Written by Dr Angela Prout, Lecturer on the Doctorate in Clinical Psychology and Lead Clinical Tutor, Consultant Clinical Psychologist, member of the ‘Vulnerable Victims and Offenders in the Criminal Justice System’ research theme from the Centre for Applied Psychological Science.
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In March 2020 the UK was put into lockdown. At the start of the pandemic I think we were all unaware of what would become a year of uncertainty, losses, and fundamental changes to our way of living and how we do our jobs. I have two posts: one at Teesside University and one with a local mental health trust. In the latter, I work as a consultant clinical psychologist in an adult psychiatric hospital. In both organisations, like everyone, I have seen and been part of implementing some rapid changes.
In the hospital, initial concerns centred around safe staffing, managing patients with covid-19 symptoms, and an expected general increase in patients, given that services that people relied on were at best stripped back and at worse closed completely. Initially, at least, we did see some staffing issues (staff shielding, working from home for family reasons, self-isolation / sickness etc.) which required some rethinking of service delivery but rather surprisingly was a decrease in referrals. Indeed, data from the Office of National Statistics suggests that the number of referrals to NHS funded secondary mental health, learning disability and autism services decreased by 39% between February and April 2020. Some patients may have been put off seeking support wanting to protect the NHS. For others the switch from face to face appointments to telephone or video consultations no doubt acted as a barrier for a number of reasons.
However, despite this initial decrease in routine referrals the presenting issues of patients accessing secondary care services changed, with 43% of Psychiatrists surveyed in May 2020 reporting an increase in urgent and emergency cases. By the third lockdown (January 2021) staffing became increasingly difficult to navigate for managers and patient numbers significantly increased with high acuity, with the added complication of isolating admissions; whilst Covid-19 testing was put in place and became streamlined. As time has gone on, we can see more and more of the effects the pandemic is having, not only on people with existing mental health difficulties but also on the average person; people who have never accessed mental health services in the past but now feel vulnerable, with their usual coping strategies and support inaccessible. Although Covid-19 is yet to be thoroughly researched the neuropsychiatric effects of viral pandemics on general population have been demonstrated (research from the SARS and MERS epidemics) and suggest that psychological distress is more severe among groups who contracted these infections, compared to other critically ill patients. We are seeing long term Covid-19 symptoms (long covid) and psychologically the long-term consequences may include depression, anxiety, and post-traumatic stress disorder; with some patients experiencing significant cognitive impairment (Meeting the psychological needs of people recovering from severe coronavirus [Covid-19], BPS Guidance, 16/04/2020).
Remote working was obviously never fully possible in some services, such as crisis and inpatients where face to face was continuing with personal and protective equipment (PPE). Most countries and health organisations (e.g. the WHO) recommended wearing face masks to reduce the spread of the virus. This was the initial requirement within the hospital but quickly changed to include a uniform, plastic apron, surgical gloves and during the third lockdown a visor. As you can imagine the use of PPE dramatically altered the dynamics of the patient-therapist relationship and the ability to engage and build rapport with patients in more traditional ways. Indeed, Dr Natalie Butcher’s blog (16th March 2020) detailing the impact that wearing a face mask has on expression recognition was of particular interest to me, as I have personally struggled to know how much non-verbal therapeutic communication can be conveyed through my eyes alone (indeed walking through the corridors I have felt almost compelled to tell people I am smiling and have certainly used a lot more verbal acknowledgements than previously).
Looking back, for me, a day in the last year began with acclimatisation, a little mindfulness (3 min mindful breathing meditation) and a change into a uniform (I’ve never had to wear one before). The first task became deciphering the latest guidance, working out what may have changed (guidance became a lot more fluid and subject to regular changes). Attending the SITREP (situation report) meeting established the priorities for the day (our roles also became more fluid in line with business continuity). When not on the wards, in PPE, I was fortunate to have an office I could retreat to and sit in meetings (on MS Teams, off course) with the comfort of not having to wear my mask. No longer do we sit in meetings, in large rooms, business was now conducted via online platforms. I’m still in the company of others but from a distance. I’ve never felt alone in my profession, but I have over the last year! We have all developed new habits and engaged in some interesting new practices such as the ‘zoom wave’ when leaving a meeting (not usual business meeting etiquette!).
Along with the complexity of maintaining a service for vulnerable people, suffering mental health issues whilst considering infection control, it’s been crucial to acknowledge the increasing cost to staff’s wellbeing. Staff have gone above and beyond to provide care for both COVID-19 and all other patients. They have at time placed themselves at personal risk and ensuring a positive work life balance has become a distant memory. A number of initiatives have been put into place to support for staff both formally and informally. I myself have had staff come to me for support and offered more formal approaches to support my colleagues but on a daily basis my greetings (like many others) have changed. I admit that asking how someone is, was sometimes simply a greeting, now I really want to know how people are because I see the accumulative effects of the pandemic. Despite all the difficulties, the thing that has struck me the most, in my job, has been the resilience I have seen and the determination to keep going when all are just so weary.
As we hopefully start to reach an end to lockdown, the ability to see our loved ones up close, resume our social lives and enjoy the things that matter to us, I can see how we all may initially appear reinvigorated. However, I don’t see patients or staff’s mental health needs reducing in the short or longer term and it is important that we use this opportunity to keep in place sustainable practice and accessible psychological support.