Mental health: Grief, loss - we are all traumatised, says psychiatrist on the Covid-19 frontlines

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In her bright white office, Psychiatry Professor Jackie Hoare leans against a faux fur blanket on her sofa as she reflects on grief in a time of Covid-19.

Even though we are socially distanced, our masks remain on, as Hoare is in daily contact with Covid-patients at Groote Schuur Hospital, the academic healthcare facility attached to the University of Cape Town (UCT).

At the time of the interview, South Africa just exited its third wave, which saw Hoare inside Covid wards for the past three and a half months.

“I’m managing the mental health of patients admitted with severe Covid pneumonia,” she says. “So I work with and am part of the frontline Covid team at Groote Schuur.

I’m based in the high-care nasal flow oxygen units, across three different wards with about 55 beds, and also in our ICUs [Intensive Care Units] which expand, as required.”

Physical touch in a time of Covid

Hoare pioneered the Division of Consultation-Liaison Psychiatry at UCT’s Department of Psychiatry and Mental Health in 2011. Voice low through her mask, she explains that this model brings mental healthcare directly to patients, across hospital sectors.

Within the Covid pandemic, this has meant being at the bedsides of Covid patients, providing counselling, comforting and holding the hands of the very sick and dying, and at times breaking the news of a family member’s passing.

“I manage distress through whichever appropriate kind of talking therapy,” she says. “I tailor the talking therapy care to the patient that I have in front of me and that could be anything from using a CBT [Cognitive Behavioural Therapy] model to mindfulness, to problem-solving therapy. But sometimes talking therapy isn’t enough, and I need to use medication to manage the distress - which is enormous.

“This is a critical condition and people are very much aware that they’re fighting for their lives. And not only that, many of them have witnessed people die in the wards around them and have witnessed people being intubated and have witnessed people being resuscitated. So it is an incredibly traumatic unit. The high-care and intensive care units, in particular, are very traumatic.”

In a show of compassion, Hoare decided during the first wave - against a backdrop of public fear and scientific uncertainty - to physically touch up to fifty Covid patients a day.

“It was frightening,” she says. “But I made that decision. I mean, it was very hard. In a usual consultation, I have an hour with the patient to make an emotional connection. In a critical care unit, where people are exhausted, fighting for their lives, and short of breath; sometimes all I have is five to ten minutes to make that connection; to help somebody feel safe, to help them feel listened to, valued, and respected. I could not do that in PPE [Personal Protective Equipment], standing a meter away.

I pretty much douse myself with alcohol sanitiser while in there - because I’m touching people all the time, holding their hands, sometimes sitting on their beds. Every single time I touch something; before touching something else, I sanitise. That’s the job, that is what I need to do.”

Running over capacity

According to hospital spokesperson Alaric Jacobs Groote Schuur treated a total of 20 771 Covid-patients between April 2020 and August 2021, of who 741 were admitted to ICUs.

While the end of the third wave comes as a huge relief, Hoare points out that time for respite is scarce as psychiatric services, previously de-escalated to care for Covid patients, are resumed.

Hoare describes the mental health fallout due to Covid-19 as “massive, absolutely enormous,” with Cape Town psychiatric wards running at 20 to 30% over capacity. This includes wards at Groote Schuur Hospital, and state mental health facilities Stikland and Valkenberg.

She notes a lack of research into Covid’s mental health impact in South Africa, however pointing to a global study published this month in the medical journal The Lancet, which cites a quarter increase in major depressive disorder and anxiety due to Covid. According to the study, women and children are the most affected.

The complexities of grief

Essentially, an individual’s grief response is shaped by personal resilience, which can be traced back to early childhood nurture and possible abandonment wounds or other trauma. Starting in infancy, humans form bonds to special people, animals, places and securities. When these bonds break, painful losses ensue. Grief is a normal response to loss.

While Hoare dismisses the notion of a “grief crisis” - as put forward in some more sensational media headlines - she says that within the pandemic grief is prevalent and complex. She adds that “normal grief” can last up to six months, within which time it is normal for a person to struggle and to feel distressed.

“Grief is personal and it’s individual, and it may be different for each person,” she says. “Normal grief can be conceptualised as lasting for up to six months. Symptoms in this time vary and can include even more unusual experiences, like hearing the voice of the person who passed away or seeing the person who passed away.

"That is considered normal grief and is not pathological in any way. It is when symptoms extend past the six-month period or start to include worrying things like suicidal ideation, that we start thinking about it as so-called abnormal or complex, or prolonged grief. But the vast majority of people, even those who have really intense symptoms, they’re usually resolved within the first six months.”

Hoare reiterates the complexity of grief in this time - saying that it occurs in layers.

“We are all grieving,” she says. “We’re living in a world of tension where we don’t know quite how or when we might get to the other side. And of course, the assumption of whether we’ll ever be on the other side is still up for debate. We have lost our normal way of life. People have lost their jobs. There’s been financial stresses, et cetera. Many people have also experienced Covid or severe Covid. So then add to that the experience of losing a parent or losing a child. Or losing a brother and a sister...”

‘The unimaginable and the unspeakable’

Also to be reckoned with is the accumulated trauma impact on healthcare workers. Especially given the perception in the profession that vulnerability is a weakness.

In a letter to The Lancet published earlier this month, Hoare notes how healthcare workers in low-income and middle-income countries such as South Africa face additional challenges. She points out that pandemic trauma is compounded by the burden of HIV and tuberculosis; a strained healthcare system, and a social context of inequality and violence.

“Initially, we had difficulty accessing the doctors working in high-care and intensive care units, to provide mental health support to them,” she says. When contacted to offer support, she says the common reply from doctors was that others need your help more and we’re fine.“This changed when we made the decision to work in the high-care wards, experiencing the work in those units first-hand.”

Once she joined the frontline team, sharing in their trauma, frontline healthcare workers opened up more readily, says Hoare. “Our colleagues were experiencing the unimaginable and the unspeakable. The only way they could begin to speak of what they were going through was through us having had an embodied experience alongside them.”

Hoare’s “collegial-based intervention” argues for integrating mental health professionals into Covid frontline teams.

“People in the [Groote Schuur healthcare frontline] group said a number of times: ‘We can only talk here because no one can understand exactly what we’ve been through’ or they would say, ‘You understand because you are here with us, you are one of us’. Trauma can isolate one from those who have not been through the same experience, while at the same time binding together those who have,” she says.

Empathy first

How does she herself absorb the sadness associated with her work? Behind her mask, Hoare’s face is impassive. “It is hard,” she says. “I am, we are all traumatised.” She declines to discuss her personal feelings further.

While gearing up for the fourth wave, Hoare hopes to encourage more people to get vaccinated. The “vast majority” of recent Covid hospital admissions were unvaccinated, she says.

Wrapping up, she draws a distinction between so-called “anti-vaxxers” and vaccine-hesitant people, highlighting the key roles of empathy and patience.

“My experience of working with vaccine-hesitant people admitted to our wards is that an open, empathic listening approach by healthcare workers helps to overcome many of their difficulties,” she says.

“You know, face-to-face, as long as you can approach them with empathy first - not evidence first - being open and patient and listening to their fears really helps. Because their fears are real for them.

"Their reasons for not being vaccinated are real. And you need to respect that. And if you can do that, you can help them through that ambivalence. Because that’s what I mean, vaccine-hesitant people are actually more ambivalent than absolute. If you can help them resolve that ambivalence, they will get vaccinated.”

*This article is part of Spotlight’s special series on Mental Health.

*This article was produced by Spotlight - health journalism in the public interest.

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