Dr. Natalie Richardson tackles mental health challenges presented during COVID-19 pandemic

ADA, Okla. – As the COVID-19 pandemic continues to afflict the globe, a Chickasaw Nation Department of Health specialist is looking at a postpandemic world and its impact.

Dr. Natalie Richardson, behaviorist for the Chickasaw Nation Family Medicine Residency Program, has studied traumatic stress among the military population for years.

Yet, it is another experience – not fully defined but labeled "moral injury" by researchers and experts – weighing on Dr. Richardson's mind.

"At times, military service may require an individual to engage in activities or make decisions that may go against their personal morals or ethical code. We are often taught 'thou shalt not kill,'" Dr. Richardson said as an example. "However, in a military context, that may not be possible. Taking the life of another may be necessary during a time of warfare for the greater good.

"These experiences that may go against the values we were taught early on have the capacity to cause deeper rooted injuries of the soul – a more shame- or guilt-based moral injury. And these injuries can become even more intensified when an individual does

not feel the system has the resources in place to support them – or even more so, when they feel that the mission of the system has let them down or even betrayed them," she explained.

"Most service members and veterans join the military because of an ultimate desire to help people and communities. However, if they are called upon to perform a task outside their core beliefs, or if they believe their involvement or service may be more injurious to the community, they risk suffering moral injury that could endure for a lifetime," she said.

The most common experiences associated with moral injury are guilt, shame and betrayal, according to Dr. Richardson. In the yearlong pandemic, we are seeing moral injury affect everyone. The longer it continues, the more at-risk the population becomes, according to Dr. Richardson.

Help available

The malady's definition may not be fully understood, but Chickasaw Nation Department of Health and Department of Family Services are already stepping in to help medical staff, families, employees and COVID-19 victims by providing emotional support and bereavement resources.

Dr. Richardson said it can be helpful during virtual meetings to ask one another to speak about something positive occurring in their daily lives that is not COVID-19 related.

"The virus dominates conversations and has for almost a year," Dr. Richardson pointed out. "It is a way of shifting the construct of our conversations away from the illness if we can. We are all struggling, so supporting one another for what is also going well – the 'small wins' – is important right now."

Dr. Paul Emrich, under secretary of family services, sees it as well.

"It is important to be aware some people experience mental health changes. Things are pretty stressful. A lot of people are feeling isolated. I think connecting is even more important this year, but we need to do it in safe ways," Dr. Emrich said in a recent interview.

"It is even more important to be aware, for yourself and those around you," he said. "It's easy for someone to be isolated right now. We are missing that faceto-face interaction, so it is harder to pick up on things. We can miss connecting with someone over an extended period and not even realize it, because we have to go through extra effort to call someone or reach out to them in new ways."

Dr. Richardson said almost everyone has experienced some degree of isolation due to responsible distancing.

"With COVID-19, we see people struggling with isolation. At the same time, it seems that folks maybe are a little bit more willing to openly address their feelings and struggles with others, including mental health professionals. We are all struggling, and it seems, we are more willing to talk about it. I can't say what life will look like after COVID-19, but I am curious what people's experiences of mental health, and the emotional and spiritual implications of this past year will look post pandemic; how does isolation now help or hinder our reconnection with others after COVID-19?"

Medical challenge

"Similar to the drive of military personnel to help others, the medical community is flooded with individuals with a deep desire and passion to serve. Therefore, we are beginning to see what moral injury also looks like in medical communities," Dr. Richardson said, pointing to California as her example.

"Physicians and nurses take the Hippocratic oath, which is the moral and ethical code by which patients are to be treated. However, when they feel that they are not able to do that – that they are not able to abide by their moral code – or when policies or systemic experiences may limit that ability – we see similar experiences of betrayal or guilt associated with moral injuries.

"When thinking about how COVID-19 has overwhelmed the medical system and that sometimes medical staff have to triage decisions based on survivability or availability of resources – those experiences cannot help but weigh on someone's soul and worldview. I am not a medical professional so I cannot say for certain. I can only imagine the internal struggle that causes (for) so many," Dr. Richardson observed.

The military routinely performs this task on the battlefield but rarely – at least not since the Spanish Flu epidemic of 1918 – have hospitals been forced to make such rapid and continuous daily life and death decisions based upon a viral pandemic.

COVID-19 has brought the battlefield to civilian hospitals.

"The term 'burnout' is often used to describe the distress endured by many in medicine, but I feel that really puts too much blame on individuals – as if they aren't doing enough to take care of themselves. Instead, moral injury needs to be addressed at a systemic level. We need to support and lift up medical professionals and acknowledge when they are struggling. We need to genuinely listen and be available. Medical professionals often battle dealing with deeper wounds that they carry around daily. With support (both on the ground and at the systemic level), my hope is that they can attend to their own needs, so they are able to attend to the needs of their patients," she said.

As vaccines are administered and the world slowly returns to a semblance of normalcy, many challenges from this fight – both great and small – will present themselves in our personal and professional lives, according to Dr. Richardson. "At the same time, I hope we can learn from it."

Top student

Dr. Richardson has worked for the Chickasaw Nation for less than a year, but her impact has been cited by awards and accolades in Oklahoma and on a national level. In 2016, she was named Outstanding Master's Student of the Oklahoma State University (OSU) College of Human Sciences.

Prior to that, Dr. Richardson garnered the 2014 Outstanding Senior Award for her exceptional involvement and academic performance at OSU. Due to her desire to work as a clinician, researcher and educator in behavioral health, Dr. Richardson transferred to East Carolina University (ECU) in North Carolina to complete her Ph.D. in medical family therapy.

Most recently, she was named the Outstanding Graduate Student for the College of Health and Human Performance at ECU. At the Chickasaw Nation, she oversees all aspects of behavioral health for the Family Medicine Residency Program as far as training and provider wellness, as well as provides integrated behavioral health care for patients.

Hailing from Arapaho, where the U.S. Census recorded 794 citizens in the far western Oklahoma community in 2010, Dr. Richardson grew up in a tight-knit, loving family that supported all her endeavors. She is finding that same support at the Chickasaw Nation.

"Everyone at the Chickasaw Nation and within the residency program is wonderful to work with. Starting my career – particularly with a job focused on mental and emotional health – during this global pandemic has been challenging. However, I have already learned so much and am excited to be a part of such a supportive team and community. To see how the medical community and educational opportunities have adapted during this time is inspiring. It will be interesting to see how my role and the program may change or adapt once things return to 'normal'," Dr. Richardson said.