The Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College and currently in private practice in Los Angeles
This presentation originally appeared as a Podcast at PsychiatryTalk.Podbean.com. Dr. Blumenfield can be contacted at MBlumenfield@aol.com
The Coronavirus: Psychological Considerations with Special Emphasis on Psychological Support for Doctors, Nurses, EMTs, Other First Responders, Including Members of the Media and the Psychological Support Teams Themselves
Hello, I’m Dr. Michael Blumenfield.
Today’s podcast is going to address the psychological issues of the victims and the potential victims of the coronavirus ,the people caring for them such as the doctors, nurses, EMTs and other first responders, the mental health professionals who are involved in supporting these groups and also the members of the various media, print TV, etc., who are also fully exposed to the psychological impact of this epidemic by the nature of their work
Of course every one of us is a potential victim of this life threatening disease. We know that if you are older or have a chronic disease, you are more susceptible and of course we know that transmission occurs by exposure to people who are infected. This knowledge creates conflicts about personal, travel and business decisions, which can be quite agonizing and guilt producing when there is a subsequent loss of business or personal opportunity, or if the decision leads to illness and potential fatalities. The nature of this disease often requires isolation and quarantine of people identified as being exposed to this illness. This situation, of course, can be quite psychologically painful to the person involved as well as to their loved ones. However, modern technology now allows the maintenance of face to face, relatively intimate contact via FaceTime, Skype etc. so people can mitigate some of fear, anxiety and depression of this situation. As will be described below group video meetings can be held vie Zoom
Any situation that changes a person’s usual interactions and travel patterns, increases the possibility that there could be a temporary hiatus in the renewal of their regular medication. This can be important when a person is taking essential medications for diabetes, heart disease and other illnesses. It can also be very important when people with mental symptoms run out of medications in such conditions as schizophrenia, other psychosis, bipolar disorder, anxiety panic and, of course, depression. This situation can be further exacerbated if pharmaceutical companies cannot get essential ingredients from international sources during a worldwide epidemic.
Mental health professionals in the United States and in many other countries have established very sophisticated techniques for working with patients who have serious medical and even life threatening conditions as well as supporting the medical and nursing staff caring for them. There is a subspecialty of psychiatry originally known as Consultation-Liaison Psychiatry which as now been subsumed under the particular specialty known as Psychosomatic Medicine.
Of particular note was the work by these specialists in dealing with the AIDS epidemic as well as with burn and trauma patients, cancer, heart disease and other illnesses. It should be noted that during the acute phase of illness, the ideal approach is for the patient or family members to meet individually or sometimes as a couple or family with a mental health professional when there were psychological issues. Sometimes, of course, clergy would be involved. At a later phase there might be referral to some specialized grieving group meetings with others who have lost loved ones. Mental health professionals trained and experienced in this area of Consultation-Liaison may be particularly appropriate to take a leadership role in the delivery of services, especially in running any groups.
During the AIDS epidemic there were often particular fears among medical and nursing staff of contracting the disease, especially before the exact mode of transmission was understood. There were numerous other psychological issues for healthcare workers, victims and families. In situations where there were mass causalities such as after airline crashes and particularly during the World Trade Center 9/11 incident, where there were 1000s of deaths, there were many psychological issues for the families, the surviving victims and also for first responders including the psychological support teams themselves. More recently mass causality events ie. shootings or bombings have raised similar issues, many of which maybe similar to those that we will be seeing during this coronavirus epidemic.
In the past, particularly prior to 9/11, the usual approach where there were believed to be large numbers of psychological causalities, particularly among the first responders, members of the media or even among the psychological caregivers themselves, was to use the CISD (Critical Incident Stress Debriefing) approach. This is a technique where a specific group of people ie. doctors, nurses, EMTs, members of the media or even mental health personnel, would meet in a group with a psychological consultant who would lead them in a discussion of the difficult experiences that they had been through. For example, after a plane crash or a terrible tornado, the police, firemen, EMTs or even reporters would recount the horrible, sights and sounds that they have seen. They might be describing seeing dead children or maimed victims etc. This technique was based a catharsis model which might encourage the participant to “ let it out”, tell about their experiences, nightmares, fantasies and encourage them to discuss how they thought about their own families and personal thoughts. While such a technique might be helpful in an individual therapy or group therapy treatment dealing with less acute situations such as sharing a struggle with substance abuse, many experts soon realized that having each person recount their own painful horrific experience in this group setting, was usually not helpful. In fact, to the contrary, such situations were more likely to intensify the anxiety, panic and worry of the other participants of the group. It is a different situation when someone in psychotherapy is reflecting back about a difficult time in his or her life and brings up some painful memory and then gradually lets down their psychological defenses. Or even in a group therapy situation, a person may recall a difficult memory or a current struggle and is getting the support of the other group members, most of whom are not struggling with very similar acute issues. The CISD model, although very well meaning, in my opinion was not effective. In fact, I believe it had the potential to magnify the problems of the other group members and sometimes would breakdown psychological defenses which were helpful at that moment.
This doesn’t meant that there is no value for specific groups to meet under the guidance of a mental health professionals but the approach, in my opinion, should be one that is supportive and affirmative. The group meeting with a leader might address several areas depending on the makeup of the group. There would usually not be any reason to mix the members of the group and. have first responders in the same group as the mental health professionals or clergy or reporters. If group work is being done, they should ideally each be in their own group.
Depending on the particular make-up of the group there are some potential issues specific groups might address. As I will emphasize in the case of all group meetings and in many cases in individual meetings, because of the potential spread of the Coronavirus, remote face to face techniques should be considered and often will be the preferred form of meetings. Zoom is an excellent system for conferencing with individuals and small groups. Participants do not need have an account. They can see each other. One can also draw on a whiteboard for everyone to see.
Group Meetings Conducted By Mental Health Professionals with Police, Fire and EMTs, Doctors, Nurses and Other Identified Groups Such as Lab Technicians, Coroners Office , etc.
When possible the groups should be homogeneous . Although they often work side by side, there are individual situations that each group deals with and there is often an esprit de corps that would suggest any such group meeting should be homogenous. As previously stressed, using remote communication methods, such as Zoom, should be considered because of the nature of the contagious process that is confronting us. However, since these groups often do assemble regularly for assignment and briefings, a portion of that meeting might be assigned for discussion of mental health issues. That could include
1. A general review of symptoms that the people whom they are helping may be experiencing and review of resources available where they can refer any of the primary victims who need such assistance. The medical providers should be reminded to check to see if their patients have adequate medicine supplies for any mental health or other medical conditions.
2. Stressing the importance of how the caregivers themselves should be getting adequate sleep and when possible spending time with their families
3- When possible it is valuable to arrange for periodic acknowledgement by superiors or other government officials of the appreciation and value of the work they are doing. This can be an important morale builder during difficult times Acknowledgment that it s not unusual for people in their position to have symptoms of anxiety, depression, bad dreams, etc. At the same time do not encourage group discussions of individual difficulties or psychological symptoms or problems that members of the group may be having ( the CISD method). Most important, would be providing contact information where they any individual can have a confidential meeting with a mental health professional..
Group meetings with Mental Health Professionals Conducted by Mental Health Professionals Knowledgeable About Mass Trauma
Mental Health professionals are usually comfortable working together and it would be quite appropriate to have psychiatrists, psychologists, social workers and mental health nurses all meeting together. As previously stated because of the contagious nature of the disease process, remote group meeting may be necessary or advisable.. If there are people who have experience in the consultation/liaison model of providing support to patients with serious illness and trauma as well as in support of medical and nursing staff, it would be appropriate for them to take a leadership role in this meeting.
1- In the initial meetings of this group, there would be the opportunity to access the mental health professional resources available and identify those with particular applicable experiences. There would need to be a designation who would run sessions for particular groups noted above and who would be available for individual counseling or therapy sessions. Depending on contacts and relationships there could be designated mental health professionals who could reach out and offer support to various leadership people involved in the crisis situation including various agencies and the political leadership.
2- It would be appropriate for a designated experienced mental health professional person to review with the group, the nature of the psychological problems that they are dealing with such as fear, anxiety, separation issues, depression, PTSD, grief, etc which may be occurring in primary patients and their families. This would likely be something that the mental health professionals are familiar with but some may not usually work in this area on a day to day basis . This review should include the approach to children and how to answer their concerns and questions in an age related manner. There also should be a discussion of importance of avoiding the CISD approach in a group setting, as previously discussed and encouraging those with significant symptoms to be referred for individual sessions.
3- Remind mental health workers of the importance of recognizing that needed medications for mental health and other conditions may be interrupted and consider if substitute prescribers can be provided and if emergency medication can be provided.
4-As there often is loss of life, it is valuable for the mental health professionals have an alliance with clergy who can be helpful with acute grieving and general support for many people.
5- During these group meeting with mental health professionals, the importance of their valuable role should be reinforced . At the same time the potential impact on themselves should be acknowledged and there should be a method for any of them to have individual, confidential mental health support.
Group Meetings with Members of the Media Conducted by Mental Health Professionals
During the course of a disaster situation or a public health crisis, members of the media are usually totally involved on a full time basis. They become knowledgeable of the seriousness of the situation and the threat to life, sometimes even more so than the general public . They frequently interview the victims and their families as well as the various first responders and others knowledgeable about the seriousness of the crisis at hand. This group can include reporters, commentators, producers, camera people etc. A group meeting with them where there is an acknowledgement that it is not uncommon for them to have symptoms can be helpful at the same time reminding them that they play an important supportive role in the mental health of their audiences. As previously discussed, the CISD method should be avoided in group meetings but certainly individual confidential counseling sessions should be available as needed .
I would like to conclude with a brief vignette concerning the important psychological role of the media in supporting the worried public at the time of a major incident
Shortly after the 911 World Trade Center Incident, I was scheduled to do a psychological debriefing with various members of the media and the night before I received a call from a family member. She told me she had a dream that a well known TV news personality was comforting her about this horrific event. In my meeting with the media people I used that story to show them how they provided emotional support as well as the news. At the end of my meeting one of the participants came up to me and told me she was senior producers for the network personality my relative dreamt was comforting her and she was sure he will be very pleased to learn he appeared in a comforting role in her dream in addition to providing the news. My relative was also very surprised and also comforted to hear here he would know about her dream
This presentation was originally presented on a podcast by Dr. Blumenfield (PsychiatryTalk.podbean.com). Dr. Blumenfield can be contacted at Mblumenfield@aol.com
Dr. Blumenfield is the Sidney E. Frank Distinguished Professor Emeritus of Psychiatry and Behavioral Sciences at New York Medical College and is currently in private practice in Los Angeles, Californria
Intervention and Resilience After Mass Trauma, Edited by Michael Blumenfield and Robert J Ursano, Cambridge University Press, 2008
Disaster Psychiatry (Chapter 18) in Psychosomatic Medicine by Michael Blumenfield and Maria Tiamson-Kasab, Wolters Kluwer, Lippincott Williams & Wilkins, 2009