A psychological first aid approach for the busy provider.
UPDATED ON: April 23rd, 2020
Disclaimer: This ASHM document is designed to provide available, relevant information to clinicians and other healthcare providers to optimise the health and wellbeing of people living with HIV, hepatitis B or hepatitis C and those with sexual health needs during the COVID-19 pandemic. The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence, but will be revised to include relevant future systematic review findings of the National COVID-19 Clinical Evidence Taskforce and other relevant information.
Prior to COVID-19 many people will have met their emotional support needs through family, friends, peer networks or support groups and/or personal self-management strategies and self-referred to services. The changing landscape of COVID-19 may well have made these usual support systems less effective or accessible and as such many people will require some form of additional psychological support to help them with their needs. Furthermore, those that are already experiencing isolation, disconnection and mental health issues may feel lonelier and more distressed and may have exacerbation in mental health conditions.
Frontline health workers are often best placed to assess and facilitate the psychological and mental health needs of their patients, clients and, when appropriate, their fellow co-workers. Provision of holistic care is tantamount to overall well-being. Opportunistic assessment of psychological needs is particularly important for vulnerable and/or hard to reach populations. These individuals may not typically engage with health care providers and may be presenting for a physical illness where there are underlying psychological factors requiring treatment.
An increase in the use of Telehealth and other non F2F methods at this time may exacerbate the sense of isolation experienced by some patients while making any mental health diagnoses more challenging.
This approach aims to reduce initial distress, address current needs and promote flexible coping and adjustment through promoting emotional/social support and connection, helping people feel safe and providing access to physical support and practical support.
Although there are number of ways that Psychological First Aid may be applied, clinicians may be familiar with different models and related acronyms such as ALGEE, ASSIST or the LOOK – LISTEN – LINK model, the steps remain consistent:
LOOK/ASSESS: for signs and concerns around safety, basic needs, urgency/crisis and serious distress reactions. As a health care provider, you may be familiar with both the history and mental health conditions of the people you care for and are well-placed to assess for risk of suicide, and/or self-harm and notice changes in self-care, sleep and emotional expression. If suicide risk identified usual suicide protocols should be followed.
LISTEN: Listening and understanding about needs and concerns, providing clear communication and information, helping calm, and instilling hope. It is important not to pressure people to talk or go into traumatic details but provide clear communication that you can help facilitate them to get the support they may need. Asking explicitly how people are and listening and communicating with both care and concern may be enough for many people to have their fears allayed and feel understood.
LINK: Promote safety and security, connecting and encouraging self-help strategies and referral to professional help, as indicated. Link people to practical support ensuring access to medication, food and shelter and referring those who need professional psychological and specialist support. Human connection and facilitating social support play an important role in well-being. Practitioners play an important role both as an attentive listener and as a conduit to further connection.
What patients might experience
With the emergence of COVID-19 come challenges to how we navigate our way around in life. It may also impact on the way that we view or see the world. It may increase a sense of personal vulnerability or fragility especially as it is difficult currently not to see the significant impact that the virus is having across the globe. People already vulnerable to mental health problems may suffer increased pessimism and low mood and/or increased agitation and anxiety as currently we do not know how long it will be before we are free of COVID-19.
Recommendations for patients to lessen their sense of isolation
There are impacts associated with increased periods of social isolation. Interestingly promoting social connection is something that a lot of health providers do every day with their clients; keeping social networks going; communicating with friends and family and meeting at coffee shops/restaurants are all limited options currently due to social distancing rules across Australia. Adapting our behaviours can be easier for some to do and very hard for others dependent on their own personal coping resources.
The impact of COVID-19 on people living with HIV, hepatitis B or hepatitis C
People who have previously been diagnosed with a blood-borne virus (BBV), such as HIV, hepatitis B or hepatitis C, especially many years ago, may be re-traumatised by COVID-19, which is more of a present-day virus experience. It is important to listen to their experiences and validate accordingly. Blood-borne viruses are different to COVID-19 but to some people a virus is a ‘virus’, so we need to be vigilant in supporting people. Under these circumstances it would be useful to look at how the person recognises differences, current methods of advanced detection and treatments applied to COVID-19 as compared to where we were when diagnosed with a BBV, such as in the 1980’s and 1990’s trying to deal with the devastating impacts that HIV had.
Many people living with HIV, hepatitis B or hepatitis C have experienced feelings of stigma and discrimination that may be compounded by the threat of another viral illness.
Specific concerns experienced by people living with a chronic BBV and other chronic conditions
Common concerns of people living with HIV, hepatitis B or hepatitis C are that they are more likely to become unwell if they develop COVID-19. Currently, there is no evidence that this is the case for HIV or viral hepatitis.
Another common concern is that there may be a shortage of antiviral medication. Again, there is no indication of any shortages of key medication. Pharmacies are only providing a maximum of 2 month’s supply in order to prevent stock-pilling.
Resilience in people living with HIV, hepatitis B, hepatitis C and COVID-19
Although COVID-19 has unique challenges for many, some people living with HIV, hepatitis B or hepatitis C recognise that their experience of living with another virus has given them considerable resilience and coping skills. Some people living with HIV, hepatitis B or hepatitis C may express feelings of belonging, a sense of feeling more part of the general community as they see others struggle with some of the concerns that they themselves have previously navigated e.g. financial strain, job loss, isolation, anxiety and health uncertainty. Practitioners can help people harness these strengths by asking reflective questions about how they manage their health conditions and highlight their strengths.
HIV and hepatitis B and C community peer workers and related non-government peak bodies remain a valuable resource and support for communities.
The impact of COVID-19 on marginalised and vulnerable populations
The devastating impact of COVID-19 on the wider community may be compounded for many communities that may already be considered marginalised or vulnerable because of economic, psychological, social, health and other inequities. Concerns about a rise in domestic violence, drug and alcohol use, loss of income, housing and access to food and health services are of concern for many populations. Health providers may need to sensitively assess and refer for complex psychosocial concerns that they identify.
Resources available to recommend to patients
There are several excellent support and information resources that are provided as part of this contribution particularly focussing on what people can do whilst coping with social distancing and personal isolation. Some health protective and immunising behaviours include having structure in your day – get up around the same time, freshen up, get dressed and get ready for the day, even if there is not much planned. Spending lots of time in your PJ’s may sound fun but after a while gets boring and can be problematic for those experiencing mental health problems such as depression. This ritual ‘resets’ the brain each day to be ready for any possibilities that may come along. Plan some time with friends to catch up, Skype, Facetime, text … anything that maintains contact which is important currently.
It is important to link people to resources and peer-based organisations that understand their lived experience. Many peak bodies have specific tailored resources and supports (see some of these at the end of this article).
Managing the Media in our lives
Be careful around media and news items which have a relentless coverage of COVID-19. Try minimising the exposure to perhaps breakfast time and dinner time only – most news outlets tend to get repetitive at times – there is only so much news available in any one cycle. Give yourself a break away from COVID-19.
Adapting to Telehealth to provide patient care
Practitioners are now frequently practising Telehealth. When using Telehealth communication and assessment issues worth considering include: people who might find it hard to understand or be understood on the phone, people who are particularly isolated and may benefit from visual connection, and where communication and assessment may be difficult either due to mental health issues and/or culturally and linguistically diverse nuances. Such circumstances may indicate consideration of visual media or face to face consultation.
It is important to become familiar with how telehealth can work and what is involved in setting up telephone and/or video conferencing modes of interaction. The Australian Psychological Society has developed some very useful support guides that can help people (health provider and consumer) new to the area (e.g. Psychological Services via telehealth: Information for consumers 20APS-IS-COVID-19-Public-Telehealth-P2_1.pdf)
Assessing client’s well-being via telehealth may be more challenging as many contacts are by phone
Importantly one of the first things to check is the client’s physical well-being. This would include a general enquiry about any current concerns. You could start with a general question such as “do you have any worries about your physical health at the moment?” This could lead on to more specific questions if indicated about specific concerns such as a cough or fever that may indicate that the client needs to see their relevant health care provider.
It is important to conduct a brief psychosocial assessment including housing, food security, current employment, financial security, support networks, and current drug and alcohol use.
Recognise that situations are often beyond our control
Recognise that for much of the population we often are challenged by things that are outside of our everyday control and COVID-19 provides a good example as we don’t know yet with any authority when it will end. Be patient and understanding regarding how people are coping currently.
Responses to COVID-19 will vary between different patient populations and different patients
Try to be culturally relevant and sensitive. Also note that some vulnerable groups or communities have experienced increased racism and/or stigma as a result of COVID-19.
Don’t assume everyone will respond to COVID-19 in the same way. As we find when people grieve or come to terms with a significant event in life such as death or loss of a pet, we do it differently. Some people find it easier to ‘move on’ whilst others take longer to adjust to the situation. Try to work out with the person what elements of COVID-19 are they most worried about? Which aspects do they feel more in control of?
Be honest about what you don’t know
Being honest with people is important. Sometimes admitting that we don’t know is ok as long as we are authentic in that situation. This may sound like “you are right, it is really tough at the moment to know how long it will be before we can get back to normal”. It can be useful to explore with the person, have there been any examples recently where they may have surprised themselves with how well they did in a situation or responded to a problem or barrier? Sometimes we need to help the person to search for previous examples of positive coping or adapting.
Involving the patient in decision making
Try to involve the person in decisions regarding their medications, how are they finding them? Impact on their mood, sleep, appetite, sex drive etc. Check in for medication compliancy and sense of relevancy in use.
Supporting people’s decisions around PrEP for HIV
Some people may stop taking daily PrEP, preferring to give it a break for a while due to decreased sexual activity. Some may be using more ‘on demand’ methods of protection which rely on recommended guidelines that ensure effectiveness. It is important that we check in and have the conversation with our clients regarding their choices and decisions at this time.
Sex and social isolation
Due to the requirements of social distancing to minimise infection rates of COVID-19 some people, particularly those who are single, may be struggling to cope without sexual intimacy or connection.
For people who have previously utilised sex on premises venues (e.g. Saunas) alternate ways of connecting sexually with others may need to be considered. Hook up’s may require review and checking in with your clients regarding how they are coping is important.
Planning, negotiating and navigating gets more difficult when chemicals such as crystal methamphetamine (Ice) are involved in sex given the associated euphoric and dissociative effects. The complex interplay between sexual connection, mental health and alcohol and drug use may require specialist services to assist and facilitating referral to specialist services is recommended.
Supporting patients to explore options around sex
In supporting people to self-isolate alternative sexual play behaviours should be explored. It is important that this is provided nonjudgmentally and with a problem-solving approach focused on reducing risk of harm, transmission and infection and helping people adhere to and understand social distancing laws. Open and supportive conversations around harm minimisation strategies such as encouraging masturbation, use of pornography and time related abstinence may be helpful. It is important that people understand that any direct personal contact (including kissing and touching) is a risk for COVID-19 transmission. Practitioners should help people understand the importance of self-isolation and social distancing and emphasise both the self-protective, legal and altruistic elements of our individual responses to this worldwide issue.
Supporting people who inject drugs
Injecting drugs continues to be the most common way to contract hepatitis C, and to a much lesser extent, hepatitis B or HIV. While many people living with HIV, hepatitis B or hepatitis C no longer inject drugs a proportion of people do continue to do so. Many people who inject drugs manage their use effectively in their everyday lives, but the COVID-19 pandemic may inhibit this due to reduced access to needle and syringe programs or increased stress or decreased coping if socially isolated.
Practitioners need to be conscious of and check for changes in a person’s drug use and discuss this in a sensitive, non-judgemental and supportive manner where the focus should remain on the health of the individual. Access to drug therapy may be limited and referral options may be restricted; highlighting the focus on health maintenance.
Have the conversation …how are you going currently with COVID-19? How are you coping? What are you learning about yourself at this time? These are all good ways to learn more about how people are going currently. Be careful not to assume that everyone copes the same way – clearly this is not the case as we all process and respond to significant events differently.
Check in to see if there are any significant changes in people’s lives, this may be through things we see during presentation or behaviour generally. Has their usual social contact(s) changed, are they still able to pay bills/rent?
Talk through telehealth and home visiting options – Is the client happy to engage this way? Sometimes if trauma is present some people will be much more interested in face to face options. If this is the case, then we would ensure a safe and hygienic environment is established and maintained.
Increasing the focus on help seeking behaviour is important especially for those experiencing increasing distress and despair. Encourage maintaining social connections (within social distancing guidelines) such as ringing or skyping / facetiming friends, so we maintain some sense of connection consistency.
Useful therapeutic steps are required that offer practical, reassuring approaches and relevancy. Promoting psychological flexibility has proven useful especially when working with people who are constrained and challenged by anxiety and uncertainty. A modern, scientific approach such as Acceptance and Commitment Therapy (ACT) enables us to explore with our clients how they maintain openness (accepting that events such as COVID-19 do happen and we can learn to adapt), stay present focussed (trying not to get so caught up in the future ‘what if the Virus never ends?’ or dwelling too much on the past); and learning to do what matters based on their lived and valued experiences. Dr Russ Harris, one of Australia’s best-known ACT trainers and author has a range resources available at his website (www.actmindfully.com.au/) and has recently added a practical series of steps called FACE and COVID:
FACE stands for:
F – Focus on what’s in your control
A – Acknowledge your thoughts and feelings
C – Come back to your body
E – Engage in what you are doing (be present)
and COVID stands for:
C – Committed action
O – Opening up
V – Values
I – Identity resources
D – Disinfect and distance.
Teaching people ways they can problem solve using their own personal resources (e.g. resilience, tenacity, willingness, curiosity, genuineness and compassion) can be helpful.
Looking at activities that help people to relax can also be helpful including using music, calming visual and auditory sounds and general mindfulness approaches that teach inner kindness, stillness and boost awareness.
Learning to appreciate and practising gratitude and investing in acts of kindness (saying hi to a neighbour, cooking a meal for someone and volunteering safely).
There are several useful and informative tools and resources for health workers that offer important details regarding how to cope and deal with COVID-19. The list below is no means exhaustive but have been selected in terms of current relevancy and practical use.
• The facts – Looking after your mental health during the coronavirus outbreak
• The Coronavirus Mental Wellbeing Support Service
• The five ways to wellbeing – for professionals. The Royal Melbourne Hospital
• World Health Organisation – mental health and psychosocial considerations during COVID-19 outbreak
• Tips for coping with coronavirus anxiety. Australian Psychological Society (APS)
• Maintaining your mental health during social isolation. Australian Psychological Society (APS)
• Coronavirus (COVID-19) anxiety and staying mentally healthy for older adults. Australian Psychological Society (APS)
• Australian Government National Mental Health Commission COVID-19 Mental Health Information and Support
• Mental health on-line courses
For People Living with HIV:
• Factsheets for HIV and LGBTIQ communities
• PositiveLife NSW
• What People living with HIV need to know about HIV and COVID-19
• ASHM Standards for Psychological Support for Adults with HIV – The aim of these Standards is to promote mental health and well-being, early detection of psychological difficulties and the provision of appropriate interventions for those who need them
• For HIV positive people who identify as heterosexuals
For People Living with Hepatitis B or Hepatitis C
• Hepatitis Australia
• National Hepatitis Infoline 1800 437 222
For Aboriginal and Torres Strait Islander Communities:
• Aboriginal Health and Medical Research Council has resources for both clients and health care workers
• Self-care Toolkit
For Culturally and Linguistically Diverse Communities:
• Resources include fact sheets, guidelines and other publications in: Arabic, Vietnamese, Traditional and Simplified Chinese, Farsi, Italian
• Resources from Federal and State Governments and WHO in 51 languages
• Transcultural Mental Health Centre
For Homelessness and Food (Sydney/NSW):
• From the Newtown Neighbourhood Centre. Has information on finding temporary accommodation and free meals as well as negotiating Centrelink’s processes.
For Sex Workers:
• Scarlet Alliance
For LGBTIQ+ communities:
• Rainbow Health Victoria: COVID-19 Impacts for LGBTIQ communities and implications for services
• Trans HUB
1. National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/
5. Tips Centre for Posttraumatic mental health https://www.phoenixaustralia.org/
6. The Australian Red Cross (2013). Psychological First Aid: An Australian guide to supporting people affected by disaster. Available at https://www.redcross.org.au/getmedia/23276bd8-a627-48fe-87c2-5bc6b6b61eec/Psychological-First-Aid-An-Australian-Guide.pdf.aspx
7. World Health Organization (2011). Psychological first aid: Guide for field workers. Available at https://apps.who.int/iris/bitstream/handle/10665/44615/9789241548205_eng.pdf;jsessionid=37E2EC031F9A571F14FA8D114BB9D893?sequence=1