In light of the coronavirus disease 2019 (COVID-19) pandemic, we are speaking with healthcare professionals from diverse backgrounds and specialties to learn more about their response to the current crisis.
We recently interviewed Jamieson Webster, PhD, and Victoria Malkin, PhD, LP, both psychoanalysts based in New York who teach at the New School and recently spent time on the frontlines of the COVID-19 pandemic in a Brooklyn hospital.
To share your own unique perspective on the pandemic and its effects on behavioral health, please get in touch with us via our submissions page. The following interview, with responses cowritten by both Dr Webster and Dr Malkin, has been edited for length and clarity.
You recently volunteered as a social worker at a hospital in Brooklyn amidst the COVID-19 pandemic – tell us a little about that experience.
We began the experience when the pandemic was at its height; the hospital was overwhelmed and filled with patients with COVID-19. The staff were attending to immediate life and death decisions, with minimal resources to attend to the psychological experience of patients or their families. Alongside this chaos, hospitals were hermetically sealed bubbles separated from the outside world. Families and friends were only able to watch in horror, anticipating what might be happening to their loved ones through the media. We were called in as the hospital attempted to find ways for families to make contact with their loved ones. The solution was a technologically mediated encounter, primarily for the sickest patients who were unable to do this for themselves.
We entered into this environment, beginning with the simple project of using iPads to create a connection between patients and anxious family members. A seemingly simple task devolved into a more complex encounter with others’ suffering and no recourse to the usual sensual processes that might allow for contact and comfort. Forced to watch a loved one from uncomfortable angles, as iPads focused on different portions of a patient’s body, small screens that cut off larger realities, tensions mounted quickly.
What may have seemed simple expanded into a myriad of emotional worlds: working through family conflicts and regrets, keeping warring families out of Zoom calls, helping patients who were too tired to talk, trying to update families who felt out of their depth with the medical system, explaining plasma antibody treatment to a family whose immigrant mother wanted to go home and refused all treatment, monitoring patients who were deteriorating and trying to make sure families could talk, helping patients who were extubated and experiencing intensive care unit (ICU) psychosis find some level of orientation, if possible, with family members, in a chaotic and at times indifferent environment. Each call held the seed of a family drama that was put on hold or tragically, for many, cut short.
In your experiences with patients and their families, how is the process of grieving affected when limited to a virtual space?
Families are grieving in a disembodied space, with some talking to their loved ones on ventilators; in many cases, it was unclear if the family was attuned to the liminal space occupied by their relatives. The varied ways that they managed this was both extraordinary, and at times, completely ordinary. Some people would bring in priests to pray, others would have a picnic, and a few of them would make phone calls every day to talk to a loved one, looking for the smallest sign as a reassurance that they have made some contact with a family member hovering between life and death.
Often, when the screen turned onto the patient, it would permit some connection to the shock of the present, but we can only imagine what it must be like to end the call, with no ability to know what happens next. Many people had a very difficult time ending these calls, wanting to stay on for longer, asking for 5 more minutes. While we were trying to aid their grief, the technology and its limitations, indeed our availability and limitations, would often become the source of anxiety and anger.
When and how grief is processed after a death where the usual rituals are prohibited — no burials or possibility of comfort — must be agonizing for all involved. Perhaps nowhere is this loss more evident than in the morgue, where the anxiety of retrieving patients’ belongings and the need to have something to touch works as a stand in for the inability to be with loved ones and attend to their bodies. The only visit the family gets is one where they can recover objects of their loved one, an exchange that can only highlight the loss, and seems to have enabled all manner of mix ups, disappointments, and overwhelming affects.
Patient representatives have had to field a great deal of anger and resentment from families, accused of losing the belongings of a patient, when, in fact, it was often the private mortuary services or something that took place during transport to the hospital or transfer between hospitals. We hope that mourning is possible for these families, even when a loved one is last seen virtually (if at all) and treated nationally as a statistic, with their physical body having disappeared without a trace.
How has the pandemic affected your private practice and the patients that you see on a more regular basis?
Moving between private practice and the hospital means experiencing the pandemic and lockdown on multiple fronts. The chaos and intensity of the hospital, including the life and death environment, social life, and hierarchies that are present even in the midst of tragedy, is contrasted by our own mediated encounters with patients, which remind us what we can no longer do: see our patients in person. At times, the very real and intense encounters with patients in the hospitals — the sight, smell, and feel of a body, that embodied suffering — contrasted with the separated and disembodied meetings on Zoom or by phone with our patients who were managing their own deprivations and lacks that quarantine amplifies.
The separation and desperation of families separated from loved ones in the hospital gets replicated in our own physical separation from our patients. There are moments of intimacy through a screen, but they can be sporadic. Witnessing can transform into a spectacle. If psychotherapy assumes that the presence of the other allows for someone to process and tolerate their distress, the danger of the disembodied contact is that it becomes viewing as opposed to sharing, spectacle as opposed to witnessing. A potential transformation from being with a person to seeming even more separate felt very present in both the hospital and our experience as therapists during the pandemic. Both situations challenge us to make contact in the context of a separation that can only amplify what is absent.
What insights can the field of psychoanalysis offer during a pandemic, a time of mass anxiety and suffering?
The mass anxiety and suffering that has taken place in the pandemic has thrown open and exposed the fault lines of our society, but it is not something that psychoanalysis can cure or even imagine to fix. If it is insightful for this moment, it might be more as an ethos: psychoanalysis asks us to think about how we live with our conflicts, how we come to terms with the fault lines in ourselves, and hopefully in doing so become a person who can actually be with others and take action if one makes a decision to do so.
Psychoanalysis asks us to think and speak what at times feels unspeakable, but in speaking we come to find a way to make it bearable. The pandemic has seemingly driven a wedge between what politicians and media say and do, and what they refuse to acknowledge or do anything about – from the terrible state of our healthcare system to the racism evident in poverty being a pre-existing condition endangering black and brown lives, not only with COVID-19, but also police brutality.
Much of the time we live disassociated from how precarious life is. The pandemic forces us to see vulnerability, even if we are less vulnerable than others: elderly people, people at risk due to poverty and social conditions, and people of color whose social suffering puts them at greater risk. Psychoanalysis traffics in fictions, the fictions we tell about ourselves and the world around us, namely, what we cannot bear to know. The pandemic has broken open these fictions: that we have the best medical system in the world, that a virus attacks everyone equally, that the Centers for Disease Control and Prevention would save us, and that everyone has a chance to raise their place in society through hard work. Psychoanalysis asks us to know that we use these fictions to survive, but they condemn us to repeat the past.
Concerns about mental health related to COVID-19 have been fairly ubiquitous in the media, perhaps more so than ever before in a pandemic. What does it mean to face this pandemic when the general public confronts itself in psychological terms, even if limited in scope?
The extreme situations seem to have encouraged a new concern for mental health. There is the trauma of seeing your world radically change in a space of 2 weeks and losing a sense of control when watching daily death numbers and no real conviction of how this will end. We are now living in ontological insecurity. The very nature of who we are is challenged, as trauma does. The public have been exposed to this sudden shock, from a bedroom and a screen, and rendered mostly impotent, locked inside and waiting to see what happens next. The encounter people had with themselves and their world during this pandemic we could see in our treatments, and will be magnified for those who do not have the resource of therapy.
Everyone experiences distress, despair, and anxiety in their own ways. For many, being stuck at home brought back feelings of an unhappy childhood, for others the deprivations felt haunting, and for some, they were liberated from everyday demands, which allowed for a personal renaissance. As people settled into their quarantines, some made peace with it, others wrestled every step of the way. Now we have a new moment, remerging in the face of the unknown, aware of one’s vulnerability, but anxious for something else, and left on the precipice, in an extremely contentious election year, about what this world will be.
Despite the daily death toll, which seems to have replaced the stock ticker on most news channels, on a collective level, mourning seems absent. Why does society seem more preoccupied with going back to normal than the tragic loss of life?
What would it mean to be preoccupied with the tragic loss of life? Is it possible? Do we ever confront trauma willingly, or is the wish to forget, to move through the trauma as if it were not there, always present, meaning the trauma is only there when it comes back to haunt you? Trauma needs to be processed, and at present there is no way to symbolize it. The political process has upended this with the politicization of even the actual numbers of deaths. The issue is not preoccupation, but whether what has happened can be named, processed, and lived with in a way that is not traumatic.
This does not happen overnight. Trauma needs to be integrated and that takes time. Psychoanalysis shows us that we need to be given a space to speak. That other might be the analyst, but in many societies there are multiple ways to process social trauma. War and tragedy are not new, and many cultures have developed ways to process tragedy; perhaps it is us, the United States, who are the worst in this respect, with our emphasis on life, love, and the pursuit of happiness. But we see multiple examples of forced forgetting, or a desire, political and social, to avoid tragedy with a triumphalist narrative. It seems human to adapt, but when done through an active forgetting, we run the risk of the return of the repressed, a social tragedy that can haunt us through generations.
Remembering, in many places and cultures, can be dealt with through rituals, religions, custom, and memorialization. When and how we do this remains to be seen. The sudden lifting of the lockdown in a collective grief over George Floyd, but also many black lives lost, seems to be a displacement and extension of the failed mourning for COVID-19 deaths. The chant you hear often — say their names — is an attempt to beat back against this forgetting. So what we do know is that failing to mourn can lead to social trauma and haunting.
How will we look back on this moment? Will those of us who lived it endlessly wash our hands and wipe surfaces — part of our own tribute to the dead — while grandchildren laugh and wonder why? Will society now acknowledge the death of black lives but not those of the elderly, something that will haunt the generation of millennials and Gen Xers who felt invulnerable during the pandemic, when they in fact begin to age?
What needs to be done to help the providers you are working alongside, who are on the frontlines in hospitals?
Something that we confronted in our work in the hospital was the presence of ICU delirium or psychosis. It is already a phenomenon that is underdiagnosed and has been specifically tied to the use of ventilators and the extreme bodily stress of the ICU. The loss of a sense of time and place is made more extreme during COVID-19, given that patients can have no visitors, know that they have a virus with no cure, are on ventilators for an average of 40 days (when the usual average is 4 days), and are visited by seemingly anonymous health providers in PPE who treat them as contaminated.
Patients were declared to be “agitated” and “confused,” which made the nurses and doctors upset because of the difficulty managing these patients, especially since patients often ripped off their oxygen masks, leading to more anxiety and delirium due to increased lack of oxygen, or tried to get out of bed or physically fight with nurses or PAs. This situation led doctors to threaten patients with intubation or reintubation and to increase sedative medications or use antipsychotics, which expressly goes against the attempt to reduce ICU delirium.
If and when there is a second wave, we think that psychiatry and psychology need to be brought into the conversation about what to do to help patients given these circumstances, whether it is to mandate some visits from family members, demand more moderate use of sedatives and times off the respirator, implement ways of orienting patients, and/or offer regular conversations with talk therapists. Likewise, literature on ICU psychosis indicates that patients after hospitalization need attention from a mental health practitioner, as part of any rehabilitation, since patients may enter into a state of degenerative dementia or severe PTSD. This needs to be addressed on a national level.