The Military’s Behavioral Health Lessons for COVID-19
Lessons from war on keeping providers psychologically healthy.
Posted May 19, 2020
The tragic suicides of an emergency room physician and an Emergency Medical Technician offer vivid examples of the psychological strain that the COVID-19 pandemic has caused across the nation and for healthcare workers in particular. The New York Times quoted one doctor’s blunt assessment that “We are being asked to do things that are tearing at our souls.”
The American Medical Association has offered advice to professionals treating COVID-19 patients, but healthcare systems must do more to address providers’ psychological needs.
To do so, they should consider lessons from The United States Army, another large organization that faced the challenge of meeting the behavioral health needs of people working under unimaginably challenging circumstances. The psychological toll of deployment and combat was a central concern during the Iraq and Afghanistan wars, the nation’s longest, and the Army’s efforts to identify, mitigate, and treat behavioral health issues yield important lessons during this pandemic.
- Providers’ Psychological Responses Are Usually Normal Responses to Abnormal Conditions. During wartime, soldiers might witness injury or death or have to make complicated choices. Afterward, many experience sleeplessness, nightmares, feelings of guilt or shame, or other symptoms. They may also develop adaptations — for example, hypervigilance or not displaying much emotion –— that are beneficial in a crisis but troublesome under ordinary circumstances. Such responses, however, are most often normal reactions to trying circumstances. They are usually not pathological, and that most veterans recuperate their prior level of psychological health quite quickly — usually on their own, but sometimes with short-term treatment. Communicating this reality to soldiers was a responsibility that the Army took seriously, particularly through the BATTLEMIND pre- and post-deployment program. As former Army Surgeon General Eric Schoomaker argues, “Maintaining one’s emotional well-being under these onerous circumstances begins with validating that fear, guilt, feeling depressed and other jarring reactions are normal human responses.” During the COVID pandemic, clinicians will have encounters and responses similar to soldiers at war. “In war and in the battle against COVID, clinicians may be repeatedly asked to make impossible predictions, address morally wrenching decisions, and witness seemingly meaningless destruction and death,” retired Colonel Charles Engel, the former head of Walter Reed Army Medical Center’s Institute for Deployment Psychology, explains. Healthcare systems should thus train their workers to expect potentially troubling responses to abnormal conditions, but to recognize them as adaptations will likely dissipate on their own but which might benefit from short-term treatment if they do not.
- Providers Must Be Encouraged to Recognize the Importance of Their Own Psychological Well-Being. Soldiers belong to an organization that prizes toughness and self-sacrifice in the face of challenge, values that have sometimes led mental health issues to be stigmatized as weaknesses and seeking help as selfishness. The same can be true for healthcare workers. “As a group, clinicians and other first responders are naturally inclined and subsequently professionalized to subordinate their personal needs to the needs of their patients,” says retired Army Colonel Charles Engel, who led Walter Reed’s Institute for Deployment Psychology. “That comes with many positives. However, the downside is that they may be the last to recognize their own limits.” Hospitals must create a culture where hospital staff look out for each other. Hospital leaders, like commanders in Army units, must actively monitor and support their team members’ welfare. Daily check-ins by mid-level leaders, such as department chiefs, can help build this culture.
- Maintaining Healthy Behaviors and Attitudes Are Powerful Mitigating Factors. Not all negative psychological responses are preventable, but staying well-rested, well-fed, pursuing hobbies, engaging in mindfulness, connecting with loved ones, and reflecting on the value they found in their service helped soldiers cope. Healthcare providers must likewise engage in restorative practices. “Despite their ‘helper instincts,’” retired Colonel Rebecca Porter, the former Director of Psychological Health for the Army maintains, “they need to take special care to process what they’re experiencing and get adequate rest, exercise, and nutrition. If they do not stay mentally and physically healthy, they will be unable to help others.”
- Behavioral Health Professionals Must Actively Reach Out to Hospital Staff Impacted by COVID. After the Pentagon attack on September 11, 2001, the military moved mental health providers from Walter Reed Army Medical Center to the Pentagon, where they formed working relationships in offices that had suffered significant losses. Rather than offering formal mental health treatment, these providers performed what became known as “Therapy by Walking Around,” making themselves accessible without appointments in locations where Pentagon staff were comfortable, like conference rooms. This helped normalize people’s responses to the attacks. Hospital systems should consider how behavioral health professionals can become highly visible within units treating COVID patients. Their presence might reduce stigma, assuage concerns, and route workers who need it towards additional care.
- Hospitals Should Restructure How They Provide Care for Hospital Staff for Months or Years to Come. “Therapy by Walking Around” became the basis for a broader initiative, the Army’s Embedded Behavioral Health program, which permanently positioned behavioral health providers in support of each combat brigade. There, providers became familiar and trusted faces in the spaces where soldiers worked each day, people with whom soldiers were comfortable sharing concerns. Utilization of outpatient behavioral health care remained high, but hospitalizations decreased by almost half, an indication that soldiers’ mental health needs were being addressed earlier and more successfully. COVID may force a similar restructuring of the mental health care model for hospitals. Traditional approaches that necessitate hospital staff to receive treatment in established mental health clinics will exclude most hospital staff, but hospitals that permanently reorganize their mental health personnel to eliminate barriers will find that many staff will take advantage of services and avoid bad outcomes, such as leaving the profession or developing chronic mental health problems.
The United States Army does not, of course, have a perfect track record in addressing soldiers’ behavioral health needs, and the COVID-19 pandemic is not a war. However, just as soldiers sometimes struggle to process wartime experiences, healthcare workers will find this public health crisis psychologically challenging. The nation should thus embrace the Army’s hard-won lessons, as they can help ensure that individuals confronting extraordinary situations maintain the psychological well-being necessary to remain engaged in what promises to be a lengthy effort.
This post was co-authored by Colonel Christopher Ivany, MD. As a Psychiatrist, Ivany served as the Army Director of Psychological Health between 2013 and 2017. He is currently stationed at the Defense Health Agency.
The views are those of the author and do not necessarily reflect the official policy of the Department of Defense, Defense Health Agency, Department of the Army, U.S. Army Medical Department, or the U.S. government.