Who will care for the mental healthcare professionals? A wake-up call from the Netherlands

The COVID-19 pandemic taught us many lessons; one is that mental healthcare workers are not immune to the ravages of mental health problems. The pandemic put them under considerable stress in ways unimaginable before; many are still feeling it. Dr Anneloes van den Broek and Dr Lars de Vroege, senior researchers and clinical psychologists in mental healthcare in the Netherlands, reached out to their colleagues during and after the pandemic to find out how they were coping. What they learned is worrying.

Mental healthcare workers are human – an obvious fact, but one worth remembering, especially in the wake of COVID-19. Few events since the Second World War have globally fractured the human condition more than the pandemic, and mental healthcare workers are still picking up the pieces. They are trained to deal with mental healthcare problems, but that doesn’t mean they are immune themselves. Trying to help those scarred by the impact of an event on a scale unprecedented in most people’s lifetimes has come at significant personal and professional cost to many of them. It has also prompted the question of who is caring for the carers. A team of mental healthcare researchers in the Netherlands have provided a clearer picture of the mental health professionals in their field, during and after COVID-19, with alarming implications for the profession’s sustainability. They have also given guidance on supporting mental healthcare workers and helping them prepare for the next pandemic.

The Dutch DFY-study (‘Don’t Forget Yourself’) is an excellent case study in mental healthcare. The Dutch government places significant importance on the mental health of its citizens, the care for which falls to services under the umbrella organisation Geestelijke Gezondheidszorg, or GGz. The government also invests considerable resources in supportive research into the field. Dr Anneloes van den Broek is a clinical psychologist and director of postgraduate training for psychologists at Breburg GGz, based in Breda and Tilburg in the country’s far south. Together with fellow psychologist and senior researcher Dr Lars de Vroege, van den Broek reached out to hundreds of mental healthcare professionals in the Netherlands during the pandemic to see how they were coping, encouraging them not to forget themselves. The researchers repeated the exercise post-pandemic, hoping their colleagues were faring better. That was not necessarily the case.

The claws of the pandemic

When the COVID-19 pandemic was in full rage, significant media attention turned to the frontline healthcare professionals at patients’ bedsides. However, the claws of the pandemic stretched well beyond the hospital wards. Lockdowns cut people off from their social support circles, leaving them isolated and stripped of the security of routine. Uncertainty and wild, false narratives about the virus fed the stress. Levels of anxiety and depression escalated, often with long-term consequences. In the Netherlands, people turned to the network of GGz facilities and the professionals who staff them, seeking help. With restrictions on services, reduced resources, and staff numbers cut by COVID-19, workloads became unbearable. Concerned by the effect this was having on staff, GGz Breburg, under guidance of van den Broek, designed a web-based support platform for mental healthcare workers. The platform’s stepped-care format provided guidelines to prevent burnout, support for those experiencing anxiety, and short-term post-traumatic stress disorder treatment. The platform’s overall message was this: ‘Vergeet jezelf niet’ – ‘Don’t forget yourself’.

Healthcare workers logged into the platform in their thousands. They embraced its offering, downloading factsheets, information on how to cope with feelings of sadness and exhaustion, and tips for mental support. It was symbolic of the Dutch investment in mental health. ZonMw, the Dutch national organisation for health research and healthcare innovation, called the platform ’a showcase for regional cooperation in healthcare’. When, in 2021, at the height of the pandemic, visits to the platform rose rapidly, van den Broek and de Vroege realised they needed to reach out.

On 4 August 2021, they activated a month-long online survey and invited all the country’s mental healthcare professionals to participate. In total, 1,372 professionals across 20 organisations responded on how they were coping, answering questions on variables such as their mental state, how they were balancing their private and professional lives, and sick leave. It was one of the most detailed snapshots of the mental health of those entrusted to care for the mental health of others in the Netherlands. Van den Broek and de Vroege published their report in January of the following year; their findings reverberated through the country’s healthcare system.

Conspiracies and anti-government anger

Half the respondents to the survey admitted to feelings of severe stress; a third reported symptoms of depression. Again, it must be emphasised – these are professionals trained to identify and deal with mental health problems such as those they were experiencing. Who was treating them? The most common causes of stress and anxiety reported were the increased workload of people affected by the pandemic and the reduced capacity for face-to-face care because of restrictions. Beyond the physical and emotional exhaustion, they were reeling from the effects of secondary traumatic stress – the emotional duress resulting from hearing clients’ first-hand trauma experiences.

The survey further showed how mental healthcare workers had, in response to the increased workload, shifted their personal/professional work balance during the pandemic and not taken sick leave. Angry, frustrated, and downhearted, they were re-evaluating their priorities, even considering quitting the profession. Concerned, van den Broek and de Vroege took to writing opinion articles in leading newspapers and other publications, warning the government of the consequences if mental healthcare professionals did not get the help they needed. However, Dutch healthcare workers tackled the challenges with little outward qualm. What concerned the researchers was whether it resulted in any longer-term harm.

The survey also made them more aware of changes within the treatment room concerning the public’s growing mistrust in clinical authorities and conspiracy theories amplified by social media. Together with colleagues, they postulated these changes in a national opinion piece to alert fellow therapists how to deal with these topics and clients’ frustration with how the government was handling the pandemic. The country’s mental health service had not equipped its staff to deal with conspiracies and anti-government anger.

Nowhere near normal

Towards the end of 2022, with the worst of the pandemic over, the researchers conducted a second online survey to see whether the country’s mental healthcare workers had bounced back.

For the second time, they structured the questions to assess any increased symptoms of anxiety, sadness, levels of stress, and anger over time; identified challenges regarding work/private-life balance; explored if the professionals had managed to take sick leave or time off; and revisited any considerations about them re-organising work or quitting. Again, professionals from across the sector responded honestly and passionately.

It became clear that although post-pandemic, the stress, anxiety, anger, and frustration levels among the country’s mental healthcare workers had subsided, they were nowhere near normal; too many of the respondents were still close to burnout.

This was partly reflected by the high number of respondents who admitted needing sick leave or time off to recharge. The good news is that the break seemed to help – the percentage of respondents considering quitting was significantly lower than in the first survey.

A wake-up call

The work of van den Broek and de Vroege is a wake-up call for the Dutch mental health service. It would be naïve to think that mental healthcare workers are bulletproof; indeed, professionals in this field have their fair share of mental health problems. However, the fallout from the COVID-19 pandemic is far from over – there’s no vaccine for the longer-term mental health issues it triggered, and those feeling its effects are still seeking help from mental healthcare professionals. There’s little sign the workload will subside any time soon.

For van den Broek and de Vroege, the message at the start of the pandemic remains: ‘Don’t forget yourself’. They are encouraging fellow mental healthcare professionals to find the time to use systematic mental health tools on themselves. They are also reminding healthcare institutions they have the responsibility to protect their employees in the field of mental health and that this is an essential precondition for sustainable employment. Staff must have the opportunity to talk safely and openly about their mental health and their workloads, and management must be sensitive to the signs of mental health issues amongst their own staff; prevention is better than cure. The pandemic may have passed, but the effects still linger.

Finally, van den Broek and de Vroege want the Dutch government to prioritise the mental health of its mental healthcare workers. These professionals may be the solid cornerstone of the country’s proud mental healthcare system, but they’re still human. Who is going to care for them?