Arrow ImagePICU & Rapid Response

Facing a new challenge – treating brain injury during a pandemic

Dr Jenny Brooks, a consultant clinical psychologist, and Dr Keith G Jenkins, a consultant clinical neuropsychologist at St Andrew's Healthcare, write in the Neuro Rehab Times on supporting brain injury professionals during COVID-19.

Click here to read the full article on their website.

The current pandemic has generated varying levels of anxiety in people around becoming infected or infecting others. In extreme cases, this anxiety can be debilitating.

Overwhelming anxiety can lead to withdrawal from others, and in brain injury work settings, can cause staff members to refuse certain duties that make them feel unsafe, which can cause conflict with managers.

Feeling a loss of control can be difficult for some, whether that’s at work or at home, and this can be exacerbated by restrictions designed to minimise infection risk.

Changes in the workplace include virtual meetings, wearing PPE for client or patient encounters and working remotely.

Meanwhile, many families of those required to shield have developed decontamination rituals on returning from work, such as changing outside and immediately showering.

The challenges of working at home include loss of workplace social contact and camaraderie, and difficulties accessing adequate technology and maintaining work routines and work/life boundaries.

Moral injury

There’s also a risk of ‘moral injury’, which is the psychological distress that can occur when  a person’s actions – or lack of them – violate their moral or ethical beliefs or values.

During the COVID-19 pandemic, moral injury may occur when care can’t be provided in the usual way or to the usual standard.

If leaders or managers are seen as avoiding responsibility for events that occur during this time or are unsupportive of their staff, or if staff feel or are unprepared for the emotional and psychological consequences of any decisions that may be required of them, there’s a risk of moral injury.

Fear/anxiety can trigger instincts that magnify the sense of impending harm, which can trigger a fight or flight response.

Seeking to control these instinctive responses can come at a cost to emotional and physical wellbeing in people who don’t have adequate coping systems or strategies in place.

Research suggests that people usually recover from moral injury quickly, and are more likely to experience long-term distress when they’re confronted with numerous moral injuries that cause cumulative effects.

As a general approach to moral injury, frontline staff ought to be made aware of events that could trigger such feelings, and managers should be encouraged to seek formal support if they are troubled because they think they may have contributed to or directly caused an employee to experience moral distress.

When informal support doesn’t help, professional help should be sought as soon as possible, particularly when the moral injury effects the employees’ day-to-day functioning.

Employers of essential staff need to be aware that psychological debriefing techniques and psychological screening approaches are ineffective. Instead, they must monitor and have appropriate support for staff exposed to difficult and challenging situations that may cause moral injury or wider psychological distress.

Generally, supporting physical and emotional health should always be in the minds of employers and managers. Well functioning team dynamics are key to providing the essential social support required for workforces to cope and work well.

Change and loss

Working at home can bring its own challenges to employees, including the guilt that others are risking their health in work environments.

With the pandemic bringing threats to everyone’s wellbeing, workforces are at a higher risk of experiencing health anxiety, which can add further to emotional distress and difficulties coping.

Being able to make a valued work contribution is key to the wellbeing of many home workers and shielding colleagues, who may also be particularly at risk of physical health problems at a time when they don’t have access to leisure facilities and gyms. Some may also be more likely to indulge in unhealthy, comfort-seeking behaviours, such as drinking, smoking and eating unhealthy foods.

Employees may have lost loved ones during the pandemic – and with normal grieving rituals and social support compromised by the pandemic, feelings of grief may be exacerbated.

Grief is most commonly associated with death, but it can occur after other types of loss, including the losses brought about by Covid-19. Employees may be grieving aspects of their lives previous to the pandemic.

Not only are people now experiencing the loss of normality, but also may be anticipating greater losses to come. There may also be increased financial stress and other tensions occurring more often within families.

The familiar stages of grief, originally outlined by psychiatrist Elisabeth Kubler Riley and author David Kessler, are not meant to be a linear process. People may go back and forth between each of the five stages, rather than following a sequential timeline, while some may not experience one or some of these stages.

In the denial stage, individuals may believe a situation isn’t real. In relation to the pandemic, those experiencing grief may have not have fully digested the situation.

In the anger stage, people recognise that denial can’t go on any longer and they become frustrated or angry. During the pandemic, this may manifest as people defying the government’s social distancing guideline, for example.

The bargaining stage is where people hope they can avoid anymore grief, so they may think it’s okay to break social distancing, for example, as long as they’re careful. They may think “it’s okay to spend time with others as long as they wash their hands before they see me” or “I’ll be fine as long as I stay around people that who are healthy”

Within the stage of depression, the person recognises the impacts the pandemic will have on their life, such as not being able to see family and friends or not earning as much money.

Finally, there is acceptance. People come to realise they can’t control the outcomes of the pandemic, but accept what is in their control and find a way to move on.

Social distancing, feelings of isolation and loss of human contact, as well as changes to routines, could cause up to 50 per cent of people to experience anxiety and depression, as well as some post-traumatic stress symptoms .

People who have pre-existing mental health conditions, particularly anxiety, mood disorders, substance abuse or obsessive-compulsive disorders, may experience heightened symptoms, but it’s unclear how much this is affecting those working in the brain injury field.

The pandemic is likely taking a huge toll on the population’s mental health. Chronic stress can cause people to become physically and mentally unwell and, if it goes unmanaged, can become debilitating, or manifest as anger.

But there could also be a silver living. The pandemic has also provided people with the opportunity for personal growth.

In the workplace, sharing the experience of the pandemic is likely to bring teams together, and could improve employees’ confidence and performance.

Getting through the pandemic may help people feel more resilient, and more confident in their ability to cope under stress.

Psychological first aid

One of the ways negative and unhelpful feelings in the workplace can be overcome or supported on a day-to-day basis is through psychological first aid, which helps to provide practical, non-intrusive care and support.

It is recommended in crisis and disaster situations, such as during the COVID-19 pandemic, and in the aftermath; when it can provide a useful guide in supporting each other when experiencing feelings and reactions that may have been lurking under the surface during lockdown.

When delivering psychological first aid, it’s important that the first-aider remains calm and shows concern, and offers a confident, reassuring presence.

They need to ask questions and most importantly actively listen, and also take note of practicalities such as whether the patient is looking after themselves by taking breaks, eating and drinking.

It’s also important to understand that there might be a need for someone better equipped to help, and to act as a liaison between this person and the patient, while continuing to advocate for them.

The first-aider shouldn’t rush the person or be dismissive, or offer opinions. They also shouldn’t make promises they can’t keep or feel wholly responsible for  individual’s recovery.

For non-emergencies, there are many ways for people to alleviate the strains of the pandemic. For example, prioritising contact with family and friends through phone and video calls throughout the week.

Working at home and living

Daily routine and structure has changed for everyone during the pandemic, and this can feel very unsettling, so structure is important. It increases feelings of normalcy and a sense of control, meaning and purpose – and can reduce feelings of distress and anxiety from providing distraction/engagement.

Keeping home and work separate can be another challenge of working from home during the pandemic.

For this reason, it’s good to have set start and finish times for work, as well as a fixed area in your home that can be kept relatively separate from where you have downtime, if possible.

Another way to establish a work/home boundary is to dress for work during working hours.

It is natural to be worried about loved ones catching COVID-19, however, if these worries start to spiral, it’s always worth talking to friends or colleagues, or contacting your GP.

And anyone feeling acutely unsafe or risky yourself should go to A&E or call 999, and in non-urgent situations, consider calling a helpline, such as the Samaritans, which is open 24 hours a day on 116 123.

It’s best to approach the internet with caution, especially when seeking out Covid-19 information. Only use reliable sources, such as the World Health Organisation, NHS or UK government – and consider limiting exposure to the news.

It’s important to not work in the bedroom, as getting a good night’s sleep is vital – and some people will find their sleeping habits are disrupted by the pandemic.

This could be because of changes to bedtime, the working day, additional stresses, or not getting as much exercise. A lower mood can also contribute to disrupted sleep.

Disrupted sleeping habits can cause a poor sleep-wake cycle, which can cause tiredness and fatigue throughout the day.

This can lead to a vicious cycle where it becomes more difficult to sleep, and lack of sleep makes it more difficult to relax. Those drinking more alcohol during the pandemic may also experience a negative effect on the quality of their sleep, as alcohol disturbs sleep rhythms.

One way to improve the quality of sleep is to improve sleep hygiene, which includes going to bed and getting up at the same time each day, exercising during the day, cutting down on caffeine or nicotine and avoiding the blue light from screens in the evening.

Try to have a bedtime routine that supports winding down. What people find relaxing tends to vary from person to person – for some it may be a warm bath, for others it may be listening to music. Bedrooms must be conducive to sleep – that means considering the lighting and temperature.

During the pandemic, some people are tending to spend more time in their bedrooms, perhaps to have space away from members of their household that they wouldn’t normally spend so much time with, or because they’re having to isolate from a shielding family member.

In these instances, it’s best to sit somewhere other than the bed, so the bed isn’t associated with being awake.

During the night, try writing worries down on paper, and allocating time to address them the next day with a family or friend, if necessary, or a relevant professional.

Covid-19 is presenting an immense challenge to brain injury professionals, and is also changing many of the ways we live and work.

But we can adapt to these changes and, in doing so, may well find better approaches and strategies that prevail and offer benefits long after the pandemic is over.

This article is based on a webinar produced for ABI London (ABIL). Dr Keith G Jenkins is consultant clinical neuropsychologist at St Andrew’s Healthcare and chair of Headway East Northants. Dr Jenny Brooks is a consultant clinical psychologist working independently and a director of The ABI Team.