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Theater Of War: Using Greek Tragedy To Help Frontline Medical Workers Cope During Covid-19

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During the Covid-19 pandemic, being a frontline healthcare worker has been one of the most difficult jobs, involving both personal and professional challenges which are truly unprecedented.

Many workers have suffered in silence, experiencing ongoing feelings of anger, fear and betrayal. And for some, the pandemic has led to suicide—a painful reminder of the fragility of life, and the ongoing toll of this crisis.

Confronting death on a daily basis and feeling unable to provide optimal care of patients—from inadequate inventory of personal protective equipment (PPE) to safely treat patients, making difficult decisions involving allocation of limited lifesaving resources, or having lack of adequate staffing itself—embodies the concept of “moral injury” which has been devastating to all healthcare providers.

Moral injury is distinct from “burnout” and was first offered as an explanation for military veterans were not responding to treatment of PTSD. It refers to the emotional, physical and spiritual harm people experience after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs or expectations.” Simply put, repetitive episodes of moral injury, combined with physical and emotional exhaustion can lead paralyzing anxiety, depression, PTSD and ultimately suicide.

Addressing such moral injury is challenging to say the least, but a unique collaboration between the Johns Hopkins Berman Institute For Bioethics, Johns Hopkins Programs in Art, Humanities, and Health and Theater of War Productions, a production company that presents dramatic readings of Greek tragedies to modern and contemporary works— aims to do just that. At its core, Theater of War for Frontline Medical Providers represents an innovative project that has the ability to reach all frontline medical workers—nurses, doctors, respiratory therapists, social workers and hospital staff— who may be struggling in isolation, providing them the opportunity to name and communalize their experiences, connect with colleagues, and access available resources.

But Bryan Doerries, artistic director, and co-founder of Theater of War Productions, realized that his approach—originally conceived to help veterans cope with intense emotional distress and the lingering effects of moral injury from combat—could be communalized to help health care workers who experience this similar injury on a daily basis.

“To be clear, Theater of War Productions’ approach is not medicine, nor is it therapy,” said Doerries. “The aim of our projects is to lift people out of isolation and into community. If there is one thing I have observed over the past twelve years of doing this work it is that trauma, loss, and moral distress all leave people feeling isolated and alone.”

Doerries ultimately views Theater of War for Frontline Medical Providers “as a public health campaign, and the message of the ancient stories we perform for medical providers is simply this: You are not alone in your community, not alone across the country and the world, not alone across time.”

“Through Theater of War for Frontline Medical Providers’ performances, clinicians of all types are invited to connect to the universal struggles embodied by the Greek tragedies and through them to connect to their own experiences during the pandemic,” said Cynda Rushton, PhD, RN, Professor of Clinical Ethics at the Berman Institute of Bioethics/School of Nursing, Johns Hopkins University, who leads the collaborative effort with Theater of War for Frontline Medical Providers.  “Through the performance and the panel that follows, it is possible to give words to feelings, thoughts and experiences that clinicians are carrying and in doing so to find some solace that they are not alone in their experiences and that they are neither failing or deficient because of their responses to these unprecedented circumstances. They learn that they are experiencing normal responses to an abnormal situation and by recognizing this, begin to restore their integrity by cultivating and strengthening their moral resilience.”

In a nutshell, Theater of War for Frontline Medical Providers’ current approach during the pandemic is this: harness the power and messaging of Greek Tragedy, and use it as a medium to explore moral dilemmas that frontline care providers confront on a daily basis via Zoom Webinars, followed by a de-brief that explores real-life issues which mirror the themes that are displayed during the actual production. After the performance, the actors are replaced by four panelists—a diverse group of front-line medical providers—who then respond to what they heard in the plays that melds with their own experiences of caring for patients during the pandemic.

After the panelists’ remarks, a facilitator encourages the audience to join the discussion with a series of questions encouraging reflection and dialogue about themes raised by the plays. The discussion provides an opportunity for the medical workers in the audience to take center stage, sharing the impact of COVID-19 on their lives and finding comfort and support in the community of their peers.

The sharing of common experiences and their desire to improve life after such emotional trauma creates a powerful bond, but also empowers workers to approach management with constructive criticism and potential solutions as they embark on their emotional recovery and healing. Prior to the pandemic, Theater of War held powerful stage performances, but Covid-19 changed all that, requiring an adaptation to the world of online Zoom theatre.

Late last month, Theater of War for Frontline Medical Providers performed “Ajax”, a famous Greek Tragedy set during the Trojan War, to enable EMS providers to draw parallels between their personal struggles during the pandemic to those experienced by a mythical Greek figure.  It explored the themes of anger, jealousy, revenge, misdirected rage, and guilt leading to suicide.

Presented on July 30th, with over 900 Zoom viewers from over 18 countries, “Ajax” brought out feelings ranging from personal risk, betrayal, anger, sadness, abandonment, powerlessness, survivor’s guilt, along with remorse. In a post performance survey, 88% of respondents said that participating in Theater of War Frontline reduced their sense of isolation, while nearly 79% said that viewing made it more likely for them to use resources if needed, according to Doerries.

“When frontline medical providers, who may be reluctant to talk openly about the impact the pandemic has had upon them, their clinical practice, and their families, see their own struggles reflected back to them in ancient stories, it creates a non-threatening space in which it’s easier to talk about challenging topics, such as guilt, betrayal, deferred grief, personal risk, and deviations from standards of care, opening a door to pathways of healing, community, resilience, and moral repair,” added Doerries.

Communal activities via Greek Tragedy

Doerries further explains that the ancient Greeks realized that it wasn’t healthy for people to be “overwhelmed with emotion in the midst of violence, illness, and conflict. “But they also knew something that I think we’ve lost touch with as a society—that it is morally and emotionally toxic to defer and compartmentalize our emotions indefinitely. This is one of the factors that leads to burnout, depression, and even suicide,” he added.

“The Greeks knew that there had to be a time and place for people who had experienced violence and death to be given permission and empowered to acknowledge their emotions, collectively, as a community,” offered Doerries. “The word amphitheater in ancient Greek means ‘the place where we see in both directions.’ In the amphitheater, I see you and you see me. It is the place where we bear witness to the truth of our respective struggles.”

Doerries is “convinced that humans heal best in groups, and that isolation and betrayal are the wounds that cut the deepest. In this regard, and out of necessity, the Greeks developed tragedy as a tool to communalize the trauma of nearly 80 years of war and a pestilence that killed nearly one-third of the Athenian population.”

He qualifies that we are quite fortunate the process still works well. “It’s like an external hard drive that just needs to be plugged into the right audience: the ancient technology knows what to do, and so does the audience, as evidenced by the dynamic, powerful discussions that take place during our events.” 

An article by Rushton, Doerries and colleagues published last month in the Lancet focuses on how their initiative is equipped to help medical providers, but especially in the setting of Covid-19. The authors write that “we have found that presenting scenes from ancient tragedies about complex ethical situations for frontline medical providers generates an open, non-threatening space in which health personnel can begin to process, interrogate, share, and bear witness to experiences of loss, betrayal, grief, and other forms of moral suffering during the COVID-19 pandemic.”

“A nearly universal response to moral suffering is that we feel alone; that we are the only one who is struggling; that everyone else is coping better than I am,” explains Rushton. “The design of Theater of War for Frontline Medical Providers creates a safe space for reflection, insight and wisdom by fostering a community of belonging: often clinicians are able to meet each other as human beings rather than their titles, roles or professions.”

“This dissolving of hierarchy allows us to connect to our shared vulnerability and to see the humanity in others and ourselves. It also allows clinicians to loosen the grip of unrealistic expectations and the disempowering narratives of powerlessness to see themselves as already having resources to meet the challenges they confront with the support of their community,” she added.

Dr. Loree Sutton, a retired Army Brigadier General, psychiatrist, and former Commissioner of Veterans Services in New York City, feels that Theater of War’s benefit may offer a form of deeper connection than we can gain from our virtual world which often seems relatively empty and fleeting.

Theater of War for Frontline Medical Providers draws us in as active participants and engaged witnesses—the very opposite of what our social media world of tweets, clicks and ads is designed to elicit. In short, Theater of War for Frontline Medical Providers facilitates the experience of being human — eschewing titles depicting stature, hierarchy divulging status or expectations demanding performance or deliverables.”

“Participants, including medical providers, respond accordingly — with a renewed sense of purpose, engagement and connection to community, enjoined by Theater of War’s parting gift: the work serves to comfort the afflicted and to afflict the comfortable,”  she added.

Mental Health Legacies of Covid-19

But the broader issue is that we need to discuss the mental health legacies of Covid-19. Simply put, there is a wave of adverse mental health effects building, and the legacy we will write will be determined by how we handle this surge of health-related effects.

Yet, Doerries argues that Covid-19 is actually an extension of a pandemic that has largely been under appreciated. “There was a pandemic before the COVID-19 pandemic—of unaddressed trauma and mental health; poverty, substandard housing; homelessness; addiction; educational apartheid; and state-sanctioned violence against communities of color,” he said. “COVID-19, and the awakening that has accompanied it, has brought all of this into the light, showing the world how social justice and healthcare are inextricably connected and interdependent.”

“Given what we have seen and learned as a society over the past five months—things that are impossible to unsee and unlearn—there is seemingly infinite work now to be done to address the mental and physical wellbeing of people who have been systemically cut off from adequate healthcare, including mental health services and resources: in order to be successful in this effort we'll also need to break down the stigma associated with accessing mental healthcare in many communities, when it’s available,” Doerries offered.

“I think this needs to start within the field of medicine, with frank and open dialogue about the impact of the pandemic on frontline medical providers, and then radiate out into the general population, in larger, community-driven conversations. My hope is that the mental health legacy of COVID-19 will be an awakening and consciousness that leads to social and mental health justice,” he added.

Rushton concurs and adds a sense of reality: “I suspect that we will see a full range of physical, psychological and moral responses that will need targeted and sustained attention. What keeps me up at night is whether we will be able to sustain the healthcare workforce during and after the pandemic.  The level of exhaustion among clinicians across the country is profound.  The heroic response has now progressed to a phase of deep disillusionment and despair as the pandemic marches on without an end in sight.”

Theater of War’s Positive Legacy

Theater of War for Frontline Medical Providers premiered on May 24th with 417 medical providers from the Baltimore area logging onto Zoom for a performance featuring Frances McDormand, Jesse Eisenberg, David Strathairn, and Frankie Faison. In a post-performance evaluation, 93% of respondents reported that the program offered new insights about their experience during COVID; 92% said the program made it easier to talk about difficult subjects related to COVID.

As a result of this success, the Arts in Health Initiative of the Laurie M. Tisch Illumination Fund provided a grant to fund 10 performances of the project in New York City.

“We got to know Theater of War’s extraordinary work through prior projects, and when they came to us with the idea of a new project to help frontline medical providers, we immediately saw why it is so timely and important, said Laurie M. Tisch, President, Laurie M. Tisch Illumination Fund. “Theater of War Productions is stepping up to help heal the people who are caring for us through this terrible pandemic, and we are proud to be among the supporters making it possible.”

“We know from the organizations in our Arts in Health initiative that the arts are a particularly effective tool to address issues related to mental health challenges such as trauma, and they provide unique ways to combat the stigma that makes it difficult for people to seek help. These are issues that frontline healthcare providers are facing every day as they risk their lives and health to save ours,” added Tisch.

 It’s also possible that Theater of War’s approach may serve as a means to tap into and alter neural networks which develop as a response to emotional trauma, quite distinct from more traditional approaches such as cognitive behavioral or group therapy.

“There is every reason to believe that this type of theatrical production is facilitating a powerful form of processing that we know from other research is a means to potentially mitigate against the negative outcome of trauma,” said Christine Moutier, M.D., Chief Medical Officer for the American Foundation for Suicide Prevention. “That it uses not only major talent portraying events and themes related to moral injury may be a way to engage different parts of the brain that likely connect experiences and memory with emotional and intellectual neurological processing.”

“This may make it unique from other forms of processing that primarily engage our intellectual mind—like facilitated groups and individual conversations between us and therapists, peers or mentors. One hope is that participants would continue the dialog in some way and even build on those gains in their relationships at work or at home,” she added. 

Moutier also offered that “it engages a tactic of using ancient events to evoke people's humanity living through present challenges, which the ancient tragedies also did in their own time.”

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