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Healing the Mental Wounds

As more Covid-19 patients are recovering and the disease is gradually being brought under control, society is just beginning to deal with the psychological trauma of the past months

By NewsChina Updated Jul.1

A man scatters flowers for the dead at Qingming Festival, the day China traditionally mourns the deceased, Wuhan, April 4, 2020

At 4pm on April 5, a long line still snaked outside the outpatient clinic of the mental health center of Wuhan University People’s Hospital. Liu Zhongchun, director of the center and head of the psychological crisis intervention group on prevention and control of Covid-19 in Hubei Province, said that even from the end of January, an unprecedented number of patients had sought counseling or medical help over psychological trauma due to the Covid-19 pandemic.  

“The emergency treatment phase has already ended... for the next two weeks, we are going to refocus our efforts on local communities to start our psychological interventions at the community level,” Liu told NewsChina. “Follow-up interventions should led by the government and society, rather than just us.” 

Compared with the SARS epidemic in 2003 and the Wenchuan earthquake in 2008, the provision of mental health services and counseling for people suffering from stress due to Covid-19 is more organized and was better prepared for. The long, strict quarantine in Hubei Province and the worry over whether the disease would break out again have manifested in deeper and more widespread effects, posing more challenges for those helping people to rebuild their lives.  

Public Memorial Day
February 7 was a key moment in the mind of psychologist Du Mingjun. That day, Li Wenliang, the doctor who tried to raise awareness of the novel coronavirus in late December, died of Covid-19, and the public was distressed. The pandemic in Hubei was at its peak, and people were anxious, angry, depressed and panicked. During the 14 days from January 23 to February 5 as Wuhan was locked down, the counseling hotline received over 500 calls. 

The second moment, Du said, came on April 4, this year’s Qingming Festival which is also known as Tomb Sweeping Day, when families usually gather to remember their deceased loved ones. Call volume to the counseling hotline had gradually decreased, particularly since early April. During the first 10 days of March, there were 285 calls, an average of less than 30 per day. By the beginning of April, the number of daily calls had dropped to 20.  

“The Qingming Festival as a public memorial day provided an opportunity for psychological relief for society,” Du said.  

The focus, now that the risk of the disease has lessened, is to treat those with post-traumatic stress disorder (PTSD) and to provide bereavement counseling. Those requiring help include surviving patients, family members who lost their loved ones and healthcare workers.  

Du said that while one may rely on personal strength for support, society provides an external support system too. If an individual experiences psychological collapse, they need social support. Psychotherapists should be able to stimulate the internal potential of an individual, but they also need other support from the government and communities, as well as society. While Wuhan started easing its lockdown on April 8, control and monitoring at the community level were not loosened, and the psychological fallout is still to come.  

Survivor’s Sorrow 
When Li Jianguo was notified of his son’s death from Covid-19, it was already a month since he died. His son was divorced, a healthy 40-year-old. After his son was diagnosed with the disease, Li took care of him, asking other family members, including his own wife and granddaughter, to move away.  

But then Li was also infected, and father and son were admitted to intensive care on different floors in the same hospital. In his last conversation with his father, Li’s son said he thought he was going to die and asked his father to come to him. But Li was in bad shape himself, so his wife chose not to tell him their son had died until a month later, when Li was out of danger. 
Li was heartbroken. He felt anger toward his wife for not telling the truth earlier, but he started to come to terms with her decision. He had moments of extreme grief, like when the vehicle taking him from hospital to a rehabilitation facility passed near his home.  

On March 31, after a 14-day quarantine, Li was allowed home. Du Mingjun visited Li twice in the rehab center for psychological crisis intervention. Li talked of his fear of going home and having to see his son’s belongings.  

Du said that Li’s situation was worse than some, as he had also been infected and was facing survivor’s guilt. “Surviving family members feel guilty and blame themselves for not being able to take care of the others. Especially older people, they are even willing to die to save their children’s lives,” he said. 

Li Jianguo is 70, and his son has left a daughter who is not yet 10. He was unprepared for the sudden loss of his son. The pandemic means people are not able to say a proper farewell to their loved ones, Du said. For most, it is a short call from an ICU or the moment the ambulance leaves for the hospital with their loved one on board.  

Many bereaved relatives are unable to accept their loss, or they hide their sorrow. Du said the first step is to guide the bereaved to face reality, release their emotions before moving on to relieving their remorse or feelings of responsibility for the death. 

Trauma of Health Workers 
Liu Zhongchun has noticed more healthcare workers coming to seek therapy. Once they had time to stop and think, the stress of what they had been through started to surface.  

The weeks of intense work left some medical workers with PTSD. Even though they are no longer treating and caring for Covid-19 patients, they still wake up suddenly. “We have [fight-or-flight hormone] norepinephrine in our bodies, and during the worst stage of the epidemic, healthcare workers were driven by nervous energy since there was no other outlet. But you can’t go on like this for more than one or two months. They need time to rest and recover from the exhaustion. Otherwise they may never recover or they will experience burnout from the psychological perspective,” Liu said.  

Since the outbreak of the pandemic, Liu has maintained close contact with his colleagues all over the country, and cooperated in publishing academic papers in professional journals abroad, sharing the experience from Wuhan with medical counterparts all over the world. 

In an article co-authored by Liu published in the Journal of the American Medical Association, researchers surveyed 1,257 healthcare workers in Hubei, summarizing common psychological symptoms, including stress (50 percent), anxiety (44.6 percent), insomnia (34 percent and psychological distress (71 percent).  

Among them, medical staff in Wuhan were more prone to psychological pressure, while female medical staff and those with senior titles faced more pressure.  

The sources of stress are multiple. Witnessing a large number of deaths every day creates a sense of not being in control. The continued spread of the virus extends to personal concerns about themselves and the safety of their families. In addition, the temporary changes in the working environment and content, as well as the state of isolation, can all become the source of psychological problems, requiring timely crisis intervention, otherwise problems may recur. 

Doctor Li Qiguang, from the Department of Psychosomatic Medicine of Shaanxi Mental Health Center, was part of the first psychological assistance medical team dispatched from Shaanxi Province to Wuhan. On February 24, he arrived in Wuhan with his colleagues and was assigned to Wuchang Hospital.  

Unlike other medical teams whose main focus was the psychological needs of Covid-19 patients, Li Qiguang and his team devoted two-thirds of their energy to doctors and nurses at Wuchang Hospital. He said all the medical staff at the hospital were under great pressure and were generally feeling depressed.  

General crisis interventions require 10 to 12 courses of treatment, but due to the circumstances, time was limited and treatment was shortened to three to five sessions. More often than doctors, nursing teams, the majority of them women, displayed higher psychological needs. Every day they had to cope with arduous work and witnessed frequent deaths.  

Return to Society
The community has become the focus of Liu Zhongchun’s recent work. Psychological consultants are trained by professional psychiatrists and stationed in different communities to provide psychological counseling to residents and rehabilitation patients who are in need. This model is being developed in 13 streets of Wuchang District in Wuhan and is planned to be rolled out in other areas.  

“Those who know the local situation best are community workers and volunteers who play an important role in our psychological intervention. The psychological consultant, though stationed in a community, may receive no patients, and the consultant needs help from a social worker to promote the connection with the local community,” Liu told NewsChina. 

Recovered patients themselves may also develop PTSD, and if there is no prompt intervention, the symptoms may repeat time and again. Du recently treated a male patient in his early 30s who had developed obvious PTSD symptoms. After his recovery from Covid-19, the patient was irritable and developed violent tendencies, to the extent that he was self-harming and harming those around him.  

He saw fragments of memory in his mind. He claimed to have almost died three times during his treatment. The first was when he was in the ambulance on his way to hospital. There were no beds, so he had to lie on the floor, and although his mother pleaded to admit him, he ended up walking home with her. The second time was when he went to the hospital to get an IV, and was terrified when he saw his blood leaking out. The third time was after he was finally hospitalized. He was sure he would only last at most two more days. Although he pulled through, those flashes of memory haunted him.  

During the treatment, Du tried to let the patient realize his fears were temporary, and that while it was important to vent, he should not put himself or others in danger.  

More generally, many patients have a sense of panic about how to go back to normal life. Liu Zhongchun has communicated with some patients and community workers, and discovered that some patients who have recovered are unwilling to go home, worrying about discrimination, if their neighbors will feel nervous, or that they are not fully recovered so their return might jeopardize their family. There are also a few occasions when patients were ready to go home, but their family was reluctant to let them.  

There is still uncertainty over people’s understanding about the ramifications of the pandemic, and this poses more difficulties for doctors like Du and Liu when they are trying to give psychological guidance.