The Whittier Health Network is happy to offer this on-line presentation entitled: Stress and Holiday Blues: Learn ways to lower the dread too many feel during the holiday season. Take steps to reduce stress and its impact. Learn to be resilient and do not dread the holiday season. Be a part of this zoom continuing education presentation and learn the steps you need to reduce the powerful impact of stress. “Learned resilience can be taught and leads to reduced stress and psychological hardiness rather than psychological weariness.” according to Leo Polizoti, Ph.D. Psychological weariness is a drain on personal coping and adaptation to situational stress. Contact Joanne Swidersky at 508-871-2134 to reserve a place at the holiday table.
Stress is well-known to the medical community and is treated with lifestyle adaptation and management of symptoms and disease. Once stress becomes too intense, it has a measurable impact on one’s own health. I have posted blogs about a variety of stressful circumstances, some are associated with personal behavior and lifestyle choice; others are more in line with exposure to traumatic, stressful events experienced by first responders like members of law enforcement or front line healthcare providers.
As well as impacting professional growth, research suggests that extreme stress levels can impair social skills, overwhelm cognitive ability, and eventually lead to changes in brain functioning. People who under constant stress pay a price in being unable to fully relax. They report feeling under constant threat from forces beyond their control and being stuck running in place. “In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program. The study looked at the impact on job satisfaction among members of a university faculty using weekly mindfulness meetings. Among those who participated, there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction according to Dr. B. Grace Bullock reporting on an Australian study in efficacy of mindfulness training.
Burnout can leave people exhausted, unmotivated, anxious and cynical – the consequences of which can be catastrophic to business and front line workers across all sectors of society. This is especially true among healthcare workers, where the stigma associated with mental illness still enables silence among those most in need. It is the real deal and probably underlies the recent exodus of nurses, doctors, police officers, and other front line professionals who have had enough and are moving on from their jobs. At our rehabilitation hospital more and more staff nurses are opting for a shorter commute by changing jobs. Some are leaving to become stay-at-home mothers after 18 months of fighting the fight with the virus, all the while their children were home in quarantine – going to school on their laptop computers.
“In a recent study, job satisfaction, overall there were little differences between groups in ratings after a mindfulness program but there was a significant link between feeling calm and relaxed, and greater workplace wellbeing, with those reporting less stress and anxiety also noting higher levels of job satisfaction. B. Grace Bullock 2017
Stress tends to create significant reactivity within the body. This brings forth rampant chemical flooding by the adrenal cortex and other stress hormones. These chemicals can add to a decline in physical well-being. These over active hormones are lethal for the medically infirm and physically vulnerable. Yet, for some people, stress is like a drug and creates a circular pattern of sensation seeking as described in the prototypic type A personality.
The neurobiology of stress and PTSD is being studied and may be linked to primitive brain circuits involved in the fear conditioning response and its eventual, sometimes refractory extinction or habituation of on-going perceived threat (Do Monte, Quirk, Li, and Penzo 2016). As an example, Police work carries with it a neurobiological underpinning that is well documented in terms of the impact of repeated stress and exposure to traumatic events. Chronic exposure to traumatic scenes and a host of other factors gradually elevate the hypothalamus-pituitary-adrenal (HPA) axis in the brain and body of typical career LEO’s. “The human brain, having evolved to seek safety in numbers, registers loneliness as a threat” as reported in a recent NY Times piece.
Stress effects all aspects of how we feel. Most physicians know that mindfulness techniques lower subjective levels of stress. However, even though paced breathing puts the brakes on sympathetic overdrive, people do not use it long enough to create habits. “Meditating”, according to Dr. Woolery-Lloyd, initiates “the relaxation response,” which activates the body’s parasympathetic nervous system and decreases cortisol and inflammation.” Yet even our primary care physicians and physicians in emergency rooms across the country are at risk from frontline stress, burnout and area at higher risk of suicide. This taken from a story written by Jessica Defino about the impact of stress on human skin in NY Times on 12/08/2020. The point being that the stress response is pervasive in human functioning and can wreak havoc on physical health including the integumentary system – our largest organ – our skin.
“Why don’t we come up with a program before bad things happen?” asked Dr. Englert. “Bad things are going to happen. When they do, the person, the individual, and their family will be more resilient, more able to recover quickly from that event.” said Alexa Liacko, ABC News interview. It is in being vulnerable that we are able to stretch our emotional experience that brings forth growth and reduces stigma. You cannot expect frontline healthcare and first responders to walk through water and not get wet.
Lloyd, C et al. (2002) Journal of Mental Health 11, 3, 255–265
There were times that at the end of a midnight shift in Westbrook, Maine, outside Portland, and New Braintree PD, in Massachusetts that I had reports to write for incidents I had been assigned during the shift. More than once, I snuck out of the patrol office and went home – too tired to write. And more then once, the sleep I so wanted was disturbed by the day sergeant or court officer looking for my report. Or sometimes, when I did stay, my writing was not my best effort because I was tired. Report writing is an art and is now a large part of both the academy training and field training programs. Law enforcement officers are better trained and more highly educated than ever which is essential in these times where every word is public property. The media, the citizenry, and the police hierarchy are all slicing and dicing every paragraph of today’s reports looking for your mistakes, it seems. The reason I write this is that police reports have consequences and if important statements, or officer observations, or photographs are omitted, cases may be lost. It is essential that report writing be taken seriously because, in the setting of domestic violence, lives depend on it.
Just like any report document that is to be handed out to anyone who might request it, particularly underpaid defense attorneys who swim in circles, like sharks looking to devour a poorly written report and its author. Report writing needs to be concise and laser focused. Particularly important is the reason for the call. Why did this victim call today? We know that the abuse tends to escalate successively. Sometimes, it is only when children become involved that a victim will move to stop the violence. In Vermont, a teen boy shot and killed his father when the man drunkenly waved a pistol threatening the family. And in Maine, a 13 year old boy was found to be hiding a 20 gauge shotgun and ammunition on the day he and his family were murdered by his father Steven Lake. Our analysis of the Maine case led us to understand that the boy was likely intending to defend his mother and sister against a violent and unpredictable father. He may have been seeking to load the weapon when his father snuck into the unlocked house and overpowered the family. 20 gauge shells were found in the child’s bed and under his pillow.
When conducting assessments or forensic exams with a victim of domestic violence (DV), any reported history of strangulation places the person at a higher risk for more serious violence or homicide by the hands of their intimate partner. By recognizing signs of strangulation, healthcare providers can help to mitigate long-term damage, properly document any evidence of abuse, and provide referrals for seeking safety assistance. Sara Vehling 2019
Risk assessment tools provide quantifiable data that may be used to develop actuarial projections as to degree of risk and dangerousness. Report writing now should include assessment tools that uncover potential risk to victims. Jacqueline Campbell, RN has a valid risk assessment tool for determining whether there is high risk to potential victims that can be living in the home while officers are still on scene. Campbell’s work is readily available in the DV literature and known to most of us. The Ontario group in Canada also has a reliable tool – ODARA used by law enforcement agencies across the country. In my agency we adopted both tools after the research was complete from The Maine homicides. The national leadership includes Lenore Walker, in addition to Campbell, who both have published a good deal over 25 years on DV and its cycle. Walker believes that women and families are exposed to great harm when the abuser is out of jail only hours after terrorizing his family. It rarely mitigated the next beating.
I propose holding the abuser until his first arraignment perhaps as long as 2 days. This allows for a cooling off period. Minutes are like hours while sitting in a municipal cell block often eating fast food 3 times a day. But the 8th Amendment of the Constitution guarantees that bail shall not be unfairly denied or excessively harsh. In truth, the modification of bail conditions in some instances must be done in real time to account for the severity of individual cases of DV and unique red flags. Experts have said that when a victims says ”I know he is going to kill me” then there is a greater likelihood that she may be correct and a protective, safety plan should be put in place. On the continuum of risk, expecting to be killed is only slightly less dangerous as physical attempt to kill or maim. In these most dangerous cases, there are tactical measures that must be written into protective orders such as GPS monitoring, forfeited bail and remand to custody for violation of protective orders, social media restriction, no contact with victim and children, no contact with victim’s family or friends, and supervised visitation, when only appropriate. It is these cases where the police officer’s report must be first rate and bullet proof.
A period of being held in custody until initial arraignment will enhance public safety and public trust in the short run. If applied to all persons arrested because of domestic abuse, then it would not unfairly impact only the poor or disenfranchised. Abuser’s should not be able to buy their way out of jail nor should they be free to wander their communities stalking their supposed loved ones. Steven Lake who killed his family and himself in Dexter, Maine posted his love for his children nightly and had piteous social media “friends” encouraging him to “fight for his children”. Little did they know he was planning the onerous events that would end the Lake family timeline forever. The Maine Law Review in 2012 reviewed changes in conditions of bail and cited our research over 12 times in its review of conditions for the release of persons in jail for domestic violence. Protective factors include the abuser having full employment and a substance free environment.
As the reader begins to understand report writing requires a visceral response and poignant understanding of this hidden social maelstrom. There are legitimate reasons for seeking “no bail” holds on some people arrested for domestic violence when high acuity and high risk exist together. These have been posted by me in the Human Behavior blog.
Campbell, J. (1995). Assessing dangerousness. Newbury Park: Sage. Nicole R.
Bissonnette, Domestic Violence and Enforcement of Protection from Abuse Orders: Simple Fixes to Help Prevent Intra-Family Homicide, 65 Me. L. Rev. 287 (2012). Available at: https://digitalcommons.mainelaw.maine.edu/mlr/vol65/iss1/12
Ronald Allanach et al. (2011) Psychological Autopsy of June 13, 2011, Dexter, Maine Domestic Violence Homicides and Suicide: Final Report 39 (Nov. 28, 2011), http://pinetreewatchdog.org/files/2011/12/Dexter-DVH-Psychological-Autopsy-Final-Report-112811-111.pdf.
Vehling, S. (2019) Taking your breath away – why strangulation in domestic violence is a huge red flag. Blog post https://www.mobileodt.com/blog/taking-your-breath-away-why-strangulation-in-domestic-violence-is-a-huge-red-flag/ taken March 15, 2022
Mac Walton. (2019) Bail Reform and Intimate Partner Violence in Maine, 71 Me. L. Rev. 139. Available at: https://digitalcommons.mainelaw.maine.edu/mlr/vol71/iss1/62
This video is about an introduction to a post that will be forthcoming in a short while it is reference to law enforcement officers and the suicide death of officers￼ who carry trauma.
The NYPD is making use of psychological autopsies, a research-based approach that attempts to better understand why someone took his or her life.
The fight/flight mechanism that keeps us on guard plays a primary role on how people feel after episodes of high stress. Feelings of frustration, lack of focus, chronic fatigue, and even depression can result from an over reliance social media stimuli like an unfed addiction.
I have worked with older clients for over 25 years first as a post doctoral fellow at Boston City Hospital – now BUMC. Long before the pandemic, my work at Whittier Rehabilitation Hospital has been to provide support and direct service to patients’ suffering from debility associated with decline in physical health along with the psychosocial needs and changes. All too often, this includes feelings of loss of control and sadness that is palpable in our short conversations. Many seniors feel invisible and the virus exacerbates these feelings. Declining health further instills the loss of purpose and amplifies the stigma of being seemingly infirm. The lack of purpose germinates from the passing of a spouse, close friends who move or have died, food and financial insecurity. It precedes a death wish and it’s associated demoralization. My mother was infected with the coronavirus in mid-April 2020 before the vaccine was introduced. She lived in the same nursing facility where I lost my 93-year old aunt in the first wave of the virus in May, 2020. My mother survived the virus but it has taken a significant toll on her physical and cognitive well-being. We were not permitted to see my mother during her illness and my aunt was alone on May 1 when she succumbed to the virus.
Trauma informed therapy refers to the critical understanding of one’s emotional history and supports the model of early traumatic experience being one underpinning of many mental health outcomes and threatened resilience later in life. These kinds of experiences have an impact on people who have had loved ones die while in lock down across the country and can engender guilt and helplessness. Often, singular front line medical staff are alone with patients who succumbed to the virus – sometimes holding the fading grip of another disappearing life. This heroic act of empathy happens without fanfare or even a moment to process its importance and acknowledgment of the person’s passing.
The man stopped breathing.His color signaled that he had only moments to live. His nurse called the code. This brought a hospital team of
nearly 20 staff members assigned to the code blue team. Their job was to provide intervention for advanced cardiac care to return circulation and restore breathing. Every member of this team had a job to do. Starting with the scribe who kept track of everything. “Is somebody writing”? Inquired the maestro. Things like the minutes since the heart stopped and when he first received medication, when IV access was achieved, or the time he received the lifesaving shock to his heart, known as defibrillation. Her voice was sometimes shrill as she tried in vain to speak above the calamitous scene by tracking time since last dose of epinephrine, adenosine, or vasopressin or changing vital signs. Her job was essential and had to be accurate. These are high stress low frequency events that nobody enjoys.
The code team works like an orchestra led by the maestro – sometimes a senior nurse. The maestro must be laser focused and have full knowledge of the patient’s recent medical history and all possible causes leading to this event. Maestro follows an ACLS protocol that guides the decision tree. The team had assigned jobs for CPR and back-up to the person assigned to be first on chest compressions. And there was the rescue breather, respiratory therapist, IV nurse, the runner for blood and other equipment, pharmacist, and physician – usually the maestro. For many team members, there is an intangible calling that underlies a doting sense of purpose which brings them into nursing.The less experienced team members may be second chair in this orchestra but all feel cheated when outcomes are bad.
The man in question wanted no heroic measures taken and did not wish to be transferred to the trauma center if his heart were to stop beating. It was his advanced directive.
On this particular day, the nursing staff on duty watched the patient closely. His heart was being monitored for rate and rhythm. His breathing sounded scary in the early morning hours on the Saturday after Thanksgiving. The family had not been able to see the man who had been diagnosed with covid-19 following a stroke. By all reports his viral load was mild. He seemed to be getting better leaving most of us to believe he would slowly improve and one day make it home. I spent time with him that Friday assessing his language. It too had improved during his time in the unit.
The physician on the day shift was not on the unit yet on the Saturday morning. It would be the man’s last day. He was running a low grade fever perhaps 99.8 degrees. This was lower than it had been the days prior. The man had started to show signs of improvement after being diagnosed with coronavirus shortly after being admitted to the rehabilitation hospital. He was fully vaccinated. So what happened? He went from being on the mend to not breathing in a matter of hours. This is what front line ICU nurses and doctors have been dealing with for 18 months during this pandemic. We saw very few cases of this type at our hospital. Afterall, he was in our hospital to rehab from his CVA.
These events take a human toll and put a chink in the armour. Outcomes whittle away at job satisfaction, personal efficacy, and professional.purpose. The coronavirus was making its fourth appearance with a growing wave of breakthrough cases which had us all on edge. The man in this case was sick well before my breakthrough surprise. I became infected in mid-December and was sent home for quarantine.
The man was transferred to us following a significant left hemisphere stroke. He was sent for retraining to advance the functionality of his language so he might return home. He had global aphasia but was getting better with using words and helping himself. Slowly, his receptive language was starting to make connections again. He started to understand nuance and gesture. He could make his point using the tools he was learning during therapy sessions. These are good signs in early stroke recovery and represent the plasticity in the human brain. He had become able to follow some perfunctory directions and express his basic needs, still sometimes missing the point by using jargon. This is known as the language of confusion in speech pathology circles. We have excellent speech pathology services at Whittier and I especially respect their efforts and expertise.
He was not depressed and was working with his therapy team as much as he could. For their part, the staff is passionate when it comes to helping patients gain function. By standing, speaking, and eventually, directing their own care.
When he was admitted, the man and his family decided that they wanted no heroic measures taken should his heart stop beating. No CPR, no intubation or breathing tube, no transport to a higher level of care such as the nearby trauma center. He was not a young man and believed he had lived a good life. His wishes.
Remember, his breathing and respiratory drive took a rapid turn for the worse. Quickly, he went from looking bad to looking better, to looking worse. In a matter of a few hours his breathing had become more shallow. Agonal in quality. His nurse called the code.
Agonal breathing usually signals a cardiac arrest. Nurses are trained to respond with the code cart and a dozen or more advanced cardiac rescue interventions geared toward restarting the heart and saving a life. Not the outcome last Saturday morning. His choice was very clear – no heroic measures. So staff were instructed to stand down and watch. Some staff became emotional and were consoled by senior nurses.They could do nothing but sit on their hands.
The younger staff felt traumatized, as this was not supposed to happen. Even support personnel were watching as team members slowly backed away to hear witness.
His family was called and the sad news was shared. They had not said goodbye because of the mandated virus protocols. He did not yet receive the Sacrament of the Sick, as he had wanted. He was not alone and in the end, the group came together to recognize this man for the good fight he brought forth at rehab and for having the courage to know what he did not want, and for those few things he did. He died at 8:12 as he wished, without fanfare. The maestro on this day, reminded them all of this and that he lived a full life, and the scribe recorded the time.
There are now sufficient numbers of individuals who have had the coronavirus during the past 15 months who are presenting to their physicians with lingering symptoms of the disease. They are now known as long-haulers. People who have sometimes multiple complaints that suggest to researchers that they are a different group of patients. They tend to be younger, they generally have more complex medical histories including a variety to pulmonary conditions, and they are not the case you might expect to be most debilitated. This report is derived from the literature recent review and live zoom presentation on the Cognitive Impact on Long-haul survivors of the coronavirus held on May 20, 2021. It is available on the Whittier Health website. I want to thank Lauren Guenon, MS, SLP, CBIS for her help in this program and the data mining we are continuing.
It was first reported that overwhelming viral spread was thought to be primarily respiratory. The virus multiplies inside the body and is likely to cause mild symptoms that may be confused with a common cold or flu. This changes in many as the viral load evokes a cytokine autoimmune response in the body. As the virus takes, hold during the worsening pulmonary phase primarily respiratory symptoms such as persistent cough, shortness of breath, and low oxygen levels are observed. Too many survivors say the ignored this phase and just tried to rest at home. Often they were transported to hospital after being overwhelmed by the inflammation in their lungs and other organs. Hyperinflammatory phase, occurs when a hyperactivated immune system may cause injury to the heart, kidneys, and other organs as covid-19 devours healthy cells leading to death of cells in a process called apotosis.
Experience shows most long-haulers were expected to fall into the high risk category. like those with chronic COPD, but there is also a growing percentage of people who were otherwise healthy before they became infected and are not the older, sicker cases first described.
About 33% of COVID-19 patients who were never sick enough to require hospitalization continue to complain months later of symptoms like fatigue, loss of smell or taste and “brain fog,” that can interfere with functional tasks including the return to work.
University of Washington (UW)
It remains unclear if neurological complications are due to the direct viral infection of the nervous system, or they are a consequence of the immune reaction against the virus in patients who presented pre-existing deficits or had a certain detrimental immune response from their immunocompromised status when infected. 38 males, ages 22-74
The first studies of long haul survivors are being published. They are small studies reporting on the Italian first wave in 2020. The cases are hospitalized, non-intensive COVID units in Milan, Italy. These were not the patients who needed intubation or ventilatory support. Most had ARDS (mild, moderate, severe) Ferrucci, R et al. Subjectively, 31.6% reported overall cognitive decline 4-5 months after discharge when they were screened using a commonly administered cognitive test, then assessed using BRB-NT. Results for this group of moderately infected patients included: 42.1% processing speed deficits; 26.3% delayed verbal recall; 10.5% immediate verbal recall; 18.4% impaired visual long term memory, 15.8% visual short term memory; and 7.9% semantic verbal fluency deficits. Helms et al. reported on 58 patients who were evaluated in the ICU with over a third (33%) exhibiting dysexecutive syndrome, poorly deployed attention, and decreased capacity for organization
In another Italian study, 81% of patients had cognitive deficits including difficulty in areas of attention and executive functioning with pronounced weaknesses in divided and sustained attention (complex attention) set-shifting, speed of processing, and working memory. This was a group of 57 patients who were sent to acute rehabilitation after they were cleared of having active virus. All were debilitated and had a mean age of 64. 75 percent were male, 61 percent non-white and 56 percent were fully employed. In this group 88 % had suffered hypoxic respiratory failure with most being intubated for ventilatory support. 29% went on to get a tracheostomy tube inserted indicating a likely longer-term need for breathing support. 84 % need assistance with activities of daily living, has impaired mobility, and support for IADL’s. Neuropsychology services saw them an average 6.6 days after admission to the rehabilitation hospital. In general, the Whittier cases admitted for covid-recovery were referred to a neuropsychologist within 48 hours of admission. Ventilation-induced hypercapnia has been experimentally shown to lead to cognitive impairment due to acute inflammatory response advancing the cytokine storm and its multi-system impact.
Studies have described long-term risk and short-term risk to cognitive health from the coronavirus. Severe cognitive decline like dementia may be associated with co-occurring illness from anoxia, respiratory failure, blood clots and is associated with more severe disease and chronic long lasting symptoms. These are linked to prolonged risk of systemic inflammatory illness, increased risk of stroke and white matter disease within the brain and even reported cases of acute transverse myelitis (Budson,A, 2021). Budson reported on symptoms in 30-50 percent of people who experienced mild to moderate disease. Zhou et al. described a sample of 29 patients who were assessed 3 weeks after discharge home who were found to have dysfunction in the system of attention – most notably in sustained attention and reaction time. This may be the result of decreased mental endurance, slow processing and fatigue that are reported across several studies reported here. These patients were positively coorlated with C-reactive protein – a marker of the bodies inflammatory response when elevated.
Elevated level of CRP may be a valuable early marker in predicting the possibility of disease progression in non‐severe patients with COVID‐19, which can help health workers to identify those patients an early stage for early treatment.Nurshad, A 2020
Rampage published in the table below in the American Journal of Speech Pathology in 2020. The long-haul covid-recovered are likened to patients described as having post-intensive care syndrome that occurs as a result of the changes in the system of cognition and emotional regulation. This is one of the best tables I have seen that illustrates the impact of the virus and the systems that are impacted. Rampage et al.
Delirium is another concern and fits in with what is called post-ICU syndrome (PICS), a collection of problems that can present—and linger—after a critical illness. “The three domains we worry about are impairments in physical function, cognitive function, and mental health” .Yale School of Medicine Carrie MacMillen June 2020
The long term impact may be seen later on in life. Chronic systemic inflammation has been shown to promote cognitive decline and neurodegenerative disease makes it more likely that COVID-19 survivors will experience neurodegeneration in later years that has been known for a long time. Those with short term cognitive consequences may have had less viral load and for a shorter duration of time. Interestingly, those who were in covid-recovery units and on ventilators tended to report less cognitive symptoms suggesting there may have been some protective element to consistent ventilatory or simply timing and getting to the hospital before the hyperinflammatory (cytokine storm) phase of the viral process. A global increase in the prevalence of fatigue, brain fog, depression and other “sickness behavior”-like symptoms implicates a possible dysregulation in neuroimmune mechanisms even among those never infected by the virus .
Whittier Rehabilitation Hospital in Westborough, MA is looking at the data of 73 patients. This is very likely the first and largest subset of surviving long haul cases of the coronavirus. Our population is older 70.6 years, 66% white males versus approximately 64 years reported in the Italian studies reported here. The Italian samples were largely male as well. The average length of stay was 19.6 days. 21% had signs and symptoms of clinical depression or generalized anxiety co-occurring with their physical and cognitive symptoms. 14% had persistent delirium and encephalopathy.
Recovery from the long-haul symptoms reported in this paper will take weeks to months we predict. It has been recommended that aggressive multidisciplinary rehabilitation be initiated as soon as endurance permits. Intensity shoould include 4-5 times a week PT, OT, and speech language pathology. In many cases the comorbid depression and anxiety must be dealt with concurrent to the restorative physical and cognitive work. Some have likened the neurocognitive impact of covid-19 to that of a moderate traumatic brain injury in the breadth of its impact and tough return to a semblance of normalcy. Aggressive treatment is strongly recommended and should be commensurate with endurance and debility. There is evidence that the likelihood of full return to work is decreased after 6 months or more of recovery.
Ferrucci, R et al., (2021) Brain Sci. 11, 235.
Jaywant et al., (2021) Neuropsychopharmacology, 0:1-6
Budson, A. (2021) B.U.Medical School — https://www.health.harvard.edu/blog/author/abudson
Heneka et al. (2020) Alzheimer’s Research & Therapy. Long and Short-term Cognitive Impact of Coronavirus. 12:69 https://doi.org/10.1186/s13195-020-00640-3
Lawton, MP, Brody, EM. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 9(3): 179-186.
Ramage, A. Potential for Cognitive Communication Impairment in COVID-19 Survivors: A Call to Action for Speech Language Pathologists. Nov. 2020, American Journal of Speech-Language Pathology. Vol. 29. 1821-1832
Sigurvinsdottir, R, Thorisdottir, I, Gylfason, HF. (2020). The Impact of Covid-19 on Mental Health: The role of Locus of Control and Internet Use. International Journal of Environmental Research and Public Health, 17:6985: doi:10.3390/ijerph17196985.
Nurshad, Ali, (2020) J Med Virol. Jun 9 : 10.1002/jmv.26097.
Ludovica Brusaferri, Zeynab Alshelh, Daniel Martins, Minhae Kim, Akila Weerasekera, Hope Housman, Erin J. Morrissey, Paulina C. Knight, Kelly A. Castro-Blanco, Daniel S. Albrecht, Chieh-En Tseng, Nicole R. Zürcher, Eva-Maria Ratai, Oluwaseun Akeju, Meena M. Makary, Ciprian Catana, Nathaniel D. Mercaldo, Nouchine Hadjikhani, Mattia Veronese, Federico Turkheimer, Bruce R. Rosen, Jacob M. Hooker, Marco L. Loggia (2022) The pandemic brain: Neuroinflammation in non-infected individuals during the COVID-19 pandemic, Brain, Behavior, and Immunity, Volume 102, Pages 89-97, ISSN 0889-1591, https://doi.org/10.1016/j.bbi.2022.02.018.
During the pandemic, mental hygiene is just as important as hand washing. It’s time to disinfect your thoughts and kill the ANTs to overcome anxiety, depression, trauma, and grief. ANT is an acronym for —Automatic Negative Thoughts. Daniel G Amen, MD 2020Over one year into the pandemic while only 50 % of the US population is currently vaccinated with at least the first shot, we are seeing the importance of mental health in managing the pandemic. It is now abundantly clear, that it is because of mental health underpinnings, that the next wave of the pandemic is building. People cannot remain in isolation forever. The indefinite duration of confinement grew insurmountable to enforce and the collective civility toward social distancing and mask wearing became politically untenable for many governors. People need to socialize, be free to worship, attend weddigs and funerals, even dance in the streets, as we have seen Americans do ever since it “reopened” when state governor’s decried the pandemic under control. And we have paid the price for this. Mental health tends to be the ugly step-child of physical illness in a society that is strongly biased against the emotionally infirm in favor of the medical model of well-being. For one thing, alcohol sales increased 200 percent among Americans coping with loneliness and frustration while in quarantine. There is no doubt that people felt the stress of being cooped up during the first weeks of the pandemic. The quarantine put a strain on sensible behavior and emotional credulity over social distancing, all the while putting ANTs in our heads. In places like India and across Europe where the vaccine roll out has been less successful the infection rate has risen, and given the propagation of variants that have been reported, those who are not yet vaccinated have much to fear. Michael Sefton
Two Capitol police officers have taken their own lives since the insurrection at the U.S. Capitol on January 6, 2021. This information came after the two officers spent 5 hours fighting the insurrectionists sometimes in hand to hand combat often being humiliated and threatened. Jeffrey Smith, a Metropolitan D.C. Police officer, and Capitol Police Officer Howard Liebengood both “took their own lives in the aftermath of that battle” of January 6, according to an article in Politico on January 27, 2021. A third officer, Brian Sicknick, age 42 collapsed while on duty the day of the attack. He died in the aftermath of the insurrection a day or two later.
The manner of his death has been determined to be natural causes. Officer Sicknick died from multiple strokes according to the medical autopsy. Some reported seeing Officer Sicknick being struck in the head with a fire extinguisher during the riot. The official cause of death was stroke – or cerebral vascular attack and it is well-known that high stress situations can lead to stroke such as an insurrection or even shoveling one’s drive following a snow. Sicknick was only 42 years old and in good health prior to the Capitol attack. Officer Sicknick was afforded the honor of laying in honor in the Capitol Rotunda after death. Antoon Leenaars, past president of the American Association of Suicidology, described the patterns of thinking among depressed or suicidal persons, and explained how the use of “psychological autopsies” can uncover the key elements that are present in many suicides. This is an important first step in the battle to change officer suicide to become more attributed to line of duty death. This determination is owed to many of these brave men and women who died as a result of the recurring emotional trauma to which they were exposed.
“Jeffrey Smith was still fighting to defend the building when a metal pole thrown by rioters struck his helmet and face shield. After working into the night, he visited the police medical clinic, was put on sick leave and, according to his wife, was sent home with pain medication. Smith returned to the police clinic for a follow-up appointment Jan. 14 and was ordered back to work, a decision his wife now questions. After a sleepless night, he set off the next afternoon for an overnight shift, taking the ham-and-turkey sandwiches, trail mix and cookies Erin had packed. On his way to the District, Smith shot himself in the head.Smith’s wife Erin reported after her husband took his own life
“On April 2, 2019, PERF and the New York City Police Department took an important step to elevate the national conversation on police suicide and to identify concrete actions that agencies can take to address this public health and public safety crisis. Our two organizations hosted a one-day conference at NYPD headquarters that brought together more than 300 law enforcement professionals, police labor leaders, researchers, mental health care and other service providers, policymakers, and others—including three brave officers who themselves have dealt with depression, PTSD, and suicidal thoughts in the past and who were willing to tell us their stories” according to published executory summary 2019. “The NYPD is making use of psychological autopsies, a research-based approach that attempts to better understand why someone took his or her life. Following an officer suicide, personnel try to reconstruct what was going on in the person’s mind by systematically asking a set of questions, in a consistent format, to the people with the greatest insights into the person’s life and mind—family, co-workers, and friends.” The psychological autopsies contribute to the existing database of information about law enforcement suicide in general, and they help guide individual prevention programs and establish in the line of duty rewards for those whose death’s may be directly associated with their recent tours of duty as in the example of the Capitol officers who died immediately following the trauma of the insurrection where each of them was prepared to die.
The multiple deaths by suicide have renewed attention on another troubling and often hidden issue: Police officers die by their own hands at rates greater than people in other occupations, according to a report compiled by the Police Executive Research Forum (PERF) in 2019, after at least nine New York City police officers died by suicide that year. I was involved in the April 2019 presentation at 1 Police Plaza on the impact of LEO suicide as it related to the high incidence of police officer death by suicide. Police Commissioner James O’Neill gave an impassioned presentation imploring officers to get help and promising to “listen and eliminate stigma” of having trauma-related illness.
Regrettably, first responder suicide is generally not considered a line of duty death and as such, fails to yield the honor given to officers who die in car crashes, shoot outs, or other direct line of duty incidents. “Now, the surviving families of the courageous defenders of democracy, Jeffrey Smith and Howard Liebengood — who were buried in private ceremonies, want the deaths of their loved ones recognized as “line of duty” deaths”. These deaths lack the honor and pageantry that accompanied Sicknick’s memorial service in the Capitol Rotunda — Why is the distinction made between the many ways LEO’s die?
The denial of this recognition diminishes the honor of one man’s service and by doing so, fails every man or woman who puts on a uniform by saying “your experience is yours alone”. And even worse, it amplifies the stigma attached to law enforcement deaths at a time when all else has failed them.Michael Sefton, Ph.D. 2022
The careful analysis of antimortem exposure and actionable behavior that follows and event like January 6 or September 11 draw the clear, indisputable facts that link officer suicide to line of duty traumatic exposure. The denial of this recognition diminishes the honor of one man’s service and by doing so, fails every man or woman who puts on a uniform by saying “your experience is yours alone”. And even worse, it amplifies the stigma attached to law enforcement deaths at a time when all else has failed them. I cannot stand by this exception to what may be obvious line of duty exposure and police officer death especially after 9-11 and after the Capitol insurrection. But it should in no way minimize the loss of life attributed to suicide when years of exposure have gone unnoticed and even unreported by a law enforcement officer.
After the September 11, 2001 attack on the World Trade Towers there was an increase in LEO suicide. Men and women who witnessed the enormity of the attack coupled with the deaths of hundreds of police officers and fire fighters lost the will to grudge onward by no fault of failure character of their own. They swam in the muck and got wet and could not recover from darkness that engulfed them. The psychological autopsy would quantify these wounds just as the pathologist counts entry and exit wounds from an ambush.
The juxtaposition of these facts cannot be ignored. Every one of the hundreds of police officers put their lives on the line as a result of the former president’s truculent narcissism. It would be a dishonor to the men who gave their lives by denying the causal underpinning of their deaths. Suicide by law enforcement officers exceeds the number of officers who die in in gun fights, car accidents, on-duty heart attacks, attacks by citizens, calls for domestic violence, and other police calls for service. “This fact thrust these most private of acts into the national spotlight and made clear that the pain of the insurrection of January 6 continued long after the day’s events had concluded, its impact reverberating through the lives removed from the Capitol grounds” as written in a recent Washington Post report. “It is time the District recognized that some of the greatest risks police officers face lead to silent injuries,” Weber said. “Why do we say that one person is honored and another person is forgotten? They all faced the exact same circumstances.” according to a report in the Washington Post by Peter Hermann in February 2021.
There are things that must be done when law enforcement officers die as a direct result of the the calls they take and the trauma they experience that directly results in their death. Neither of these officers would have died if they had not jumped into the crisis taking place at the U.S. Capitol. Both men were solid members of the Capitol and Metropolitan Police Departments and had no history of behavioral health claims. Neither officer was in trouble with finances, gambling or substance abuse, internal affair investigation, or marital trouble. In the days that followed, Erin said, her husband, Capitol officer Jeffery Smith seemed in constant pain, unable to turn his head. He did not leave the house, even to walk their dog. He refused to talk to other people or watch television. She sometimes woke during the night to find him sitting up in bed or pacing. Her husband was found in his crashed Ford Mustang with a self-inflicted gun shot wound that occurred on his way to the job.Peter Hermann Washington Post 2-12-2021
Rioters swarmed, battering the officers with metal pipes peeled from scaffolding and a pole with an American flag attached, police said. Officers were struck with stun guns. Many officers were heard screaming into their radios “code-33” the signal for “officer needs help”. This usually is a signal bringing an “all hands” response to the scene of the emergency – in Metro DC, that would mean hundreds of officers would roll. Situations like this send chills down the spine of officers responding to calls for help – some are injured in car crashes racing to back-up officers in danger. It is always hoped that when the call for help goes out as it did that day that enough manpower will respond with enough force to push back on the crowd, however large. In this case, the crowd far exceeded the number of LEO’s available for duty and many officers expected to be killed by the mob.
The psychological autopsy is a single case study of a death event that serves to uncover the psychological causes of death. This study would answer these questions and establish an understanding of worst case scenario of frontline exposure to trauma and possibly offer insight into underlying history that may have been anticipated and stopped. Without its use men and women die alone and often flooded with shame and loss of dignity. When law enforcement officers take their own lives this careful analysis of the hours and days preceding their time of death is essential to understand. “From this information an assessment is made of the suicide victim’s mental and physical health, personality, experience of social adversity and social integration. The aim is to produce as full and accurate a picture of the deceased as possible with a view to understanding why they killed themselves.This would answer the question as to whether or not the deaths may be considered to be line of duty, as they must. Psychological autopsy is probably the most direct technique currently available for determining the relationship between particular risk factors and suicide” Hawton et al. 1998
The evidence on Crisis Intervention Team (CIT) programs is thin, in part because these programs vary widely, with some representing basic officer awareness training and others composed of full-fledged and well-funded co-responder programs. However, the evidence on the impact of de-escalation training, which includes instructing police in how to identify and respond to people in crisis, is relatively strong.Council on Criminal Justice https://counciloncj.foleon.com/policing/assessing-the-evidence/xvi-shifting-police-functions/ taken February 6, 2022.
I have proposed a Behavioral Health initiative in conjunction with changes in police policy and transparency that has been the central posit of social clamor since the death of George Floyd this summer. The International Association of Chief’s of Police (IACP) has a broad-based Mental Wellness program it is reporting on its website that highlights the importance of this kind of support. “The IACP, in partnership with the University of Pennsylvania (Penn) and the Bureau of Justice Assistance (BJA)’s VALOR Initiative, is customizing a program specifically designed to help officers and agencies by enhancing resilience skills. The cost of such a program will reap rewards in the form of career longevity, officer well-being, officer morale, quality of community policing, and greater faith and trust in law enforcement in general. Without psychological autopsy systemic failures in training and support often go unnoticed leaving men and women without a life saver to hold on to.
This investigation is an individually designed case study that elicits a broad range of factual data regarding the antemortem behavior of a decedent in the immediate day or days leading up to the suicide. In this case, what are the events that transpired in the days before the two Capitol police officers took their own lives? The fact is that both men were exposed to incidents and participated in protecting the Capitol on January 6, 2021. Both men were engaged in hand to hand combat. It is known that the insurrection resulted in the death of a fellow officer and the deaths of 4 other people engaged in violent mayhem in which these men and hundreds others may have been killed. Both men believed the insurgency was potentially deadly to them or their fellow officers. The psychological autopsy is especially important when first responders and essential workers are involved and die soon after. When LEO’s and first responders are put in fear of death or see other officers being placed in the direct line of fire, are vastly outmanned, and have no way in which to stop an attack, they are at high risk for the “hook” that comes from an acute stress reaction and over time and soon becomes a monkey on the backs of so many fine men and women.
Some agencies, such as the Fairfax County, VA Police Department, are beginning to implement periodic mental health check-ups for their officers and other employees. The goal is twofold: 1) to “normalize” the act of visiting a mental health professional, thus reducing the stigma against seeking mental health care, and 2) to identify and address potential issues early on. (PERF 2019)
“This heroic sequence of behaviors is besmirched by the bias against mental health responses to events that would bring any one of us to our knees. Men and women of law enforcement walk in the darkness, always in death’s shadow. It is time to recognize these officers and help them and their families to know they do not walk alone.”
Michael Sefton, Ph.D. 2018 Direct Decision Institute, Inc.
Departments should consider flexible job assignments or adding exercise to work schedules as a way to release stress. Mental health should be regularly addressed at roll calls, and departments generally have to reduce the stigma — in part by acknowledging the deaths. According to Dr. Leo Polizoti at the Direct Decision Institute, Inc. in Worcester, MA, an annual stress inventory should be conducted as part of the official officer evaluation program. This may be easily done by tracking high lethality calls that may be followed by mandatory defusing/debriefing as close to high stress incidents as feasible. Officers in Worcester, MA are given paid time for these aftermath behavioral health sessions.
Hawton, K., Appleby, L., Platt, S., Foster, T., Cooper, J., Malmberg, A. & Simkin, S. (1998). The psychological autopsy approach to studying suicide: a review of methodological issues. Journal of Affective Disorders 50, 269–276.
IACP (2021) Officer Resilience Training Conference https://www.theiacp.org/projects/law-enforcement-agency-and-officer-resilience-training-program, Blog post taken February 13, 2021
Police Executive Research Forum. (2019) Washington, D.C. 20036 Copyright by Police Executive Research Forum
Buckley, M and Sweeney, A. (2019) Chicago Tribune. Alarms sound after 6 suicides in Chicago PD. https://www.chicagotribune.com/news/ct-met-chicago-police-suicides-20190315-story.html?
Donovan, E. (2019) Former Director of Boston PD Stress Unit.” https://www.linkedin.com/pulse/po-ed-donovan-former-directorboston-pd-stress-unit-brian/
Sometimes being present in the moment is enough to allow feelings of vulnerability to emerge and for healing to begin. Cops, and I dare say fire fighters, are not used to being vulnerable. Often less is more when is comes to shared space, personal pain and having a connection with one or more people who understand. A quiet moment of reflection after a difficult call may be enough to diffuse the experience of trauma and provide damage control going forward. Career hardiness and satisfaction requires that some moments be recognized with a circle of shared vulnerability and authentic empathy that can be just a few seconds to minutes.
During the coronavirus after a particularly deadly shift, members of ICU teams took a moment to share the names of those who had died in their care. These were somber events that acknowledged the losses and a measure of desolation shared among team members. People undergoing enormously stressful events can unburden themselves only if they acknowledge their inner feeling state. “We’ve seen chaplains accompany COVID patients in their last moments when loved ones could not be present. The year 2020 inflicted deep wounds on many in our communities and chaplains were there offering support,” said Wendy Cadge, the project’s principal investigator and Senior Associate Dean of Strategic Initiatives at Brandeis University.
“When we can feel and acknowledge our deepest fear – it can be liberating and reduce the perceived stigma of being vulnerable and in pain.”Elissa Epel, Ph.D., UCSF, as quoted in NY Times
Police, fire, and first responder agencies across America have called upon the chaplaincy when their membership has experienced an out-of-the ordinary exposure to trauma like fatal car crash, death by suicide, death of a member, school or mass shooting, and more. Some of these are more routine like a notification of the sudden death of a family member. Meanwhile, other incidents leave a searing imprint of the entire event like the shooting of over 20 Sandy Hook elementary school students in Newtown, CT. It has been frequently mentioned that exposure to death and uncivilized brutality has an impact on wellness and personal resilience. Not a surprise. In the case of Sandy Hook how can any member of law enforcement or EMS ever forget that day? But what can be done?
Police chaplains is one part of the solution. The Chaplaincy Innovation Lab received two grants totaling $750,000 from the Henry Luce Foundation in the second half of 2020 to continue building and supporting resilience in chaplains and other spiritual care providers across the country. Chaplains often find themselves on the front line and frequently encounter operational chaos when they are called upon to minister to the troops. Yet that rarely stops them. They were there at Sandy Hook in 2012. The new program at Brandeis University in Boston aims to train chaplains to be better equipped for things like Sandy Hook or any community event that impacts large groups of people.
In Boston, the call went out that a firefighter was down. This during a 2-alarm fire in Watertown, MA. The department chaplain Father Matthew Conley was needed “now” at the Mount Auburn Hospital in Cambridge, MA for the Anointing of the Sick – known to many as “the last rites.” Fr. Matt had not been on scene during the incident as it appeared to be a routine call. But like so many calls it went south in a hurry.
Firefighter Joseph Toscano was near death from a medical emergency suffered while on duty fighting the fire. It was a hot summer day. He was 54-years old and had a large family of a wife and 5 children. The family were all members of the Catholic faith at a parish a short distance from Watertown. For many Catholics, the anointing of the sick is something to bring about reconciliation for someone who may wish to ease their suffering on the journey toward death.
Firefighter Toscano died that day while doing the job he was trained to do. The Last Rites involve prayers and the final Holy Communion known as the Viaticum. These were something Fr. Conley had done many times before. But when he arrived at the Mt. Auburn Hospital that morning he was met by a phalanx of Watertown police and fire fighters. As he walked into the emergency department of the large Cambridge, MA hospital he knew right away by the look in their eyes that this was no ordinary blessing. He was called to minister, first, to the dying public servant, his wife and children who had been brought to his bedside at the trauma center. But what’s more, he was tasked with consoling the entire brotherhood who looked to him for comfort and hope when no amount of prayer could bring back their fallen brother. But he listened, and he heard their pain, and validated their experience.
“You are here for all of them”, he would say, “and I am here for you.” Fr. Matt Conley sharing the words of former Parish Administrator Fr. Kevin Sepe at Watertown Collaborative.
The story is told that as Fr. Conley dealt with the enormity of the pain felt by all who felt the sudden loss of the career firefighter, when in-walked Fr. Kevin Sepe, the Watertown Collaborative priest administrator. The presence of Father Conley brought a strong empathic presence to the family who had lost their husband and father and to the first line firefighters who felt the loss deeply. Fr. Matt listened and he offered prayers.
From his years as a priest and police chaplain, Fr. Sepe understood what Fr. Conley was facing in the call to the hospital crisis as the department chaplain. His support was largely nonverbal that day. “You are here for them,” he would say, “and I am here for you,” bringing his presence, peer support, and understanding of the enormity the ministry at hand.
“Police chaplains aren’t there to push a religion on police officers; their role is primarily to listen and offer emotional and spiritual support” from an article in Police One, 2015. The chaplain program has been around for over 200 years and often works in the background subliminally. The military has utilized multi-denominational chaplains to minister the troops as well. These men and women are on the front lines and 3 members of the clergy have paid the ultimate price for their calling during recent wars.
Not everyone is religious and you might believe that a goal of a department chaplain is to advocate one denomination over another. Not the case at all. The chaplain may be a Catholic priest as in the illustrated case or he or she may be an ordained Protestant minister, Muslim Imam, or a Jewish rabbi or some other ordained member of the clergy. As a police officer, I worked with a female protestant chaplain who was very helpful with members of our community. I would not have hesitated speaking with her in confidence if I were in need. The role of the chaplain is to provide support and to listen. She was good at it too. Being present with someone who is in crisis or dying can be among the most gut wrenching of all human experience. Fr. Conley once told me he never goes anywhere without the Sacramental oils for the blessing of the sick. This allows him to be ready to offer the Sacrament should he be called to do so. He felt deeply that this anointing was his duty and one of seven sacraments priests are prepared to offer.
I have given death notifications before and have witnessed the soul wrenching-anguish experienced by those receiving these notifications. It is a horrible experience and I remember most all of these events and am still bothered by several.
For line of duty deaths, chaplain’s ask if prayer might be helpful. The sacrament of the sick is one “of strengthening, peace, and courage to overcome the difficulties that go with the condition of serious illness or the frailty of old age provided by the Catholic Priest. This grace is a gift of the Holy Spirit, who renews trust and faith in God against the temptation of discouragement and anguish in the face of death” according to Michelle Arnold published in Catholic Answers in 2017.
The key to a successful departmental chaplaincy is contact — if you have enough chaplains strategically placed who are artful in “reaching out and touching someone,” two things will happen. Successful interactions will take place and the word will get around. Once calls for a chaplain begin to come directly to a chaplain from the on-scene sergeant or deputy, the chaplaincy has made its mark. Chaplains can best serve when their role is defined and the confidentiality of their relationship to law enforcement is understood. Police One, 2015
The chaplaincy has been around for centuries in public service. It is making entry into many law enforcement agencies in earnest. Many have had chaplains riding in cruisers for decades like Fr. Dan Brandt in Chicago and his fine crew of law enforcement trained chaplains of all denominations. At some times, this has raised the issue of mixing government with religion. But there are guidelines in place. “In Lemon v. Kurtzman, the justices established the three-pronged “Lemon Test,” which, as it translates to the chaplain’s position, says he must have a secular purpose, must not excessively entangle the government with religion, and neither proselytize nor inhibit religion” said reporter Jon O’Connell in a 2017 report. The police and fire department chaplain is there for support of first responders, not as an evangelist, but as moral reminder of the “sacred nature” of their work, according to Fr. Dan Brandt, the director of the Chicago Police Ministry. In Watertown and now Scituate, Massachusetts, Fr. Matthew Conley brings forth his presence with kindness, reverence, and often good humor making the human connection with those in his purview.
Brandeis Now. Chaplaincy Innovation Lab at Brandeis University receives $750,000 from Henry Luce Foundation. January 23, 2021
O’Connell, J. (2017) Police chaplains take a stronger role in community policing. Scranton Times-Tribune. News article.
McDermott, M and Cowan, J. Combating Pandemic Fatigue. Quoted in NY Times. October 2020.