key: cord-0856959-tajxe1cb
authors: Sammons, Morgan T.
title: Effects of a Pandemic on Psychologists and the Public
date: 2020-11-08
journal: J Health Serv Psychol
DOI: 10.1007/s42843-020-00023-0
sha: b07ff334601aeaa60e1d3b746c7297fd48b57f0c
doc_id: 856959
cord_uid: tajxe1cb

nan

We all, every one of us, patient and therapist, young and old, all ethnicities and genders, have been touched by the COVID-19 pandemic. It has affected each of us personally and professionally, as data from our six-month follow-up survey reveal: 45% of respondents reported knowing a friend, family member, or colleague who contracted COVID-19, 15% of respondents reported knowing someone who died of COVID-19, and 2% of respondents reported that they had contracted COVID-19 themselves.

The COVID-19 pandemic has transformed our home and work lives in ways thought unimaginable scant months ago. It has transformed most of the practices of psychology. Psychology has transformed from in-office practice into a telepsychology-based profession. Its impact on our collective psyche will be felt for many years.

We will continue to address the medium-term and longterm effects of COVID-19 for many years. COVID-19 has transformed from an acute problem (though it must still mostly be addressed as such) to a chronic one. Its effects will not go away, even after an effective vaccine has been developed.

It behooves us to begin planning for what comes next. How do we effectively socialize children and adolescents when inperson contact is limited? How do we better mitigate the effects of enforced isolation on people with mental illness? In a society riven by political discord, how do we ensure that the voice of science is heard?

As perverse as it may sound, most of us have experienced some positive effects of the virus-forced changes in our behavior. Unnecessary consumer consumption has been curbed. Indices of environmental quality are improving in many areas. A new focus on family togetherness and the value of interpersonal relationships has emerged. I, for one, will not miss the handshake as a socially obligated form of greeting, nor do I plan on boarding an airplane without a mask-regardless of the availability of a vaccine.

But the negative effects of the pandemic are staggering. The popular press reports that calls to national suicide hotlines are up. Reports of quasi-scientific national surveys of mental well-being suggest that as many as half of those surveyed are experiencing either negative psychological effects or the emergence of obvious mental symptoms as a result of the pandemic. The pandemic, combined with an attendant economic recession and a season filled with natural disasters likely accelerated by climate change (wildfires in the western US, hurricanes and flooding in the eastern US), have created a perfect storm of psychological stressors with which many have difficulty coping.

More systematic investigations suggest an increase in adverse psychological responses, particularly among young adults, first responders, and some ethnic minorities. A Morbidity and Mortality Weekly Report, looking at data collected relatively early in the pandemic in June 2020, found substantial increases in anxiety and depression symptoms, and suicidal ideation rates double those observed in 2018 (Czeisler et al., 2020) .

We lead off this issue with the results of our recently completed second survey of psychologists' practices during the pandemic. In March 2020, we completed the first national survey of psychologists' practices at the beginning of the pandemic (Sammons, VandenBos & Martin, 2020a) . That survey, initiated only one week after the United States had declared a public health emergency, was quickly followed by several other national surveys. In spite of differences in methodology, results of these surveys were strikingly similar: Psychologists had rapidly and overwhelmingly switched to telepsychology service provision, and they felt largely comfortable in their ability to do so. Early in the pandemic, practice caseloads had dropped for the majority of providers. Our earlier survey also indirectly suggested that patients had moderate levels of discomfort associated with the use of telepsychology.

Our follow-up survey, almost six months later, found that the shift to telepsychology appears to have concretized (Sammons, VandenBos, Martin & Elchert, 2020b) . Many providers anticipate that this will be a significant part of their service provision after a vaccine is available and the pandemic ends. Indirect measures of patient comfort with telepsychology indicate that they are becoming more accustomed to telepsychology. Practice caseloads had rebounded for a number of psychologists.

Telepsychology is here to stay. We must increase our fluency with this technology, and we should extend its use to areas such as neuropsychological testing and other testing situations. We must ensure that the reimbursement and legal landscape is modified to support this important new area of practice. We must tackle difficult problems, such as training providers to be more comfortable and more effective in dealing with suicidal patients via telepsychology. We must ensure that telepsychological services are available to those in greatest need. Data suggest that Native Americans and Native Alaskans are over three times as likely to contract COVID-19 than other Americans (Hatcher et al., 2020) . These populations are already at heightened risk for suicide, and telepsychology is least likely to be available to rural, economically disadvantaged individuals.

This tectonic shift is not limited to psychology. The virus has had a similar effect on the provision of medical services. It has caused a dramatic decline in outpatient physician visits in the US, from an estimated 125 million visits in 2018-2019 to 99 million visits in 2020. As in psychology, medical visits occurring via telemedicine skyrocketed from 1% of visits in 2018-2019 to 35% of visits in the second quarter of 2020 (Alexander et al., 2020) .

Our survey found that over half of respondents disagreed or strongly disagreed that they were comfortable providing telepsychology services to suicidal patients. Jobes (2020) outlines some of the challenges involved in managing suicidal patients using whatever medium-with the most salient being that few graduate psychology students receive any systematic training in suicide intervention. In the absence of sciencebased training, many clinicians rely on "suicide contracts" or referrals for emergency hospitalization. Neither of these interventions is effective as a deterrent. Jobes describes the work of a Task Force of the National Action Alliance for Suicide Prevention to better organize care of suicidal patients around proven standards. Such work must now be extended to the realm of telepsychology in order to increase psychologists' competence in suicide treatment and to broaden the reach of effective suicide prevention.

Jobes points to means reduction as a key component in suicide reduction. Miller and VandenBos (2020) amplify this in their article on addressing firearm safety in treatment. The presence of firearms in the home is a known risk factor for suicide, and one that must be addressed by psychologists concerned about patient safety. The issue that a discussion of firearms removal has become so politically fraught is an almost exclusively American one, but Miller and VandenBos note that there are many other factors bound up in the decision to temporarily remove access to firearms. Proactively addressing these concerns with patients before a crisis emerges is an element of effective care. Engaging in candid discussions of the psychologist's understanding of psychosocial and intrapsychic factors affecting the patient's perception of firearms possession has the greatest chance of successfully removing lethal means. Nonjudgmental discussions of the significance of firearms ownership to the patient, consideration of occupational issues that may influence gun ownership or removal (e.g., among police officers or military members), and knowledge of local laws are all elements of maintaining both safety and the therapeutic relationship with at-risk patients.

Our knowledge of the recovery trajectory after infection with coronavirus remains incomplete. Current understanding indicates that most infected patients will have mild symptoms of relatively short duration and will make a full recovery. Some patients, however, have lengthier illnesses with longer term pulmonary, hematologic, and perhaps neurologic sequelae. Such individuals may be unable to return to work, either temporarily or permanently. How many patients will fall into this category cannot yet be predicted, but given the scope of infection it is highly likely that an increase in disability will result from the pandemic. Kuhlman (2020) discusses the process of Social Security Disability evaluations, as well as the role of psychologists as evaluators or as State Agency Psychological Consultants (SAPCs). In the latter role, psychologists have no contact with the applicant for disability services but objectively evaluate data leading to a disability determination. Demand for these roles will probably increase in the wake of the pandemic.

Each fall, our colleague Steve Smith, Dean Emeritus at the California Western School of Law, provides a summary of the previous Supreme Court term with an emphasis on those cases that may affect the delivery of psychological services. In this year's summary, Smith (2020) notes the "blockbuster" nature of the most recent term. Most tragically, of course, was the death of Justice Ruth Bader Ginsburg, a long-time advocate for the rights of the disabled and mentally ill. This author was privileged to hear oral arguments in the case of Sell v. US, where the court held that the government did not have the right to forcibly administer antipsychotic medications to patients who were not deemed to be a danger to themselves or others. In that case, Justices Ginsburg and Kennedy were most active in challenging the government's assertion of its right to do so. My lasting impression of that debate was that one needed to be absolutely certain of their facts and the law before engaging Justice Ginsburg in an argument.

As to the court's decisions, Smith focused on Kahler v. Kansas, in which a majority of the court held that states could impose differing variants of the insanity defense in capital punishment trials. As Smith noted, however, this decision may have more academic than practical influence, since the insanity defense is rarely invoked and is even more rarely successful. More immediately important was the case of Bostock v. Clayton County, in which the court held that discrimination on the basis of sexual orientation was illegal under Title VII of the Civil Rights Act. While not a constitutional decision per se, this 6-3 majority opinion extended significant protection to LGBTQ Americans. In other decisions having implications for psychology, the Court held that felony convictions must be on the basis of a unanimous jury (Oregon and Louisiana had been exceptions to this otherwise common precept), that an attempt to repeal the Deferred Action for Childhood Arrivals (DACA) law was improperly executed, and that a Louisiana law limiting the qualifications of abortion providers was unduly restrictive. We are as always grateful to Dean Smith for his review-required reading for professional psychologists.

The pandemic has created numerous challenges and brought to light some that must be urgently addressed. Insofar as we now are pressured to fix problems that have long cried out for solutions, this is not a terrible predicament. In this regard, addressing the lack of common interjurisdictional licensure standards ranks high, along with reimbursement for novel practice areas. Likewise, in the despair created by COVID-19, there are therapeutic lessons regarding resilience that may indeed be beneficial in the long run. One thing is certain: Multiple problems will strain our creativity to find optimal solutions, and in many instances there will be no "right" answers. As educators, researchers, and clinicians we have much to offer. Our input will indeed be important in shaping a positive, lasting response to the coronavirus crisis.

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic -United States

Among American Indian and Alaska Native Persons -23 States

Commonsense Recommendations for Standard Care of Suicidal Risk

Determining Psychological Disability for the Social Security Administration

Collaborating With Patients on Firearms Safety in High-Risk Situations

Psychological Practice and the COVID-19 Crisis: A Rapid Response Survey

Psychological Practice at Six Months of COVID-19: A Follow-Up to the First National Survey of Psychologists During the Pandemic

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