Coronavirus, First Responders, and Somatic Regulation

Coronavirus, the infectious virus Covid-19, is causing the whole world to be in a transitional state. It is disrupting the stability of our communities, forcing people to re-evaluate their values and live with fear on a daily basis. There will also be grief and hope components to acknowledge underneath the trauma of these uncertain times and events.

It is important to remember that individuals and community responses to COVID-19 vary across the generational life span. From the twenty-year-olds seen partying on the beaches, in defiance of social distancing suggestions, to the elderly and high-risk populations, becoming increasingly isolated in an effort to minimize infection risks. And of course, those on the front line, the essential workers in a crisis, first responders, doctors, nurses, and all health care workers.

At times of crisis it is most important for first responders and health care workers to be able to show up, to be present and engage adaptatively within both home and work environments. First responders and health care workers are at greater risk during a pandemic due to their frequency of exposure to the sick, the added psychosocial stressors of managing mandatory work hours, navigating family, staying physically healthy, and preventing primary or vicarious trauma.

Due to the potential state of overwhelm, experiencing a traumatic event, such as being on the frontlines of a pandemic, puts people at greater risk of post-traumatic stress disorder (PTSD), as their systems potentially enter into a state of overwhelm. Vicarious trauma happens when people witness traumatic events happening to others, often leading to compassion fatigue and burnout. The fight-flight-freeze response, bodily manages fear and danger, it is a brilliant survival strategy. However, this primitive nervous system response was meant to protect people from danger for a few minutes to several hours-not day in and day out.

Chronic Stress

Some reactions to getting stuck in states of continuous hyperarousal and trauma include bodily, also known as somatic, symptoms such as elevated racing heart rates, shallow breathing, digestive pains, irritability, headaches, insomnia and eventual adrenal fatigue. This mind-body overwhelm can lead to disassociation between what our thinking brains versus our physical sensation tell us. Nervous system overwhelm can create havoc in the home and compound negative experiences in the workplace especially if either place is already a source of stress. If you live alone there is the risk of feeling isolated and if you live with a partner discord can become exacerbated. Certified registered nurse anesthetist, Christine Cromm, states that, “Some medical professionals are not even sleeping at home, as they attempt to avoid infecting their families”.

Unchecked anxiety and the sense of being in a continued state of danger can have drastic consequences for general physical immunity and mental wellbeing. Psychiatrist and author of When the Body Says No, Gabor Mate, writes on the psychodynamics of healing as an essential part of supporting biophysical recovery, “We may rightly say that the immune system is a sensory organ” (2003, p.175). So, managing the daily stressors of being a health care worker or first responder during a pandemic is crucial to mitigating personal risk factors.

It is important not to underestimate the importance of the work people do in all aspects of the health care field and as a first responder. Long working hours, relationship issues, financial problems, pre-existing trauma and life stressors can also contribute to health-work-life imbalances. Any one of these types of stressors can be layered to cause accumulative chronic psycho-biological stress.

The Nervous System

Incorporating the vocabulary of the nervous system and understanding how to practice body awareness can quickly decrease stress responses and ultimately become a part of preventing occupational and environmental stress.  Attending to the nervous system and body and being in touch with somatic (bodily & nervous system) sensations, allows for engagement in the present moment with the self, family members, ultimately patients and colleagues. Peter Levine Ph.D., the founder of Somatic Experiencing ® (SE ™) explains in his book An Unspoken Voice (2010) how the complex systems of the brain and the nervous system can be viewed like a marriage, “in either blissful harmony or in dreadful unending battle” (p.123).

The ANS is made up of two branches, the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).  Vicarious trauma expert and author of Help for the Helper, Babette Rothschild states how the ANS works, “They function in balance to promote survival of the individual and maintain homeostasis in the body”.  These two branches both work at the same time, much like the delicate interplay of the gas and brake pedal in a vehicle.  Physical responses to stress are normally triggered by the activation of the sympathetic nervous system. This fight-flight response kicks in and the person is ready for action or reaction to what the body perceives as a danger. During this mobilization or defense response the heart rate will increase, the eyes and hearing will narrow in their focus, breathing will become faster and shallower, and blood flows to the major muscle groups. The PNS is responsible for the rest and digest process, and through the vagus nerve sends relaxation responses back and forth directly between the gut and the brain. When the PNS is stimulated bodily functions are controlled, breathing is steady, muscles are relaxed, and it feels safe to make easy connections with other beings. As people learn to track these autonomic responses a new awareness of these states happens, allowing individuals to deliberately decrease or increase arousal states as needed. This somatic regulation limits the risks of getting stuck in a chronic state of feeling under threat or going into collapse and shutdown.

The problem of compassion fatigue and vicarious trauma can be managed if people are aware of its associated patterns. Paying attention to how someone may demonstrate trauma related and somatic symptoms, such as black and white-thinking, emotional numbness, dissociation, anger, frustration, syndromal body pains, fatigue or substance use can help identify those in need of help. Though the responder and health care worker may be trained to administer emergency medical treatment this does not necessarily include preparedness to deal with its emotional impacts.

Physicians, first responders, nurses, respiratory therapists and many additional healthcare workers are trained to respond to the here and the now circumstances, especially in emergency and trauma scenarios. They are trained to be self-less, putting patients always first and often putting themselves last when it comes to their personal well-being. Physician, Dr. Nicole Roth states, “We put aside all of our personal feelings, wants, and needs for patients in our care. Coupled with this many healthcare workers often need to bring work home, which can at times bring added stress into the spaces of their significant others and families. Burn out has a negative impact on the health care system and it shouldn’t take a pandemic to draw our nation’s and the globe’s attention to better caring for the ones that care so much for us. There is a definite need to curb these daily stressors.”

Early recognition of symptoms of primary or vicarious trauma can eventually lead to people reaching out for support from peers, getting comfortable seeking counseling, and implementing new coping strategies.

Self-regulation can be easy and quick

Basic cognitive therapy techniques help people to relax and calm themselves but do not address the underlying causes of repetitive anxiety or physical symptoms.  Quick fixes for better stress management become possible if people intentionally slow down, plan to optimally use brief windows of time and pay attention to the sensory information of their bodies throughout the day.

Self-reflective noticing of what state the nervous system is in, i.e. a freeze-immobilized state, an activated fight-flight or functioning or calm relaxed state can help in knowing when moments of nervous system relief are needed. Social worker and Somatic Experiencing® Practitioner, Bruce Gottlieb states, “The insidious nature of vicarious trauma has always been an issue in the medical and first responder professions. Remaining conscious of your own system while working selflessly in service of others is the only way a first responder and health care worker can ultimately deliver the quality service they desire to deliver”.

Building this type of somatic self-awareness also complements cognitive and other wellness approaches.  It is a valuable precursor to developing self-regulation that will benefit both professional work and personal relationships.

15 Tips for Somatic First Aid Practices

Incorporating some basic somatic practices can provide a new way of approaching stress tolerance effectively by creating moments of relief throughout the day.

1. Start with some slow deep breaths. Simply doing a minimum of just three rounds of deep breathing is a great way to quickly regulate yourself. Deep breathing can be done by inhaling in an easy relaxed way, bringing your attention to a soft breath, staying aware of the breath for the entirety of each full breathing cycle. Whether breathing in for three, four, or more counts, simply exhale one beat longer than you inhale and extend the belly out as you inhale. This immediately activates the parasympathetic nervous system and adds some breaks to feelings of agitation or arousal. Try noticing the difference in temperature of your breath on the inhale and exhale.
2. Orienting is a great and simple technique; turn your head and neck, slowly and purposefully, look around at where you are. As you orient in this way to your immediate environment look all around and notice what your eyes might be drawn to today, name five things silently to yourself. It might be particular colors, objects or shapes. You can expand this orienting by naming to yourself sounds you can hear, textures you can touch, smells you can notice and even things you can taste.
3. Physical sensations need to be checked in with throughout the day, especially when working long shifts. Ask yourself “Am I hungry”, “Do I need to drink some water?”, or “Do I need to use the bathroom?” If the answer is yes, act on it. Set a boundary on your basic needs to get through the extra-long haul. If you need to distract yourself from dissociated eating or snacking, you will begin to notice (having practiced the pause) that you are devoid of pleasure in eating, and on autopilot. As you pause take the moment to orient to the space you are in (as above).
4. Feel the weight of your feet and body on the ground as you stand still momentarily. Do this with full awareness even when sitting on a chair, sitting in your car or resting on the edge of a bed. Practice shifting your weight slightly from side to side, or if standing gently rock from your toes to your heels if you are able.
5. Hand washing. This is imperative to do and take this opportunity as you wash your hands each day, take a shower or have a bath fully engage in the sensation of water droplets on your skin and inhale fully the smell of soap on your body.

Since health care workers and first responders need to do this so much it can be soothing to make it a mindful action.

6. Splash cold water on your face after your hands are fully clean. This decreases your heart rate, stimulates the vagus nerve, and slows your breathing as the shock of cold water stimulates the diving reflex
7. Oscillate your attention. If you are noticing things that you dislike in your environment, go back and forth repeatedly between finding things that you do like. For instance, you may not like the smell of something in the room but you can bring your attention to how the texture of the fabric of a piece of clothing you are wearing feels. In this example, alternate between the sense of smell and the touch sense instead of fixating on the thing you dislike.
8. Deliberately bring to mind a person, a place that is real or imagined, a pet or symbolic object that is comforting to you. Spend a couple of minutes fully engaging with this imagery and bring as many sensory details about them into your mind and body.
9. When we feel under threat our throat and voices can also become restricted. One way of helping your voice to open up is by putting on some favorite music and singing along (without any criticism of our singing skills) at home or in the car so you can feel the deep resonance of sound reverberating through your bodies. If you are not ready to try singing you can choose to practice humming in a long, deep and even tone.
10. A quick body scan is another way to practice bodily awareness. From the ground up, bringing awareness into the toes up through the legs and torso to the neck, head, shoulders and jaw can highlight any tightness or tension that might be unconsciously felt. This can be done repeatedly and as needed.
11. The Tapas Acupressure Technique. Another quick reset for a stressed-out nervous system comes from an energy medicine technique by Elizabeth Tapas-Fleming. As follows:

Gently place your hand horizontally at the base of the skull with the thumb touching just above the hairline.

With your other hand, place your thumb and ring finger on either side of the bridge of the nose.

Now place your middle finger in the middle of your forehead (third eye area). Hold this position until you take a natural deep breath.

12. Container. If unexpected distressing thoughts or images come up from your day, acknowledge them with acceptance, self-compassion and non-judgement. If you need, go a step further and place these thoughts and visuals in an imaginary container where they can be privately held in an imaginary safe spot. Let the thoughts or images remain there until such time as you have the resources to work with a therapist, coach or trusted friend who can attend to them with you. This can allow you to function throughout the day without continued distress.
13. Touch can be a valuable and comforting aspect to healing trauma. However, when touch needs to be avoided due to risk of viral spread, people can self-touch for somatic regulation. This can be done by tapping. Increasing the sensory awareness in the body through tapping can be done anywhere. Using the tips of your fingers, slightly cup your hands and gently tap different parts of your body alternating tapping with each hand. Try tapping the sides of your legs just above and to the side of your knees if seated. Above the eyebrows, under the nose with one hand. Crossing hands and alternating tapping just under the collarbone is another example of feeling into your body.
14. Self-hug. We can regulate our own physiology through touch. If you can’t hug others you can try a couple of alternatives. Put your hand on your heart, take a nice deep breath into the belly and tell the other person you are sending them a heart hug. You can also give yourself a self-hug. Place your dominant hand under the opposite armpit. Next place your other hand on top of the opposite shoulder. Hang out there for a couple of minutes or at least until a spontaneous deep breath occurs.
15. Check in with your posture. Are you standing or sitting with an erect spine, shoulders rolled back and down, head in alignment with your neck, feet weighted evenly? If not, shift your position to this strength-based posture for a least a couple of minutes. Imagine a Wonder Woman pose and if your hands are free you can add your hands on your hips to the posture. In therapeutic settings, practitioners often convey empathy by mirroring postures with patients. Be aware of this, giving yourself permission to change your posture, doing the opposite of mirroring, if you notice yourself becoming stressed when listening to a co-worker.

As you learn to notice the lack of adrenaline at home or during time off from work, feeling calm might be somewhat unfamiliar or even uncomfortable. As an emergency responder, doctor, nurse, or front-line health care worker there is a need to be emotionally distant when you are living in a world of victims. This doesn’t mean that you have to be disconnected from your body or live in a constant state of fight-flight or freeze in order to cope. Paying attention to body sensations when you can be in a parasympathetic state of rest allows your whole body-mind connection to get familiar with the difference between feeling calm versus a state of collapse.

As you engage in these practices of sensation building and somatic self-regulation, avoid interpretation of your experience and judging yourself. The goal is to build resilience and increase moments of feeling okay throughout each day by allowing your body to feel a sense of safety. A somatically trained therapist or health professional can facilitate the deeper processing of chronic anxiety, pain patterns, or fear that get held in the body, and may otherwise interfere with the regulation of the nervous system. Practice is essential, the above interventions become easy to do within a few minutes at home or work. As you train yourself you will soon be able to do these somatic self-regulation interventions almost subconsciously.

© Trudi Howley M.S., SEP, LPCC, CPC is a Somatic Psychotherapist and Certified Professional Coach, specializing in trauma healing.