrity of care as well as the health and safety of the responders. The concept of self-awareness focuses on realizing and exercising choices that empower responders to reestablish control over their own life and decision-making. The awareness of one’s limits and needs empowers one to make decisions about safety and self-care that are most appropriate for the situation and the professional role. ^{Reference Cherepanov1}

SUICIDE RISK AMONG FRONTLINE WORKERS IS REAL!

At times, frontline workers may have doubts about whether they make a difference and can question the meaning of their work. Updegraff et al. ^{Reference Updegraff, Silver and Holman17} cautioned that premature meaning-making may predict greater posttraumatic stress symptoms. In addition, things appear differently from a distance, and the meaning of the experience most likely will change as time passes.

The exposure to massive suffering and mortality may change the meaning and perceived value of life, resulting in recklessness, taking unnecessary risks, and even suicidal ideations or attempts. This trend has been confirmed by reports about increased suicides among COVID-19 health workers. ^{Reference Elwafaii18,Reference Cheney19}

In humanitarian work, the safety imperative (or absolute priority of safety) refers to the fundamental premise of how we can assess risks and prioritize safety for both the beneficiaries and the providers. ⁹ When existential despair and survivor’s guilt sink in, it is very easy to lose perspective and believe that joining the victims is the only moral choice left. ^{Reference Cherepanov2} Often in such situations, self-awareness is limited. In my global work, I have used 2 antitheses that serve as a grounding and reminder about the importance of safety:

• “There is no need to multiply the victims.” This statement, which is widely repeated among first responders, suggests that self-sacrifice is not going to help resolve the situation and means that fewer patients will be helped.

• “Your life doesn’t belong to you only.” Questioning the value and meaning of life is often driven by identification with the victims; this statement reminds responders about their responsibility to their family, who worries about them and expects that their loved one will do everything they can to stay safe, if not for themselves then for the family’s sake.

IT IS EASIER TO ADAPT TO EMERGENCY THAN TO REENTRY

Various studies of emergency responders have demonstrated that reentry can be psychologically challenging and has been associated with increased risks for substance abuse, depression, family breakup, and suicide. ^{Reference Hodgkinson and Stewart20} Both aid workers and frontline health-care responders have disclosed their fears about what would happen after the emergency was over. And indeed, some have reported easier psychological adjustment to the emergency mode than readjustment to “normal life.” ^{Reference Cherepanov2,Reference Cherepanov21}

To prepare and plan for reentry, emergency workers need to be aware of these challenges and know how and when to reach out for professional help. When work-life starts returning to normalcy, providers can anticipate dealing with following issues:

• Not being fully emotionally present with family and friends

• Not being able to experience happiness and other strong emotions

• A possible increase in conflicts at home and work

• Anhedonia (lack of energy and drive)

• Poor sleep, anxiety, depression, irritability, and anger

• Social isolation, having no desire or energy to socialize

• Traumatic symptoms, such as intrusions, flashbacks, nightmares, or survivor guilt

• Increased alcohol and drug use

• Being “stuck in the past,” thinking and talking only about the CE

• Worsening somatic problems, such as hypertension and diabetes

Usually, these symptoms go away fairly quickly. If they do not improve with time, get worse, or lead to developing the feeling that life is not worth living or suicidal thoughts, it is important to seek professional supports.