Mental health has taken center stage these days. The effect of the pandemic on our psyches is a top news item and a concern for every type of physician. Doctors at Massachusetts General Hospital urged the American Medical Association (AMA) to declare mental health a national emergency. The AMA hasn’t done so but we don’t need the organization’s permission to acknowledge what’s right before us.
Of course, we must prioritize the care of those who are experiencing pandemic-related anxiety, depression and other illnesses. But we also must factor in vicarious trauma, the changes that clinicians and loved ones experience as a result of witnessing another person’s mental struggles. When we include vicarious trauma in the analysis, the burgeoning mental health crisis becomes even bigger than we imagined it to be.
The term vicarious trauma was coined more than a quarter century ago by two psychologists to describe the changes undergone by “helping professionals” — psychiatrists, psychologists, nurses, therapists, social workers — when they work with clients who are themselves traumatized by the effects of mental illness. Conceptualizing vicarious trauma recognizes a universal truth: empathizing with others makes us vulnerable. It also proposes a contagion model for mental illness. The last two years should have taught us; disease will find a way to spread.
I have some experience with these secondary effects of illness. Last summer, I shadowed a psychiatrist in the Tongji University Hospital in Shanghai. The unfriendly culture surrounding psychotherapy in China — combined with the fact that we had just met a couple hours prior — made it unlikely that the psychiatrist would confide in me how she also sought a therapist to treat her own anxiety. But divulge that she did. She sought treatment a few months before we met, smack dab in the pandemic. This doctor was in a stark minority; over 90% of people experiencing depressive symptoms fail to seek treatment in China and only a half a percent actually get help.
For months, the doctor’s friends, family and colleagues — including her husband — judged her decision to seek treatment voluntarily. Her parents insulted her unapologetically when they first found out. Only because she took courses from American universities did she know that broaching the topic of mental illness is more than acceptable and it should be normalized. That a professional would risk being stigmatized in an unforgiving culture like the one that persists in China only shows that the problem of vicarious trauma experienced by mental health providers during the pandemic is urgent. I doubt this doctor would have done the same in, say, 2019.
The statistics on mental health problems are startling. The Centers for Disease Control and Prevention (CDC) found that 41.5% of American adults reported symptoms of anxiety or depression in early 2021. “There’s no doubt that the coronavirus pandemic will be the most psychologically toxic disaster in anyone’s lifetime,” said Dr. George S. Everly, Adjunct Professor of International Health at the Johns Hopkins Bloomberg School of Public Health.
Assuming that the CDC sample is representative of the adult population, if every person who’s experiencing symptoms has just one person who’s caretaking or supporting them in some way — and therefore undergoing at least some vicarious trauma — that means that another 41.5% of people may undergo a form of secondary illness, with as many as 83% of United States adults poised toward an eventual mental health crisis. For comparison, even after the Omicron surge, only about 60% of the country will have contracted detectable forms of the illness; the breadth of the growing mental health crisis is almost 25 percentage points higher.
To be clear, this story isn’t all gloom. Clinical science has acknowledged an upside to trauma. Post traumatic growth – those positive changes resulting from grappling with a major life crisis or a traumatic event — can make us better than we were before. The term post-traumatic growth has been around since the 1990’s but only recently has systematic study of it commenced. With that new research we will likely be able to pull people out of post-traumatic illnesses much more efficiently than we have in years past.
But we won’t reach that growth period if people who need help aren’t shepherded to it by mental health professionals and we don’t have enough of them. Approximately 77% of all United States counties don’t have enough specialists to work with patients with mental health problems.
We can get around those limitations, too, if we accept the reality of the burgeoning crisis. Innovations like apps that assist with therapy — one, Learn to Live, just received a cash infusion and is already available to 33 million people. Other options include tweaks to telemedicine laws and rules — like rethinking requirements for providing care and payment parity and tossing burdensome requirements like an in-person intake visit. The bipartisan Telemental Health Care Access Act of 2021, introduced by US Senators Bill Cassidy (R-LA), Tina Smith (D-MN), John Thune (R-SD) and Ben Cardin (D-MD) aims to correct these problems by addressing a shortsighted provision of the Consolidated Appropriations Act of 2020 that requires an in-person visit within six months of the first telemedicine session, but it hasn’t gained traction, at least not yet. That’s unfortunate since those modifications can get us out of this crisis.
But we’ll get through this only if we recognize the magnitude of the problem. Very few of us will leave this pandemic unscathed, including the helpers and the healers. Let’s admit that and take the necessary steps to mitigate the damage.