Providers Find New Ways to Reach Patients
The mental health fallout of COVID-19 is unprecedented, and few feel the sting quite like behavioral health practitioners on the front lines. Breanna Banks, PhD, director of clinical education at Centerstone Research Institute, said the virus is taking a toll on patients and providers, alike.
A Different Type of Crisis
"I've been in training every day with clinicians in five states," said Banks, who oversees instruction of 4,000-plus frontline providers treating 180,000 patients a year. "We're seeing clients across the life band with full diagnostic criteria, from inpatient to outpatient, in-home care, foster care support and military support. It's a full gamut of service provisions."
The virus has triggered a worldwide increase in suicide, post-traumatic stress disorder, addiction and depression, and it is worsening anxiety in children and adults - particularly those with autism or developmental disabilities. A recent survey by the Chinese Psychology Society found that of 18,000 people tested for anxiety related to the outbreak, 42.6 percent registered positive. Of 5,000 people evaluated for PTSD, 21.5 percent had obvious symptoms. In Italy, a psychological support centre run by the Red Cross is overwhelmed by calls from people struggling.
Today's patients are at an intersection of anxiety and grief, often worsened by loss of a job or loved one. Psychosocial barriers also exasperate mental health diagnoses. Lack of resources like bus transportation, or tending to childcare while working from home, are logistical issues affecting mental health, as well. In addition, a majority of Centerstone's clients are already struggling financially and less likely to receive medical care or virus education accessed by many Americans. "The CDC has highlighted cross sections having the most complications, and there's a higher incident rate with COVID in lower socioeconomic groups," Banks said.
Transition to Telehealth
Within two weeks of the virus's onset, Centerstone providers had transitioned to telehealth for the majority of patient visits. Banks oversees training on telehealth software, allowing providers to work from home. She also helps providers amend treatment protocols and engage clients, and she continues to develop curriculum ranging from telehealth suicide prevention to common patient concerns.
Banks has also developed clinician reflective process groups - a "therapy for the therapist" model that's proving successful. "It's designed for those working with difficult clients and allows therapists to assist each other in problem solving, processing experiences and barriers, share with each other and just vent," she said.
According to Banks, lack of self-compassion is a constant challenge among providers, and even more so in today's high-stress environment. "None of us are unaffected by COVID-19, and we have the same anxieties as our clients," said Banks, noting universal challenges in trying to maintain productivity and connections surrounded by distractions of home. "It's hard. Clinicians have a genuine desire to help and be of service, and we tend to sacrifice ourselves at the altar of helping others. We need to give ourselves permission to not get it right the first time around and understand that we're all in this together."
As providers transition to a new normal, Banks said there have been bright spots, such as connecting to patients who otherwise might have fallen through the cracks. "Telehealth has helped connect patients when they need it," she said.
Prior to COVID-19, providers were limited to working in their own state. Now, a temporary grant has allowed niche providers (i.e. suicideologists) to work across state lines. "Because of telehealth abilities, we can now connect patients with very specific needs to clinical specialists in highly nuanced areas, which we've never been able to do," Banks said. "We now have a wider range and enhanced knowledge to be able to place clients with specialists as we do with medical care. We're working with policymakers and payer boards to maintain these rapid changes we've been able to embed."
Additionally, Banks said telehealth has helped bust misconceptions about virtual possibilities in counseling. "There tends to be a bias against telehealth to some degree, because so much of what we do as counselors and psychologists is to leverage that relationship, working with emotions and body language," she said. "We have tools and evidence-based practices, but we use interpersonal dynamic as the secret sauce to make it work, and some assumed that couldn't work as well by telehealth."
However, science has shown otherwise. Trials comparing telehealth to traditional therapy have proven virtual sessions equally effective, but Banks said it requires a level of competence and confidence on behalf of the clinician, and she has been coaching providers on that initial telehealth session. "There has to be a priming conversation to call out the elephant in the room," she said. "To say, 'I know this is really different, so tell me your concerns, and I'll tell you mine so we can work together.' It's ok to admit it's weird now. By creating the space to say, 'I'm figuring this out too,' we can strengthen that alliance."
Mental Health & Kids
Younger, tech-savvy patients tend to have the smoothest transition to telehealth - good news in the face of a generation with unparalleled rates of anxiety and depression.
Meg Benningfield, MD
Meg Benningfield, MD, director of the Division of Child and Adolescent Psychiatry at Vanderbilt University Medical Center, said kids already struggling now face added uncertainty related to COVID-19. "Some of the biggest challenges for kids are wondering if it will end, when they'll get to see their friends again and what the 'new normal' will look like after the pandemic," she said.
Kids also internalize financial hardship, often allowing job loss or economic strain to inflate fears. Benningfield said it's important for parents to acknowledge challenges and not make up answers to ease minds. "It's really important for families to be aware that kids are listening all the time," she said. It's best to be honest, but we don't have to share all of the details. Sometimes the answer will be, 'We're taking care of that, and you don't have to worry about it.'"
Benningfield said it can be tough for physicians to distinguish between those who'd benefit from treatment and those who are having a normal response to a very abnormal situation. Warning signs include sleep or appetite disruption for more than a few days, irritability and a sudden focus on morbid thinking. "In this situation where we're all feeling more anxious, we still want to take it seriously," she said.