Consult-Liaison COVID-19 Systems

Protecting Mental Health During a Pandemic.

For context for this post: In my opinion, the federal government under the 45th President failed in its pandemic response. The lack of federal leadership, coordination, and interventions have led to ongoing disorganization that adversely affects every single essential worker who currently provides health care and social services.

As the federal government has not provided any coherent response to the actual disease pandemic, I do not expect that it will provide any response to the psychological suffering that has already occurred and will continue to occur due to Covid-19. Since this administration ignored the National Security Council playbook on fighting pandemics, it seems likely that they will ignore resources that describe how to boost the morale and promote the mental health of its citizens.

As I work as a psychiatrist, I wondered in the early months of the pandemic what strategies nations had used in the past to support psychological health. My hope had been to apply these nation-level strategies to the organization I work in.

The resources weren’t hard to find. There were three documents that I found helpful:

Of the three, I found the Pan American Health Organization document to be the most useful. (One wonders if U.S. officials did not deign to read something from “those” countries.) It helped me frame challenges when talking with individuals and teams. It also helped me grasp the horrifying reality and anticipate heartbreaking consequences.

… not all the psychological and social problems that occur can be described as diseases; the majority are normal reactions to an abnormal situation.

This JAMA paper describes an increase in the prevalence of depression symptoms due to the pandemic. I appreciate that the authors did not state that there has been an increase in the prevalence of major depressive disorder. The pandemic is an abnormal situation. We cannot apply our usual definitions when nothing about this year is usual.

In a major catastrophe, grieving means dealing with many other losses and implies a broader, more community-oriented feeling. It implies interrupting a life plan that not only has a family dimension, but also a social, economic, and political one.

We’ve all lost so much. Some people have lost their lives; others have lost their health and wonder if they will ever get it back. People have lost jobs and are distressed about how they will pay for rent and food. Others have lost time and wonder how they will pay attention to things other than work and disease. Kids miss their friends and classmates; parents miss things that their kids don’t realize they’re missing. The use of screens has made life more two-dimensional, though many have lost more than one dimension in their lives.

… mental health plans cannot be limited to expanding and improving the specialized services offered directly to the people affected…

There are multiple reasons for this:

  • There aren’t enough mental health professionals to serve the entire population.
  • Many (most?) people do not need specialized services; they (we) just need more support.
  • Some professionals will diagnose illness and treat accordingly, when illness may not be present. (“When you only have a hammer, everything is a nail.”)
  • Specific communities will often provide more tailored and meaningful support to their members than professionals, specifically when grief is the diagnosis and support is the treatment. (What I say to an Irish dancer may not be as helpful as the support from the rest of the Irish dance troupe.)
  • Mental health professionals should focus their specialized expertise on people who are experiencing more severe symptoms and conditions.

Can and should people with specialized expertise, like psychiatrists, teach and train laypeople to provide support to their communities during and after a pandemic? I think so. (While not related to a pandemic, the Friendship Bench is an excellent example of training laypeople to provide valuable support to others.)

There are three basic messages:
1. We should not think only in terms of psychopathology, but also in broad terms about collective problems.
2. The area of expertise of mental health professionals needs to be expanded.
3. The majority of psychosocial problems can and should be addressed by nonspecialized personnel.

Most psychiatrists, like most physicians, are trained to treat individuals. Pandemics affect populations and our individual interventions are often ineffective and do not scale. Furthermore, some interventions done without care can cause harm (“benzos for everyone!”). Collective problems require collective solutions; expertise must be decentralized and shared; community members can provide good enough, if not better, support. The Psychological first aid during Ebola virus disease outbreaks provides a useful framework for this support.

A good mass communication strategy is critical to maintaining calm and an appropriate emotional state; a well-informed population can act appropriately, protect itself better, and be less vulnerable in terms of psychosocial aspects.

The federal administration has already demonstrated no interest in a “good mass communication strategy”, whether related to Covid-19 or other events. It didn’t have to be this way.

My hope is that, as the “C.D.C. and other public health institutions awaken from their politics-induced coma,” we will see not only the execution of a federal strategy to address the Covid-19 pandemic, but also the implementation of a federal strategy to support the nation’s mental health. We’ve already witnessed psychological stumbling across the population; none of us want to see ourselves, our neighbors, our communities, and those beyond beyond fall further.

Consult-Liaison Nonfiction Reflection

Doors and Ducks.

Three people were standing outside of his apartment. His voice was muffled, though it was clear that he had no intention of opening his door. One person recrossed his arms; this group of young staff had already spent about 15 minutes trying to persuade him to open his door.

I offered to try; they obliged. In less than 60 seconds, he opened his door, showed his face, and greeted me with warmth.

Their face masks did not conceal their surprise.

This is how I did it. I:

  • read many books that describe different ways to listen and talk to people
  • watched many people (professionals and otherwise) talk to other people (patients or otherwise) and stole successful strategies
  • received and incorporated feedback from teachers who watched and listened to me talk to people
  • sat through hours of watching videotapes of myself talking to other people
  • have spent literally years talking to people who often did not want to talk to me

They didn’t see:

  • the many, many errors I have made in trying to connect with people
  • patients telling me directly how my approach was offensive and disrespectful
  • that one time someone threw a shoe at me because I wouldn’t leave him alone
  • the many times patients said nothing to me despite all my efforts to encourage them to talk to me
  • all the times I said something stupid that ruined any rapport we had
  • the times patients have yelled at me to leave because I didn’t respect their requests
  • that other time when the guy in the wheelchair literally rolled out of his room at high speed to get away from me (and I couldn’t find him anywhere on that floor in the hospital)
  • the variety of insults I have received (and will continue to receive) from people for reasons both valid and invalid

They also did not realize that:

  • luck played a large role in this outcome
  • the clinical relationship I have with him is different from the relationships they have with him (i.e., to him, I am novel)
  • I have been doing this sort of work for many more years than they have
  • I still consider everyone my teacher and continue to learn from them all
  • they can and will learn skills to achieve similar outcomes in the future

Now that winter is upon us, ducks called Barrow’s Goldeneye have arrived in Puget Sound. Sometimes a male and female swim together as an isolated pair; sometimes a flock of 10 to 20 ducks will paddle around the piers.

They look serene while gliding across the surface of Sound. We don’t see their legs and feet constantly pushing against the water.