On a dark evening in April, a month into the UK’s first coronavirus lockdown, I joined a shift for the 24/7 text support service Shout 85258. Sitting in my kitchen, I had been given permission to observe its volunteers at work (all connected to the same Zoom session) as they held real-time text conversations with frontline NHS workers. For the previous few weeks, the volunteers – all members of the public – had been talking to doctors, nurses, paramedics and others as they did their best to manage the pandemic’s shocking first wave.
“We’ve had people texting in saying, ‘I’m not sure if I’m in a crisis, but I have had panic attacks,’” Shout’s clinical director, Sarah Kendrick, told me. Our conversation was punctuated by frequent beeps as new messages arrived, most during NHS shift turnover times. A nurse on the bus into work would text to say he was frightened to go in; an exhausted consultant at the end of her shift would offload about watching yet another patient die. There were many messages from distressed paramedics.
A text arrived from a doctor who had been isolating with suspected Covid and was feeling guilty about “abandoning” colleagues. As another volunteer counselled them, Sarah O’Connor, who in her day job works for a hospice, told me about some of the conversations she’d had. “There is a lot of panic. I did a grounding technique with a frontline worker anxious about having to go to work and having a young family. I’ve got this little exercise: I ask people to list five things they can see, four they can feel, three they can hear, two they can smell and one they can taste. It brings them out of their situation.”
Dave Bush, who is an actuary, recounted a text conversation with an ITU nurse who said they were “freaking out”. “They were very anxious that coronavirus had taken over work and home,” he said. “Their concern wasn’t for themselves – they had an air of invincibility – but for family members.”
Its text support service existed before the pandemic, but Shout 85258 had joined a coalition of charities known as Our Frontline, which aimed to support NHS, social care and other frontline staff through the biggest public health crisis of their careers. “They think people expect them to be able to cope,” said Victoria Hornby, CEO of Mental Health Innovations, which runs the service. “We say: you can tell us anything. You can tell us you don’t want to go to work. You can tell us you wish you had never done this job.”
Even then, nine months ago, it was clear Covid would take a toll on staff’s mental health. Research from last April found half of health workers were already suffering problems such as stress and trauma. At that point, much of what we knew about the possible impact came from previous pandemics; a study of healthcare workers in hospitals dealing with Sars found that mental health disorders were particularly common. In the acute phase of Asia’s Sars outbreak, 23.4% were experiencing post-traumatic stress symptoms; figures remained elevated compared with the general population after a year.
In the past weeks, as the crisis has deepened, the prospects have looked worse than in April. A new Occupational Medicine study led by King’s College London found that nearly half of intensive care staff reported mental health symptoms consistent with severe anxiety, depression or post-traumatic stress – an alarming 40% had symptoms of PTSD. These can include panic attacks, flashbacks, hypervigilance, nightmares, outbursts of rage, tearfulness, numbness, depersonalisation and suicidal feelings. If you have PTSD, the traumatic things you have experienced are ever-present. Staff not used to such high mortality rates, who did not sign up for the sort of work to which critical care doctors are accustomed, may particularly struggle. “Every day, they deal with multiple traumas, and their system gets into fight or flight,” Kendrick says.
“Some of the events people have seen are horrendous, and in the meantime they are losing colleagues to Covid,” says Claire Goodwin-Fee, one of the founders of Frontline-19, a service that connects medical staff with therapists working pro bono. “They have to make decisions about who gets a ventilator and who doesn’t, who is going to live and who is going to die.” Frontline-19 launched at the start of the pandemic and is now almost overwhelmed by requests for help: 1,800 in the first week of January alone. “We know if people feel supported, the amount of trauma they struggle with long-term is reduced,” Goodwin-Fee says. The service has the potential to treat far more people but, despite repeated pleas to government, funding has not been forthcoming.
For Shout 85258 volunteer Bush, listening is key. “The main thing is validating what they are going through. It is a scary time and there’s no shame in feeling anxious.” He gets more texts from men, who may find it easier to open up in this way. “It’s within your control. And most things related to Covid are not.”
Dr Rony Berrebi, an ITU consultant who wrote a song called Super Heroes to raise funds for better mental health provision for NHS staff, says that, in 14 years, he has never been through anything like this. “We really had the sense of being on a battlefield. The number of patients was overwhelming.” He had struggled with his own mental health as a trainee, and feared that colleagues were burning out.
Lockdowns and tier restrictions have meant healthcare workers’ informal support networks and coping mechanisms – a glass of wine with a friend, a gym class – have been out of reach.
Josephine, a critical care nurse, says she reached a crisis point last May. She is in her late 50s, having retrained late in her career, and lives alone. She loves her job, but Covid presented many new challenges. “We have two ITUs. One was converted into a Covid red zone, but there was uncertainty about which unit you would be in until you got to work, and that was stressful.”
Josephine had experienced symptoms of coronavirus in April, but tested negative; she had underlying health conditions that pushed her close to the at-risk category. On top of her demanding work, she was helping produce educational materials to inform the public about the risks of Covid. “I was trying to do my bit, not realising the extra strain this was putting on me,” she says. “My self-care started to decrease. It was work, eat, sleep, do this other stuff, repeat.
At the start of May, I found myself curled up on the floor for a couple of hours, sobbing. Not being able to have face-to-face contact with my friends, the fear – I broke down, I burned out. It was life-threateningly bad.”
“The beeping… you go home and you wake up in the middle of the night trying to silence the alarms, because in ICU there are just so many sick people. You hear them everywhere, whether you are at work or not.”
I am speaking to trainee doctor Emma Jackson, 32, who looked after the sickest Covid-19 patients after being brought in to care for adults from her paediatric rotation. She caught coronavirus early on, and recovered.
“Mine is the best job in the world,” she says. “But it’s been hard. Normally, on average one in five of our patients die. With Covid that’s sometimes one in two. Seeing young people die, your colleagues dying, that’s frightening.”
Her unit has a resident psychotherapist staff can go to if they need support, though this is unusual. They also conduct debriefs to help staff, for example after losing a patient. Jackson says she is lucky, because she has friends and colleagues to rely on. But Vivienne, a 27-year-old mental health nurse, has struggled, experiencing symptoms of depression, anxiety and PTSD. Many of her patients caught Covid, and at the height of the first wave she had to move into an apart-hotel to avoid bringing the virus home to her mother and siblings.
“In terms of anxiety, there was a huge spike and I started getting symptoms I’d never had before. I’d wake up in the night and my teeth would be aching from grinding them. I was getting a tight chest, so I felt I couldn’t breathe.”
Vivienne had had a few cognitive behavioural therapy (CBT) sessions before the pandemic, and was recommended a book with exercises, but says in the worst weeks she wasn’t thinking about getting help: “I was just trying to get through each day.” She mentions that there is often a delay between a trauma and the onset of symptoms; at the moment, NHS staff are still in the thick of it. “We will need to get long-term support to unpack some of the stress we’ve experienced, because I think we’ve all just parked it and tried to get on with it.”
Vivienne is black, and learning that she was at increased risk from the virus and the poor government response added to her anxiety. “The conjunction of the report on the effects of Covid on BAME groups and the Black Lives Matter movement… seeing videos circulating of George Floyd, and hearing the story of Breonna Taylor. All these events just add another layer of trauma. The world doesn’t feel safe, and you are still trying to manoeuvre within it.”
Unlike other mental health conditions, PTSD does not respond to talking therapy or counselling; what patients need is help consigning the trauma to the past. That requires specialised treatment such as trauma-focused CBT, which helps the patient process a memory properly and address their feelings about it; EMDR (eye movement desensitisation and reprocessing), a form of bilateral brain stimulation that involves making rhythmic eye movements while recalling the traumatic event; or narrative exposure therapy, which embeds trauma exposure in an autobiographical context, allowing the memory to be rebuilt.
Post-traumatic stress can develop after a one-off trauma, but can also manifest if someone experiences a sustained perceived threat. “For many, this is the first time they may have had to think about, not just the threat to themselves, but also to their loved ones,” says Professor Neil Greenberg, a trauma psychiatrist and one of the leaders of the King’s College London study.
Greenberg has a military background: he is also professor of defence mental health at KCL. Historically, much of our understanding of the effects of trauma has related to military experiences. In the fight against Covid, war metaphors have been somewhat overdone, but in the case of trauma they are relevant. Indeed, veterans’ groups have offered NHS staff support resources, including a guide to understanding the body’s threat responses, and the emotional consequences of traumatic situations, such as negative thought patterns.
“You’re thinking not just, ‘Do I do my job?’ but, ‘Is this going to kill me?’” Greenberg says. “That is something military personnel have to deal with.” Similarly, medical staff “are put in these really challenging situations where there isn’t obviously a clear right answer”. He uses as an example the cancer specialists who have been unable to administer life-saving treatments. “Their mission is to save lives, and they are being prevented from doing so.”
The term “moral injury” is not well known outside psychology, but is key to our understanding of the pressures healthcare workers face. It means perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations, leading to feelings of guilt and shame. “It’s no surprise that the people who experience very high levels of moral injury also experience very high levels of mental ill health,” Greenberg says.
He adds that many NHS workers struggling with anxiety or depression will benefit from existing treatments; in England, NHS staff can access the health service’s talking therapy alongside the public. “These are evidence-based treatments,” he says. “A lot of people will do well as long as they get there. The challenge is encouraging people to access them.” But treating PTSD is a different matter. “There are going to be people with moral injury-based problems, and trauma. And the NHS doesn’t have a great provision to deal with that.”
Before the pandemic, there were already higher levels of mental health conditions among NHS staff than in the general population: a 2011 report found nearly a third of doctors have some kind of mental health disorder. According to a recent study, the NHS lost 348,028 working days to anxiety, stress or depression in just one month in 2019. The number of paramedics taking time off because of poor mental health has almost tripled over the last decade.
For some, the stresses of 2020 exacerbated pre-existing conditions. Laura is a community matron with a focus on palliative care, with a diagnosis of borderline personality disorder and associated depression. Until the crisis, she was enjoying her work. But when we speak she sounds low. “I think, with personality disorder, you tend to not care very much about yourself,” she says. “You put other people’s wellbeing before your own. Being told that you can’t be face to face with patients has affected my ability to do my job.”
She has continued to see patients while wearing PPE, insisting she kept her caseload, but other colleagues did not, and she struggled. She also worried about how few referrals she had while resources were focused on the virus. “That made me feel guilty and lost,” she says. “I feel I am letting people down.”
Laura, who works closely with care agencies, found the treatment of care workers distressing; at one point she tried to give them NHS masks and was told this was not allowed. “We were told not to visit patients if we didn’t have to. But carers were going to see patients with no PPE. For me that was immoral.”
Laura decided to retire early. Now 60, she had worked in the NHS since leaving school at 18. “For someone with mental health problems, my moral compass is what drives me. My work is what has kept me sane. Now it’s gone.”
Central to the idea of moral injury is “the question of who you blame,” explains Dr Julie Highfield, a consultant clinical psychologist working in critical care. She is one of the few in-house psychologists, working in an ICU in South Wales, and is a qualified EMDR practitioner. “It might be the organisation, the management, the government – it’s a common narrative. If you blame an external source, then that often breeds anger and resentment towards work, and that manifests in a real disengagement with the job.
“Something I see very commonly,” she says, “is when people feel there is no one to blame. So they blame themselves – they internalise rather than externalise. One way to deal with this is to see the virus as the external enemy. And that can really help people – to say, ‘It’s nothing we did. It’s nothing our hospital system did. We did the best we could with what we had.’”
Highfield has had 70 staff members come to see her over the course of the pandemic, but only last month did she begin trauma-focused therapy with one of them. “No one has been ready yet,” she says. “The idea is we should wait for people to be safe and out of danger. For many it feels too soon to do the processing work and send them back in.” Instead she has been focusing on stabilisation, shoring up people’s defences so they feel OK to keep going.
She has seen a shift between the first and second waves: as the hero narrative has abated, in its place has come a feeling of abandonment. The common phrase is, “I don’t know how I feel any more” and, “No one really gets what it’s like for us, do they?” It is, Highfield says, “heartbreaking to bear witness”.
Since the pandemic began, charities and other organisations have rallied to support NHS staff. As well as Our Frontline, comprising Mind, Samaritans, Shout 85258 and Hospice UK, wellbeing apps such as the mindfulness platform Headspace have been made available for free. These are positive developments, but Covid-19 has starkly highlighted the need for better mental health support systems. Units such as Highfield’s, with a designated psychologist, are rare and NHS staff can find themselves waiting weeks for treatment. In autumn 2019, NHS England announced a £15m package it says will improve access to treatment for its staff through “wellbeing hubs” and fund a national support service for critical care workers. But the press release failed to include the support line telephone numbers, the sort of omission staff say is typical.
Goodwin-Fee and Ellen Waldren initially founded Frontline 19 as a short-term solution, but 10 months later they are still working round the clock to link NHS staff with therapists who offer 12 sessions for free. “We always manage to scrape people together, but it’s becoming more difficult” Goodwin-Fee says.
Despite meetings with the prime minister, health secretary Matt Hancock and minister for mental health Nadine Dorries, Frontline 19 still has “zero funding”. Meanwhile its therapists are delivering trauma-focused therapy, including EMDR and BrainWorking Recursive Therapy, used in South Africa by the military. Online training for them was made available at a discount by Bessel van der Kolk, a world leader in trauma psychotherapy, whose 2014 book The Body Keeps The Score has, tellingly, been back in the bestseller charts.
The pandemic has given politicians and NHS chiefs an opportunity to do things differently. But will they take it? As Highfield notes, putting resources into helping people recover is a worthy goal, but it is also crucial to keep people healthy in the first place. This is what she calls a “sustainable wellbeing” model.
Dr Derek Tracy, a consultant psychiatrist and clinical director who was part of Greenberg’s mental health team at London’s Nightingale hospital in the first wave, says: “It’s about trying to intervene earlier, saying, ‘We need to focus on what will lead to an emotionally resilient workforce’ rather than, ‘When people get depressed, what do we do with them?’ That’s been a positive shift.”
Nightingale staff were briefed about what to expect and given guidance on mental health warning signs. They could speak to a support team whenever needed, and Tracy and his colleagues would walk up and down offering support and supervising debriefing sessions. Key principles, which could be exported to other parts of the NHS, were rapidity of access and the normalising of distress.
“A problem, historically,” Tracy says, “has been that, though there’s always been support for staff, in a classic NHS manner it can be bureaucratic and difficult to access. So you go on to a website with a link that’s out of date, a number that doesn’t work and the name of a person who has left. Now a unique hospital was being built, so we could design anything we wanted.”
Training managers so they know how to react when staff are struggling is also crucial, especially as it may have taken a lot for a person to come forward. “It’s a caring profession, but there can be quite a bit of machismo in the NHS. People don’t like to ask for help when their job is to help others,” Tracy says.
Debriefing sessions can help, sometimes called Schwartz rounds, after a US health attorney, Ken Schwartz, who recognised that compassion in healthcare was dependent on staff feeling supported. “It’s a chance to talk about some of the difficult things,” Greenberg says. “Admitting when things didn’t go right, admitting we’re all human. Trying to develop a narrative, for example: yes, those six people died, but the next few nights I saved lots because I did it better.”
This is one way of bringing about what is known as “post-traumatic growth”. “It’s easy to say, everyone’s going to be traumatised – but actually some people recover better,” Highfield says. “People can come through and feel proud of what they have achieved.” Those who have a tendency to internalise or blame themselves, or who have lower self-confidence, may find it harder to recover.
“The pandemic will scar us to a degree,” Tracy says of NHS staff. “But we will grow from it. We’ll look back and say, I am different and I have learned.”
There are certainly reasons to be optimistic, but the longer the pandemic goes on, the greater the likelihood of a mental health crisis among a workforce already exhausted. When I first spoke to Highfield last March, she anticipated staff burnout and some PTSD, but since then her thinking has changed. “At the start, I disliked the comparison to soldiers,” she says. “Now I really understand it.” As opposed to type one PTSD, caused by a single event such as a car crash, she is seeing complex or type two PTSD – most often seen in victims of child abuse or war. “It’s opened my eyes to what it must be like to be a veteran.”
When I ask what the difference is in treating complex PTSD, Highfield responds simply: it’s “longer, more complicated, with poorer outcomes”.
In early January, I catch up with Josephine, the critical care nurse at breaking point last May. Private therapy was far beyond her means, but after seeing her GP she was put in touch with a therapist through Frontline-19 and has been doing much better. “It is not hyperbole for me to say they were instrumental in helping save my life,” she says. She is still seeing her therapist privately, as she can afford the cheaper Skype consultations. “He has helped me identify some thought patterns, a lot of which date back to childhood. Like, if I don’t do things perfectly, then I’m a failure.”
She had struggled with not being at work. “If I had broken an arm or a leg, somehow it seems more valid than, ‘I’ve broken my mind’,” she says. “It felt I was weak, as opposed to ill. My therapist has helped me turn that around.”
She is now learning a musical instrument and practising meditation. She’s also back at work full-time, risking burnout again. “It is a terrible situation and we feel we are not able to give patients the care they deserve,” she says. “We have been told to expect a heavy period. Duration unknown.”
Some names have been changed.
• Health and care workers can text FRONTLINE to 85258 for a text conversation with a trained volunteer, anytime, anywhere. Frontline workers can register for free therapeutic support with Frontline 19