Supporting psychological health and wellbeing through COVID-19: A psychological first aid approach for the busy provider

 

Prepared by ASHM & Members of the Taskforce’s Psychological Health Cluster Group, supported by Hepatitis Australia, AFAO and NAPWHA.  Adapted to the Asia and Pacific Region by the BBV, SH and COVID-19 Regional Advisory Group including Chair Dr Nicholas Medland and Associate Professor Maria Isabel Melgar.

UPDATED ON: 3 November 2020

 

 

Disclaimer: 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. The recommendations are not intended to replace national guidance. 

 

 

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-referral to services.  The changing landscape of COVID-19 may well have made these usual support systems less effective and/or accessible and, as such, many people will require some form of additional psychological support to help them address their needs.  Furthermore, those that are already experiencing isolation, disconnection and psychological health issues may feel lonelier and more distressed and experience an exacerbation in psychological health conditions.   


Frontline health workers are often best placed to assess and facilitate the psychological health needs of their patients, clients and, when appropriate, family members as well as their own colleagues.  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-face to face methods at this time may exacerbate the sense of isolation experienced by some patients while making any psychological health diagnoses more challenging.

Often referred to as Psychological Health First Aid, 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 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, ARISE, BI 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 psychological 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 appropriate 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 rather, the aim should be to 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 to 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.  Encourage people to stay connected with friends and family, including when in quarantine or in self-isolation.  Practitioners play an important role both as an attentive listener and as a conduit to further connection.  
     

 

 

What patients might experience
COVID-19 presents challenges to how we navigate our way around in life. Across the region and around the world, COVID-19 has triggered discriminatory acts against groups that were believed to have caused its spread and those who have been victimized by the virus.   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 psychological 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 eateries are all limited options in some countries due to social distancing rules. 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.

 

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 organizations 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 on your computer and gadgets may sound fun but after a while gets boring and can be problematic for those experiencing psychological 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 either online or in person if possible. 

It is important to link people to resources and peer-based organisations that understand their lived experience.  Many local and international NGOs 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 psychological health issues and/or cultural and language differences. 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).  The American Psychological Association likewise continually update information and Covid-19 related resources developed for psychologists, health care workers and the public (https://www.apa.org/topics/covid-19). If you would like to share details of mental health support services in your country to be included here please send these to taskforce.rag@ashm.org.au

 

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. 

A way of addressing this issue of sexual intimacy is to discuss with clients the concept of  creating a social “bubble” which allows for regular dating  with a potential new partner or new acquaintances.  The social bubble can be formed as longs as the partner and/or the members who are part of the bubble mirror the strict safety measures against COVID-19 that one practices. Small intimate bubbles are less vulnerable to viral contamination than larger bubbles with more members.

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, psychological 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 in a non-judgemental way 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. It is important that people understand that any direct personal contact (including kissing and touching) is a risk for COVID-19 transmission.  The consistent use of condoms with a regular or new partner is better complied with through an assured adequate supply of condoms.  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 use 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?  

There are available brief assessment tools that one can use with clients or patients to monitor their psychological health and well-being.  These include WHO instruments such as the Well-Being 5, Self Reporting Questionnaire (SRQ) and other popular scales on depression and anxiety such as the Patient Health Questionnaire or PHQ 9 and the Generalized Anxiety Disorder or the GAD 7.   These tools can also be self-administered.

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.   Prayers, meditation and other religious rituals at home are some examples of  helpful and calming activities that promote hope and inner peace.

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 and community or peer support workers  and 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. If you would like to share details of mental health support services in your country to be included here please send these to taskforce.rag@ashm.org.au


For People Living with HIV:

 

For People Living with Hepatitis B or Hepatitis C

 

For Sex Workers:


For LGBTIQ+ communities:


 

Timor-Leste 
Mental Health Helpline 12123 7am to 7pm

 

Fiji
 COVID-19 Helpline - 158
Empower Pacific Helplines 2937141 and 7765626 

 

Papua New Guinea
Lifeline Port Moresby – 675 326 0011

 

Thailand
Thai Department of Mental Health Hotline Tel. 1323 
 The Samaritans of Thailand
Bangkok Tel. (02) 713 6793 (Thai) 12:00 noon to 22:00 hours/day, 7 days a week
Tel. (02) 713-6791 (English call back service within 24 hours) 24 hours/day, 7 days/week
Chiang Mai Tel. (053) 225-977/8 (Thai) 19:00 - 22:00 hrs (Mon, Tues, Thurs, Sat)

 

Philippines 
Free Suicide and Crisis Helpline - Landline:(02) 8893-7603Globe:0917-8001123 Sun:0917-8001123
Tawag Paglaum crisis hotline (0939)937-5433 ext (0939)936-3433
Philippines NCMH Crisis Helpline 09178998727 – 9897272

Philippines Mental Health Association - FB: https://www.facebook.com/PMHAofficial/; Mobile: 09175652036; Email: pmhacds@gmail.com
Mental Health First Responders – Free self referrals - Google Form: https://forms.gle/DN49AwPw4X4VwvFR7

 

Indonesia
 National COVID-19 Hotline number inc Mental health — 119

 

Singapore 
National Care Hotline: 1800 202 6868 (8am – 12am daily)

 

Malaysia
Befrienders Hotline
KL: 03-7956 8145 (24 hours)
Ipoh: 05-547 7933 (4pm to 11pm)
Penang: 04-281 5161 (3pm to midnight)

If you would like to share details of mental health support services in your country to be included here please send these to taskforce.rag@ashm.org.au

 

  1. National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/ 
  2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext
  3. https://www.acon.org.au/about-acon/latest-news/#acon-covid-19-update-casual-sex-and-social-distancing
  4. https://www.ashm.org.au/products/product/9781920773717
  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 
  8. Psychological Resources for Corona Virus.  Available at  https://www.psychologytools.com/psychological-resources-for-coronavirus-covid-19/
  9. Greenberg, N. et al (2020) Managing mental health challenges faced by healthcare workers during COVID-19.  BMJ; 368:m1211 Available at https://www.bmj.com/content/368/bmj.m1211.full?ijkey=Il18pprCDUiMW3R&keytype=ref
  10. IASC MHPSS Briefing note on COVID19:  (SUPPORTING PEOPLE WORKING IN THE COVID-19 RESPONSE P.11), https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/interim-briefing  
  11. WHO "How to Cope with Stress During COVID-19 Outbreak" (bottom of the page) https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public  
  12. WHO MHPSS during the COVID-19 outbreak  (Messages for team leaders or managers in health facilities P.3), https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf