This article is dedicated to Ronald Waite, my uncle, who died of Covid-19 in May 2020, and his children Bryan Waite and Dr. Laura Moore.
At the time this post will be published, according to the Centers for Disease Control (CDC), over 340,000 United States (US) citizens will have died from Covid-19. The psychological toll is incalculable. Thousands more have had traumatizing near-death experiences, including enduring medically-induced coma for the purpose of lung ventilation (Zimmerman et al., 2020). Medical trauma can result in the development of posttraumatic stress disorder (PTSD), generalized anxiety disorder, and major depression (Kaseda & Levine, 2020). Additionally, marginalized groups have been disproportionately affected. According to the American Public Media Research Lab, based on CDC statistics, one out of every 1,000 black Americans in the US has died due to Covid-related medical issues. Certain geographical regions of the US have also been disproportionately affected. The same study showed that in New York City, one out of every 200 individuals has died from Covid-19. Their sudden and unexpected deaths have psychologically impacted millions of loved ones, and their sudden deaths often result in complex bereavement (Kokou-Kpolou, Fernández-Alcántara, & Cénat, 2020). Psychotherapists may at some point have a client who has died by or lost a loved one to Covid-19, or even lost a family member themselves. Survivors present with a unique set of challenges: survivor’s guilt, chronic health issues, grief, anger, and PTSD, all of which are compounded by the negative psychological effects of isolation. As the large-scale psychological effects of a pandemic at this level are unknown and unprecedented, the purpose of this article is to provide a synopsis of what those who have survived the illness or lost a loved one to Covid-19 may be presenting with and provide recommendations on how clinicians can best help them in therapy. This article will provide a synopsis on issues patients may face due to exposure to Covid-19 news and media, guilt and grief, the psychological effects of medical trauma from Covid-19, the struggles of Covid-19 “long-haulers,” and clinician self-care during the pandemic.
Media and Social-Media Coverage
It is unclear as of now how the sheer number of deaths combined with constant media coverage may be psychologically affecting survivors of the virus. As we have not had a pandemic of this scale in the US for over a century, substantial research on the media’s impact on re-traumatization during a worldwide pandemic does not exist. One recent study found a moderate, direct relationship between media exposure to Covid-19 and mental distress (Riehm et al., 2020). Based on what research has shown in somewhat comparable previous circumstances, such as the 9-11 terrorist attacks, exposure to traumatic news media can prolong and enhance PTSD symptoms (Propper et al., 2007; Bernstein et al., 2007). As pandemic isolation increases our dependence on media/social media for a sense of connection to others, we are exposed to more Covid-19 news, and a positive feedback loop may be emerging. It is possible that our clients are seeking connection through the news and social media but are in turn being traumatized. It is natural for survivors of Covid-19 to want to seek out information, statistics, and anecdotal information, as knowledge can lead to an enhanced sense of security and control (McManus, Leung, Muse, & Williams, 2014). However, for those who have lost a loved one or have themselves been hospitalized, the constant exposure to Covid-19 stimulus can prolong psychological distress. Similar to 9-11 survivors who were negatively impacted by conspiracy theories, clients who have lost a loved one to Covid-19 may become angry when exposed to anti-mask propaganda or scientific misinformation. Clinicians should consider helping our clients to disconnect or decrease user time from news media when strong feelings of anger or fear arise. For a sense of connection, clients can call loved ones, connect over Skype, or interact with loved ones in their home. Therapists can also help patients consider limiting their exposure to media to less than an hour a day or to use social media solely for the purpose of maintaining relationships. For patients who are heavily reliant on social media for connection, you may consider incorporating dialectical behavioral therapy skills (DBT) to handle strong emotions which may arise, such as Letting Go or Opposite Action (Linehan, 2015).
Guilt, trauma, and grief
Survivors who have lost loved ones may be guilt-ridden and questioning the reason for their own survival. For those who have lost loved ones in a sudden, traumatic way, such as from Covid-19, this is a normal trauma and/or grief response (Barr, 2004). Perhaps the most valuable assets we can provide our clients in this circumstance are normalization, empathy, and psychoeducation (Buck & Hester, 2004). Clients may be comforted to know that exaggerated self-blame is a diagnostic criterion for posttraumatic stress disorder, it serves an evolutionary purpose, and that guilt and shame are normal emotions associated with sudden loss. Although the prevalence for PTSD from Covid-19 is unknown, a study looking at SARS-CoV-1 survivors in 2003 found that around 47.8% met criteria for PTSD in the aftermath and 25.6% still suffered from PTSD 30-months post-SARS (Mak et al., 2010).
Clients who believed they may have been the ones to expose their deceased loved one to Covid-19 may experience a profound sense of guilt. Clinicians can remind them that Covid-19, like the flu, is invisible. Cognitive behavioral techniques can be used to challenge the validity of “fault” in unknowingly transmitting a communicable disease like Covid-19 through methods like Socratic questioning (Haller et al., 2020). Validating and fully accepting these difficult emotions in the therapy room can be painstaking but providing the space can help to alleviate the pain for our clients (Benitez et al., 2019).
Health-care workers may present with a variation of strong emotions, including guilt, anger, and exhaustion. This population has also been working under extreme pressures including lack of personal protective equipment, understaffing, and a high rate of physical exhaustion (Anmella et al., 2020). Front-line medical workers are more likely to have a PTSD diagnosis than the general population (Robertson & Perry, 2010) and based on research from the psychological implications of previous viruses, they may be more likely to have PTSD if exposed themselves to Covid-19. One systematic review looking at the psychological consequences of infectious disease outbreak (after 2003 SARS outbreak, the H1N1 outbreak in 2009, and occupational exposure to HIV) indicated that the average prevalence of PTSD among health-care professionals was approximately 21% and was even higher if exposed to the virus themselves. A staggering 40% of them reported persistently high PTSD symptoms three years post-exposure (Kartavya et al., 2016).
For those with the most serious breathing difficulties due to Covid-19, ventilators may have been used for breathing support. Patients are typically sedated during this process and may not remember it. However, survivors who have been placed on ventilators have a myriad of physical, cognitive, and psychological ailments which develop during intubation (Scheunemann, Skidmore, Reynolds, & Charles, 2018). According to a May 2020 study in the journal of Critical Care Medicine, around 37.5 % of individuals placed on a ventilator for Covid-19 will not survive, characterizing this event as a near-death experience (Auld et al., 2020). The cognitive effects of being placed on a ventilator are also well-documented; according to The Society for Critical Care Medicine, anywhere from 30%-80% of individuals who leave the intensive care unit (ICU) have cognitive dysfunction, and up to 50% cannot return to work within one year (Scheunemann et al., 2018). Apart from ventilation, patients may have had other Covid-related life-threatening experiences, including stroke, seizure, heart damage, or lung damage (Hess, 2020). In general, around 10% of individuals in the ICU will eventually develop PTSD (Marra, Pandharipande, & Patel, 2017). Individuals who have been ventilated are even more likely to develop PTSD than others in the ICU (Shaw et al., 2009). It has also been suggested that the stress response associated with PTSD from Covid-19 may cause immunosuppression, and thus potentially make traumatized patients even sicker (Liang, Zhu, & Fang, 2020). After a hospitalization for Covid-19, survivors and their loved ones may experience intrusive thoughts and flashbacks to their experience in the hospital. They may fear doctors’ offices, hospitals, or any stimulus related to Covid-19. They may also fear reinfection or the emergence of long-term symptoms (e.g., ischemic stroke in the future).
An unknown percent of Covid-19 survivors will experience long-term symptoms, persisting past three months. Some of these symptoms include brain fog, which is marked by a frustrating loss of intellectual functioning, loss of sense of smell and taste, poor concentration, difficulty working long hours, and difficulty following conversation (Yelin et al., 2020). Clients may think they have permanent brain damage, which in turn can cause anxiety. They may be frustrated that they are not functioning as well cognitively as they are used to. There is data to back-up their concerns; one French study assessing patients 100 days after hospital admission found the most frequently reported persistent symptoms were fatigue (55%), difficulty breathing (42%), loss of memory (34%), and concentration and sleep disorders 28% and 30.8%, respectively (Garrigues et al., 2020).
They may feel shame about their new difficulties or needing extra support. Clients may be concerned or feel hopeless that there is little scientific data showing when or if they will start to feel “normal” again. If they are feeling alone in these experiences, they may find comfort in knowing there are established support groups, including the “Long Covid Support Group” on Facebook and wearebodypolitic.com, where survivors are gathering to connect and talk about their experiences. Clients who are frustrated by their lack of sense of taste and smell have found comfort in www.abscent.orgwhich is conducting research on the psychological effects of losing these senses. In terms of intervention, clients with frustration regarding these perceived losses may benefit from mindfulness and acceptance-based approaches (Owen, 2014).
Clinician Self-Care, Final Words
Covid-19 has altered our lives in profound ways. Psychotherapists play a unique role in the pandemic, as we are in a healing profession. With this in mind, we must take care of ourselves as well. We can start by acknowledging how difficult this year has been. In the coming year, we are going to make leaps and bounds in developments how we treat the psychological effects of Covid-19. My hope is that this article provides a vantage point into understanding what survivors are experiencing and allows us to better serve them.
Cite This Article
Carelli, O. (2021, January). Working with survivors of Covid-19. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/working-with-survivors-of-covid-19
Anmella, G., Fico, G., Roca, A., Gómez-Ramiro, M., Vázquez, M., Murru, A., . . . Vieta, E. (2020). Unravelling potential severe psychiatric repercussions on healthcare professionals during the COVID-19 crisis. Journal of Affective Disorders, 273, 422-424. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/j.jad.2020.05.061
Auld, S., Caridi-Scheible, M., Blum, J. M., Robichaux, C. J., Kraft, C. S., Jacob, J. T., Jabaley, C. S., Carpenter, D., Kaplow, R., Hernandez, A. C., Adelman, M. W., Martin, G. S., Coopersmith, C. M., & Murphy, D. J. (2020). ICU and ventilator mortality among critically ill adults with COVID-19. MedRxiv:The Preprint Server for Health Sciences, 2020.04.23.20076737. https://doi.org/10.1101/2020.04.23.20076737
Barr, P. (2004). Guilt- and shame-proneness and the grief of perinatal bereavement. Psychology and Psychotherapy: Theory, Research and Practice, 77(4), 493-510. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1348/1476083042555442
Benitez, C., Southward, M. W., Altenburger, E. M., Howard, K. P., & Cheavens, J. S. (2019). The within-person effects of validation and invalidation on in-session changes in affect. Personality Disorders: Theory, Research, and Treatment, 10(5), 406-415. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1037/per0000331
Bernstein, K. T., Ahern, J., Tracy, M., Boscarino, J. A., Vlahov, D., & Galea, S. (2007). Television watching and the risk of incident probable posttraumatic stress disorder: A prospective evaluation. Journal of Nervous and Mental Disease, 195(1), 41-47. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1097/01.nmd.0000244784.36745.a5
Buck, B., & Hester, N. (2018). “Just like someone without mental illness, only more so”: Normalizing beliefs and their buffering effects on psychiatric symptoms. Journal of Social and Clinical Psychology, 37(1), 69-82. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1521/jscp.2018.37.1.69
Garrigues, E., Janvier, P., Kherabi, Y., Le Bot, A., Hamon, A., Gouze, H., Doucet, L., Berkani, S., Oliosi, E., Mallart, E., Corre, F., Zarrouk, V., Moyer, J. D., Galy, A., Honsel, V., Fantin, B., & Nguyen, Y. (2020). Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. The Journal of Infection, S0163-4453(20)30562-4. Advance online publication. https://doi.org/10.1016/j.jinf.2020.08.029
Haller, M., Norman, S. B., Davis, B. C., Capone, C., Browne, K., & Allard, C. B. (2020). A model for treating COVID-19–related guilt, shame, and moral injury. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S174-S176. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1037/tra0000742
Hess, D. C., Eldahshan, W., & Rutkowski, E. (2020). COVID-19-related stroke. Translational stroke research, 1.
Hong, X., Currier, G. W., Zhao, X., Jiang, Y., Zhou, W., & Wei, J. (2009). Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: A 4-year follow-up study. General Hospital Psychiatry, 31(6), 546-554. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/j.genhosppsych.2009.06.008
Vyas, K. J., Delaney, E. M., Webb-Murphy, J. A., & Johnston, S. L. (2016). Psychological impact of deploying in support of the US response to Ebola: A systematic review and meta-analysis of past outbreaks.. Military Medicine, 181(11-12), e1515–e1531, https://doi.org/10.7205/MILMED-D-15-00473
Kaseda, E. T., & Levine, A. J. (2020). Post-traumatic stress disorder: A differential diagnostic consideration for Covid-19 survivors. The Clinical Neuropsychologist, doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1080/13854046.2020.1811894
Kokou-Kpolou, C., Fernández-Alcántara, M., & Cénat, J. M. (2020). Prolonged grief related to COVID-19 deaths: Do we have to fear a steep rise in traumatic and disenfranchised griefs? Psychological Trauma: Theory, Research, Practice, and Policy, 12, S94-S95. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1037/tra0000798
Liang, X., Zhu, Y., & Fang, Y. (2020). COVID‐19 and post‐traumatic stress disorder: A vicious circle involving immunosuppression. CNS Neuroscience & Therapeutics, 26(8), 876-878. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1111/cns.13431
Linehan, M. M. (2015). DBT® skills training manual (2nd ed. ed.). Guilford Press, New York, NY. Retrieved from http://search.proquest.com.ezproxylocal.library.nova.edu/books/dbt®-skills-training-manual/docview/1685838835/se-2?accountid=6579
Mak, I. W. C., Chu, C. M., Pan, P. C., Yiu, M. G. C., Ho, S. C., & Chan, V. L. (2010). Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors. General Hospital Psychiatry, 32(6), 590-598. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/j.genhosppsych.2010.07.007
Marra, A., Pandharipande, P. P., & Patel, M. B. (2017). Intensive Care Unit Delirium and Intensive Care Unit-Related Posttraumatic Stress Disorder. The Surgical clinics of North America, 97(6), 1215–1235. https://doi.org/10.1016/j.suc.2017.07.008
McManus, F., Leung, C., Muse, K., & Williams, J. M. (2014). Understanding ‘cyberchondria’: An interpretive phenomenological analysis of the purpose, methods and impact of seeking health information online for those with health anxiety. The Cognitive Behaviour Therapist, 7, 13. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1017/S1754470X14000270
Owen, R. (2014). Living with the enemy: Coping with the stress of chronic illness using CBT, mindfulness and acceptance. Routledge/Taylor & Francis Group, New York, NY. Retrieved from http://search.proquest.com.ezproxylocal.library.nova.edu/books/living-with-enemy-coping-stress-chronic-illness/docview/1518033998/se-2?accountid=6579
Propper, R. E., Stickgold, R., Keeley, R., & Christman, S. D. (2007). Is television traumatic?: Dreams, stress, and media exposure in the aftermath of September 11, 2001. Psychological Science, 18(4), 334-340. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1111/j.1467-9280.2007.01900.x
Riehm, K. E., Holingue, C., Kalb, L. G., Bennett, D., Kapteyn, A., Jiang, Q., . . . Thrul, J. (2020). Associations between media exposure and mental distress among U.S. adults at the beginning of the COVID-19 pandemic. American Journal of Preventive Medicine, 59(5), 630-638. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/j.amepre.2020.06.008
Robertson, N., & Perry, A. (2010). Institutionally based health care workers’ exposure to traumatogenic events: Systematic review of PTSD presentation. Journal of Traumatic Stress, 23(3), 417-420. Retrieved from http://search.proquest.com.ezproxylocal.library.nova.edu/scholarly-journals/institutionally-based-health-care-workers/docview/754051402/se-2?accountid=6579
Shaw, R. J., Harvey, J. E., Bernard, R., Gunary, R., Tiley, M., & Steiner, H. (2009). Comparison of short-term psychological outcomes of respiratory failure treated by either invasive or non-invasive ventilation. Psychosomatics: Journal of Consultation and Liaison Psychiatry, 50(6), 586-591. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/S0033-3182(09)70860-6
Scheunemann, L. P., Skidmore, E. R., & Reynolds III, C. F. (2018). Post-intensive care syndrome: The role of geriatric psychiatry in research, practice, and policy. The American Journal of Geriatric Psychiatry, 26(2), 222-223. doi:http://dx.doi.org.ezproxylocal.library.nova.edu/10.1016/j.jagp.2017.06.017
Yelin, D., Wirtheim, E., Vetter, P., Kalil, A. C., Bruchfeld, J., Runold, M., … & Bandera, A. (2020). Long-term consequences of COVID-19: Research needs. The Lancet Infectious Diseases, 20(10), 1115-1117.
Zimmerman, P., Stroever, S., Burton, T., Hester, K., Kim, M., Fahy, R., … & Nicastro, J. (2020). Mortality associated with intubation and mechanical ventilation in patients with COVID-19. MedRxiv.