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COVID-19 Frontline Guilt: How to Cope as Reality Sets In

Frontline guilt is a PTSD-related symptom that settles in with reality of loss.

Key points

  • Healthcare workers during the pandemic can experience survivor's guilt, which is a form of PTSD.
  • Putting family and friends at risk, as well as making tough on-the-job decisions are among the factors that can lead to guilt.
  • Healthy coping strategies include taking intentional breaks, meditation, and therapy.

Healthcare professionals have put their lives on the line throughout the COVID-19 pandemic. Now that there are fewer cases in many areas and millions are vaccinated, are healthcare heroes getting a chance to breathe? Perhaps, but their collective breath is far from a sigh of relief as they process stress and moral injuries.

Photo by Anna Shvets from Pexels
Source: Photo by Anna Shvets from Pexels

Many articles discuss COVID-related anxiety and burnout, but what about the guilt that comes with grief? Guilt is part of grief, and it's complicated to process guilt when the trauma is ongoing. Healthcare professionals have the vaccine but don't feel safe.

Consider the case of Dr. Hasan Gokal, who worked at a public health clinic in Texas. Dr. Gokal had 10 shots that had to be used or destroyed within hours; in December, there were no waitlists, so he contacted a public health official for the go-ahead to locate patients who met the vaccination criteria.

Dr. Gokal spent hours contacting patients and driving around to administer the shots. When he exhausted all options, there was a single injection left within minutes of expiring. He was conflicted but gave that shot to his wife, who has chronic health issues.

These actions sound appropriate — what doctor would want to waste a vaccine in a public health emergency? Instead, Dr. Gokal was fired from his job, reported to the medical board, and faced criminal charges for stealing the vaccine.

The court dismissed the initial charges, but the damage is done. Dr. Nisha Mehta is one of the thousands of physicians expressing support for Dr. Gokal on social media. "Unfortunately, the message is that we are not safe from threats to our careers and personal lives when making well-intentioned efforts to serve our patients in these extraordinary circumstances."

Frontline vs. sideline guilt

Clinicians like Dr. Gokal experience frontline guilt, not because they did something wrong, but that despite all of their training and efforts, there were adverse outcomes. They feel that they didn't do enough.

Psychology Today blogger Dr. Lawrence D. Blum explains the emotional challenges in practicing medicine in JAMA Internal Medicine: "All sorts of experiences in childhood, such as deaths in the family, illnesses, traumas, abuse, divorce, and problematic relationships, can saddle a person with an unrecognized burden of guilt. This guilt may be hidden for a long time, but then play an important role in later years." Enter COVID-19.

Past experiences can also shape sideline guilt in the professionals who worked more behind the scenes. These healthcare workers managed other essential tasks and specialties but did not care for patients in person through the pandemic. Many provided mental health services via telehealth or ran the administrative side of academic hospitals and training activities.

Sideline providers found non-traditional ways to support colleagues, including philanthropy and peer support. Following the suicide of Dr. Lorna Breen, a New York City emergency room director, Philadelphia-based psychiatrist Dr. Mona Masood saw the need for a COVID support line. The Physician Support Line provides 24/7 coverage by a group of 600+ psychiatrist volunteers. Callers often start with, "I'm sorry for bothering you with this," per Dr. Masood.

Frontline guilt is survivor's guilt

Survivor's guilt can affect up to 90% of survivors and is widespread in Bergamo, Italy, one of the world's hardest-hit towns. Survivor's guilt is a symptom of PTSD that sets in only when the reality of what's happened settles in.

Pandemic-related guilt in healthcare can occur when:

  • The job puts families and friends at risk
  • Certain decisions "have to made" — for example, limiting visitors and reusing PPE
  • They think about what they "couldn't do" due to a lack of time or resources
  • There is a sense they "could have done more" if they had better knowledge — for example, how to treat atypical end-of-life delirium
  • They receive early access to the vaccine when it's still not available to others with medical conditions
  • They feel numb or disconnected from family or friends or guilty about "unloading" their burdens on others to cope
  • They took time off for self-care when the hospital was under-staffed
  • They contracted COVID-19
  • They feel angry at the public (e.g., "deniers) for not taking precautions or the virus seriously

Symptoms of survivor's guilt

These signs can be misattributed to burnout, anxiety, or depression:

  • Physical complaints
  • Sleep disturbances
  • Intrusive memories
  • Irritability
  • Numbing
  • Maladaptive coping, like self-medication with substances

Coping with survivor's guilt

Here are some healthy coping strategies healthcare providers can consider:

  • Self-care
  • Grounding techniques
  • Mindfulness practice
  • Journaling
  • Permission to limit output at work to protect energy — e.g., setting limits
  • Controlling what you can control with regards to schedule
  • Outsourcing things like cleaning, meals, etc.
  • Taking intentional breaks
  • Utilizing time off
  • Practicing self-compassion
  • Seeking peer support
  • Engaging in ongoing therapy
  • Taking medication (for sleep, or antidepressants)

Final thoughts

Recognizing frontline guilt among healthcare providers as survivor's guilt is one step in normalizing negative feelings while providing trauma-informed supports. Healthcare professionals are finding new ways to express their needs, and many are learning to do this for the first time.

Dr. Tait Shanafelt and Stanford colleagues summarize what professionals say they need to survive and heal from the pandemic:

  • Hear me
  • Protect me
  • Prepare me
  • Support me
  • Care for me

Consider it a COVID prayer for healthcare.

To find a therapist, please visit the Psychology Today Therapy Directory.

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