Applying Psychotherapeutic Principles to Bolster Resilience Among Health Care Workers During the COVID-19 Pandemic

The COVID-19 pandemic has affected the entire globe with overwhelming speed and impact. Within 5 months of the pandemic taking hold in North America, there were more than 17 million known infections and more than 650,000 deaths from the virus worldwide (1). The pandemic is both highly threatening and poorly understood, typical of deeply distressing conditions (2). Stress associated with uncertain recommendations from authorities, fear of illness and contagion for oneself and one’s loved ones, extended periods of isolation, distress caused by moral conflicts, financial instability, perception of discrimination and/or stigma, and ongoing loss and grief imperils mental health and resilience among the general population and higher risk groups (3).

Health care workers (HCWs) face additional challenges that increase their vulnerability toward distress and burnout. Professionally, HCWs must cope with rapidly changing policies, adapt to work outside their usual scope, manage fear and uncertainty about personal protective equipment (PPE), and bear witness to individual and societal suffering and trauma. At an individual level, HCWs tend to be predisposed toward perfectionism, stoicism, and self-reliance, all of which can amplify the stigma associated with needing mental health care and can impede help-seeking behavior (4, 5).

Bolstering resilience among HCWs can improve their well-being and allow them to keep working with the intensity and focus their jobs require. Such support is crucial to maintaining the overall functioning of the health care system (6). Because of their training in understanding wellness, distress, and psychotherapeutic treatment, mental health clinicians are well positioned to respond to this need.

By studying the lessons from past and present experiences with public health emergencies and by incorporating principles from the psychotherapeutic literature, mental health clinicians can help facilitate an informed and effective response. Research indicates that HCWs experience significant distress during large-scale outbreaks (5, 7, 8), such as the severe acute respiratory syndrome (SARS) outbreak in Toronto, as well as chronic levels of stress afterward (9, 10). Years after the outbreak’s resolution, hospital-based HCWs who treated infected patients, compared with those who had not, had significantly elevated rates of professional burnout (30% versus 19%); depressive and anxiety symptoms (45% versus 30%); and increased smoking, drinking, or other problematic behavior (21% versus 8%) and missed four or more work shifts during a 4-month period because of stress or illness (22% versus 13%) (9). These findings are consistent with studies of psychological outcomes among HCWs during outbreaks of H1N1 influenza, Middle East respiratory syndrome, and Ebola (7, 8). Unsurprisingly, reports on mental health outcomes among frontline HCWs providing care for patients with COVID-19 (11–14) indicate increased symptoms of depression, anxiety, insomnia, and posttraumatic stress.

Because COVID-19 is a much larger outbreak, is associated with higher mortality, and is longer lasting than previous outbreaks, the risk of sustained psychological distress and burnout among HCWs is high. It is therefore critical to anticipate stress points and to use evidence-based strategies for providing psychological support. Because of its scale, COVID-19 requires an “all-hands-on-deck” approach to support the mental health of frontline workers. Mental health clinicians from all disciplines who have training in psychological first aid or in various forms of psychotherapy are needed to support HCWs in need. To accomplish this goal, we turned to previous experiences with large-scale infectious outbreaks at our hospital, Sinai Health, Toronto.

Much of the evidence about how to provide support during a pandemic comes from experience with SARS (7, 9, 10, 15, 16). After the SARS outbreak, the Department of Psychiatry at Toronto’s Mount Sinai Hospital co-established an interprofessional psychological health pandemic committee to develop a resilience training program for hospital workers (15). The program was implemented with more than 1,250 staff from 22 hospital departments during the subsequent H1N1 influenza pandemic in 2009. The provision of information about stress and resilience helped HCWs increase their confidence in their ability to cope with psychological distress during the outbreak (15). Furthermore, psychosocial support was found to be most effective when provided in the context of trusted and supportive relationships.

In this article, we aimed to describe the development of a model of resilience coaching, rooted in principles from psychotherapeutic literature and practice, that was designed to support psychological well-being among our hospital-based health care colleagues. This model is generalizable, can be adapted for use by any mental health clinician, and makes explicit how previous training in psychotherapy can be applied to coaching and supporting colleagues in health care.

Resilience Coaching: A Model Rooted in Psychotherapeutic Principles

Resilience can be defined as the capacity to cope with a crisis and then quickly return to a precrisis level of functioning (4). In health care, resilience encompasses retaining the capacity to care for patients and oneself while enduring the uncertainty and unpredictability associated with the work. A global pandemic and its associated sequalae are a major threat to HCWs’ resilience.

In this article, the term “resilience coaching” describes an approach to bolstering resilience among HCWs that uses an integrative form of psychotherapy. As with all psychotherapeutic relationships, this coaching starts with an assessment of the issues, fears, and dynamics of the person, unit, or team. Coaches develop ongoing relationships with clinical units, allowing understanding to evolve over time—first about the details of specific stressors, and eventually about patterns of relationships within the team and between the team and the rest of the hospital system (17). This assessment contributes to a formulation of the issues within the units in which the coaches are embedded and serves as a starting point for therapeutic interventions.

At Sinai Health, the consultation-liaison (CL) psychiatry service is largely embedded within the units to which they provide consultation. This arrangement facilitates gathering of information, listening to concerns, and developing strategies for support. By building on the work of two authors (J.H., R.M.), the CL service uses an approach informed by attachment theory (18). For example, it is assumed that people or teams under strain do what they know best to feel more secure. Through the lens of attachment theory, behaviors can be understood as belonging to one of the four basic attachment functions: providing or experiencing a secure base, seeking a safe haven, seeking and maintaining proximity, and protesting separation (19).

As an example, a particular unit manager escalating her concerns to higher levels more frequently than necessary is viewed as equivalent to the hypersignaling of distress typical of a person with a preoccupied or anxious attachment style. This behavior is considered to be adaptive, perhaps because the unit manager has learned that she can create meaningful change only when she repeatedly e-mails her manager about issues on her unit. She is not simply advocating for her team; she is enacting an attachment behavior intended to elicit support. Unfortunately, the intensity and desperate quality of that communication contribute to her team's worrying about her anxiety, and, in the time of COVID-19, feeling less assured about her capacity to provide leadership (a secure base for them) when the perceived threat is elevated. Conversely, a seasoned staff member may experience additional strain if her dismissing attachment style, which typically contributes to a sense of independence and personal efficacy, leads to reluctance to ask for clarification around ever-changing policies about PPE and difficulty tolerating the more overt distress of other team members. Understanding maladaptive behaviors in terms of their attachment goals helps develop a formulation of the problem and subsequently a therapeutic response.

Mirroring psychotherapeutic technique, coaches share their formulations with the teams they support, summarizing their understanding of the difficulties they have observed. The formulation is communicated in a straightforward, nonjudgmental manner, with the goal of creating mutual understanding and developing a platform for collaboration. Recognizing that building rapport and trust to establish an alliance is the foundation of every therapeutic relationship, the coach adapts the amount of information shared in the communication of formulations to the setting and situation. This approach also provides an opportunity to set shared goals and strategies.

Especially in newer coaching relationships, coaches focus on presence and consistency. They signal that they will be on the unit whether or not there is a crisis, that they are actively listening to all issues discussed, and that they are as interested in the daily functioning of the unit as they are in the complex dynamics of underlying issues. They acknowledge that coaches and colleagues alike are addressing both new and preexisting stressors and that COVID-19 and the pandemic response have amplified existing tensions.

In working from this foundation of alliance, understanding, and embeddedness, the coaches use a range of psychotherapeutic tools. They borrow from various modalities, including supportive psychotherapy, group therapy, cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, interpersonal therapy, dialectical behavior therapy, and motivational interviewing. They integrate approaches from each modality and aim to be nimble as they titrate the use of each technique responsively, case by case and unit by unit.

The supportive nature of this work involves actively listening to the concerns of teams to develop an appreciation of the main themes at any given time. This coaching offers an opportunity for reflection and validation and for providing psychoeducation about the nature of stress, coping, and resilience. It can be powerful to share the generous assumption that all HCWs are doing their best, and attentiveness to attachment behaviors can help staff feel secure. Coaches identify opportunities for action, including opportunities for advocacy and increased self-efficacy and unit efficacy.

Because coaching sessions are often conducted in groups, coaches draw from the theoretical and practical approaches of the interpersonal group psychotherapy model as described by Yalom and Leszcz (20). The participants set group norms about confidentiality and safety of disclosure. Typically, participants vary from meeting to meeting as in an open group model, so coaches repeatedly attend to group therapeutic factors such as universality, cohesion, altruism, and instillation of hope. Group members tend to share identities and overall clinical goals as HCWs. Most of the HCWs have worked together and feel affiliated with their jobs and roles in patient care. This cohesion allows coaches to explore team dynamics, such as conflict, by shifting focus to the here and now and by examining both intention and impact in a supported and safe way, at times honing in on relational or interpersonal issues that have been troubling to the team and magnified during the COVID-19 pandemic. As an example of one of these issues, group cohesion may be affected by deployment of staff to unfamiliar units, which may reduce their sense of the unit as a secure base. As described by Leszcz et al. (21), the group milieu provides an opportunity for the coach to hear the concerns of the unit staff and to identify their specific concerns in the moment. For the coach, recognizing that leaders must earn their colleagues’ confidence, this observation of the group milieu offers an opportunity to identify gaps in communication and possibly to recommend that the unit manager signal to staff that they are valued within the organization. This coaching leads to supporting the connections that already exist within the unit and to identifying and labeling the ways in which staff have risen to the challenges imposed by the pandemic. Finally, coaches provide explicit information about coping strategies, describing problem-focused, emotion-focused, and meaning-focused coping.

CBT principles can also be useful in coaching. Coaches can illustrate the relationship between thoughts, feelings, and behaviors and emphasize that thoughts remain a potential focus for control, even in extraordinary times when so much is beyond one’s control. They can listen for and identify cognitive distortions. Common thought patterns, which can be clinically adaptive for HCWs and lend themselves to quick decision making and following complex algorithms, may manifest as cognitive distortions in the personal and emotional realm. Some examples of such distortions include “catastrophizing”; HCWs are trained to anticipate worst-case scenarios in the clinical setting, and this pattern of thought can lead to anxiety and fear. “Jumping to conclusions” is adaptive when making a tentative diagnosis with insufficient data, but potentially leads to distress when applied to other types of thinking. “Black-and-white thinking” is useful when making clinical decisions that require categorization but contributes to challenges with coping when used in other contexts (22). Teaching individuals about identifying and labeling cognitive distortions and providing strategies to work through these distortions in the moment is an approach that coaches can use in any health care setting. Similarly, recommendations about behavior that may have a positive impact on emotion can provide colleagues with practical guidance.

Practical strategies to manage stress, which can be used both in the moment and outside of the workplace, should not be overlooked. Coaches use techniques from mindfulness-based stress reduction to facilitate stress management (23). Demonstration of breathing exercises, body scans, and short guided meditations can be grounding for staff and can empower them to use these techniques on their own and with patients.

The principles of interpersonal therapy (24) also apply, especially when colleagues are grieving—working with dying patients and their families, losing friends and loved ones to COVID-19, and experiencing the loss of typical social connection. Speaking openly about the process of grief can be normalizing and validating. Similarly, role transition is a frequent major focus, especially for staff who have been redeployed, taking on complex tasks and navigating new relationships as they address changing needs within the health care system. Another notable role transition that has emerged during this pandemic is from clinician to hero. As society applauds the heroes working on the front lines, those individuals struggle with their new identity and how to navigate it, managing feelings of being an impostor, not doing enough, and not receiving adequate compensation to take on this new title.

Dialectical behavior therapy also informs coaching. Coaches can identify gray areas where opposing ideas coexist. Sentiments such as, “I am tired and scared and I don’t want to come to work” and “this is my calling and I love my job” have been common themes, and coaches encourage colleagues to hold both thoughts in mind and allow them to both be true, reducing the tension of having to choose (25). Coaches focus on ways that HCWs regulate their emotions, identifying how they escalate into distress and how they might de-escalate themselves. Coaches also rely on peer supervision to support their own well-being and to debrief. Weekly meetings allow coaches to share themes and strategies and to support one another. To complement these sessions, coaches use ongoing e-mail dialogue for support and knowledge exchange.

Finally, principles derived from motivational interviewing, such as rolling with resistance and prompting change, can be helpful in supporting colleagues who are struggling with maladaptive habits and behaviors (26).

Coaching Vignette: ICU Staff Huddles

The intensive care unit (ICU) at Sinai Health is a busy critical care environment with highly skilled nurses, physicians, and other health professionals working closely together to care for extremely ill patients and their families. The acuteness and complexity of patient cases require staff to work collaboratively and cohesively. The COVID-19 pandemic introduced fear and uncertainty into the daily work of ICU staff. Themes identified by staff included fear of becoming infected, anxiety about protecting their vulnerable family members, access to PPE, isolation, managing family obligations, and ever-changing policies. These issues contributed to tension between staff members and were thought to increase the risk of burnout. Psychiatrists known to the ICU staff were invited to support the staff by bolstering resilience and coping skills.

Two psychiatrists began attending ICU staff huddles twice per week. They attended whether or not there was an acute stressor or crisis as a way to signal their consistent presence and to enhance familiarity and comfort. They often began with a breathing exercise to instill calm and to focus on the present moment. They would then listen to staff members’ concerns, often summarizing or validating them, allowing staff to support one another and to build on each other’s reflections. These discussions provided the coaches with information to support intervention decisions. When anxiety about a new policy arose, it became an opportunity to label fear and catastrophizing for the staff and an opportunity to advocate to senior management to enhance the leadership’s relationship with staff. When staff were particularly demoralized, coaches advocated for hospital leadership to attend a huddle and to express gratitude for the frontline ICU staff. When conflict arose about providing slower than usual care because of needing to don PPE, coaches identified the core underlying issues—fear of infection and moral distress—and examined each staff member’s intent and their impact on their colleagues. When a death occurred that affected staff, coaches helped staff work through their grief. Communication informed by dialectical behavior therapy was often used (e.g., “This is a crisis that challenges us and we can continue to support each other.”). Finally, in making coping strategies explicit, coaches used change language from motivational interviewing to address potential resistance from the team. Each huddle was different and required a different level of intervention and participation, yet each was a meaningful opportunity to use psychotherapy to enhance colleagues’ resilience.

Conclusions

Applying the lessons of coping with previous pandemics is critical to meet the psychological needs of HCWs during the COVID-19 pandemic. It is heartening to make explicit how the skills and approaches from different psychotherapy modalities can be readily applied to the coaching model. Our training and expertise as mental health clinicians position us well to support our colleagues in health care and to navigate the pandemic while building relationships, reducing stigma around help seeking, and solidifying the critical role a CL psychiatry service plays within a general hospital.