Who would have imagined that we would ever live and work during a global pandemic. Our lives have changed so much recently and drastically. The frightening Corona virus or Covid 19 virus has unfortunately become a very real issue in our everyday lives. In Ireland we are currently on lockdown and levels of anxiety are at an all-time high. The pandemic of Covid-19 is a rollercoaster for all of us and especially those impacted by the virus personally, for those working directly in immediate healthcare it has brought levels of stress that are like those reflected in war time activities. The real challenge of Covid-19 for many of us has been the risk of contracting this frightening virus and the ramifications of this for our nearest and dearest. However, when it comes to considering the role of therapist and how best to approach the task of therapy a therapist has many elements to consider not least their own emotional well-being through all of this. Essential services have been redefined by the pandemic for society and within the health services, our service is classed as a frontline service for vulnerable adolescents and their families. Our pandemic experience is not of a hospital environment but of working within the Irish health service in an out- patient adolescent addiction service.
The Changing Landscape of Work
Working environments across the country have drastically changed since the onset of the pandemic. How our service has responded seems also quite different to similar services nationally. From mid-March when Covid-19 reached Ireland most counselling and therapy services ceased all face to face contact with their service users, opting for telephone and internet options to conduct their therapeutic work. Initially there was widespread panic and an immediate health concern regarding preventing the spread of the virus. Our working team initially followed suit and ceased face to face contact, however we were concerned about our service user cohort and their vulnerabilities.
We made a decision that our service needed to respond differently. Conversations with Child and Adolescent Mental Health Teams and other professionals allowed us to discuss how they have approached similar concerns and difficulties in relation to the treatment of families and young persons. Our team decided to continue to conduct one to one face to face meetings for new assessment appointments and vulnerable service users. This approach needed to be advertised through our regular networking channels as we were one of very few services who operated semi regular services.
Our Client Cohort
Our clients are under 18’s using drugs and alcohol and their families. Our clients rarely are self-referrals and are referred to our service by their families and a variety of agencies in our catchment area. They typically have high levels of ambivalence towards treatment at the start. Building engagement and a working alliance with our under 18 service users is one of the biggest challenges that we face as therapists and clinicians working in the adolescent service. The main question occupying our service was, what impact will a lockdown have on them and their families? Answering this question for us was in the influencing factor on our decision to still see people face to face. Many of our clients have access to the technology that may allow us to work remotely with them however they are reluctant to engage in video calling and many following the school shutdown in March are not accessing online work from school. A high percentage of our clients have mobile phones but often can have no credit or no privacy to conduct a phone session. The first management directives are to close and cease all non-essential health service work for therapeutic services this means stopping all face to face work family therapy and group work. We debate and argue over how will we do this who will see our clients? Will phone or skype work for our population who generally do not have credit. We develop a telephone risk protocol and a protocol for skype or online video sessions and discuss moving clients to Skype. We move many clients to phone, our urgent high risk and first time assessment clients and family therapy clients can attend as we are in a primary care health centre this is allowed under “lockdown” or “restrictions” as the government in Ireland calls it. We attempt conference call assessments, initially using our office phone system these are difficult and not successful. Assessing a young person’s use of substances, mental health, strengths and risks by phone on a first assessment is challenging for staff and one that we are not confident meets the young person’s needs. We then set up an isolation room with washable surfaces plastic chairs and look at the possibility of working from two of these rooms. This involves thinking about how clients navigate through the building, what we bring into the room with us, what protocols we have in place if staff or client exhibits symptoms while in the unit. We try working with some forms of PPE, working with face shields/face masks is challenging, and it blunts client’s expressions and is tiring for therapists and clients voices as you have to project your voice in a big room that is required to facilitate social distancing. Clients reactions to using PPE vary we have always offered to wear masks and also have them available for clients but so far few clients have availed of them. Neural diversity can have real impact on client’s ability to tolerate PPE our clients report difficulty with the feel, restriction and discomfort that wearing PPE brings.
This approach initially generated anxiety regarding personal health and risk of contracting the virus, however we maintained strict measures on hand hygiene and social distancing as well as utilising two rooms only for face to face contact. This approach allowed us to maintain relatively normal engagement with service users as at times phone contact only highlighted treatment barriers including been unable to see facial expressions and other non-verbal communication traits.
Every morning we conduct our new wipe down/ infection control routine in work. We begin each morning by wiping down all the surfaces that are touched regularly starting at the lift and working our way back in to the unit, doors, light switches, buttons, water cooler, kettle, fridge computer, filing room. This has become our daily routine partly for our own anxiety levels as we know we have minimised as much as we can our own risks in the unit. We have created a safe zone where everyone who enters the unit has to hand sanitise. I am reminded of a piece that my colleague Umberta Telfener sent me about preparing her room to receive clients as part of her reflective and spiritual practices of getting ready to provide therapy. I think I have a deeper understanding of this now. Covid-19 has made us look at our environment and really concentrate on how we move and interact with our working space our colleagues and our clients.
Self-Regulation during Covid-19
Over the period of three months it is easy to feel the anxiety in the building, we are all social distancing and haven’t been to the canteen area since February. Our public health nursing and community health colleagues are really under pressure. Three of our colleagues in the building have had to self-isolate with suspected Covid-19 and the building has been deep cleaned on one occasion. During this 3 month period of time we began to document our own thoughts and feelings here are some snapshots.
E.L. Recognising what supported my own emotional regulation in order to be present fully to my clients, whether via phone face to face or virtually was and continues to be my priority. I realised very quickly that if I didn’t get this crucial element correct it would have greater ramifications for my effectiveness as a therapist. Self-care gained a whole new meaning and only when I developed a routine and a rhythm of applying this to my life did I feel confident in my therapeutic delivery. The kind of things that have kept me grounded included simple things like a daily walk, doing a bit of Yoga, small bit of journaling, ensuring I connected in with close friends for a chat daily, eating properly and learning to notice the changes Covid-19 was having not just on me and my clients but on the world around me. Being tuned into this helps me to then relate to peoples reality when they are reflecting on their experiences of the temporarily changed world.
M.W. In late February I had some trouble with my car, coming home one night from teaching in a family therapy institute my car started acting funny and I was not sure that I would make it home, thankfully it did but it obviously needed attention. Three days later I am picking it up at the garage and am watching as the receptionist takes the payment of the customer in front of me. Taking his card, putting it in the machine and offering him the machine to enter his number, then taking the machine removing his card and giving it back. I am watching this with increasing anxiety. How many times have they done this today? No gloves and no wiping down of the machine. This is when it really sank in for me, just how aware we were all going to have to become of touching things. We are frontline health workers continuing to travel and see clients face to face, how much risk am I to my family?
A.McD. People are losing their loved ones to this monstrous virus and not getting to grieve or even be at their bedside. Trying to make sense of society at present is difficult and what am I hearing and seeing is bizarre. There are now little or no cars on my work commute, we are conducting the majority of our work utilising our phones, face to face contact is limited, we cannot see those with any indication of cold or flu symptoms, schools are closed, shops now demand you to queue for essential items and all non-essential stores, shops and restaurants are closed. Drastic numbers of people now see themselves unemployed and depending on the Irish state for monetary supports.
E.O. When the republic of Ireland shut down all non-essential services. I would have been monitoring both local and international reports on Covid-19 prior to the restriction announcement, but given in to the naive notion that living in a modern and developed country would give protection from death by an acute infectious disease. This is now clear to me that we are a global village and when it comes to infection by an agent such as this, there will be no discriminations. It is surreal and yet a ‘new normal’ has to be accepted. As an essential worker the risks taken to maintain services even though clinically minimised continues to impact on professional and personal lives. It’s as if you are in a canoe at sea, invisible, but can hear of others in the same or worse “human predicament”. Eager to embrace the shores and reunite in a “new normal”.
New Realities of Working
Building relationships and client engagement is something that working in this way has really highlighted. For some clients the move to virtual appointments has been a seamless one for others it has been frustrating and complex. For some families being together 24/7 has confronted them with the extent of the drug or alcohol issue with their adolescent and allowed them the time to work on some of the issues without the distractions of a busy work home life. For others the young person has retreated further into day and night reversal and begun living virtually online with little connection to family or others in the household. There is certainly some anecdotal evidence during these Covid-19 times that reminds us of the helpful relationship between the young people and their relationship with schools. Those young people who have managed to remain engaged with education online appear to be the young people who have managed to either reduce or abstain from substances. There appears to be very different and less positive outcomes for young people who have declined the opportunity to engage with their school educational input. In such cases there appears to be continued or increased use of substances and associated behaviours.
One of the theories of addiction looks at the environmental factors that contribute to a person developing an addiction issue (Zinberg, 1984). Factors such as availability of substance, peer pressure, group reinforcement and identification/exposure as a substance user. You could say we have just had one of the biggest social experiments in testing the cultural and situational factors and their impact on the levels of an individual’s substance using. For some of our clients this has allowed us to see how much of the young person’s drug taking was influenced and maintained by these external factors. For families the restrictions have also allowed us to look at parental influences and factors unique to the lockdown period. We have noticed increased parental presence in the home, routines and family rituals such as meal times, communication patterns and parents reflecting and supporting one another in interacting with a substance using teen. Contact time with children is something many families have struggled with due to work demands etc. But now for the first time in the lives of many families they are spending more time in each other’s company than ever before and one might argue in the presence of each other without as many distractions leaving parents more available to be present to their children’s needs.
For the families where children are willing to adhere to the restrictions we have heard some wonderful stories of positive play and interaction. I heard one parent in my own community describe the experience of the restrictions as being a gift, a gift to get to know his daughter better and an opportunity to learn things about her that he never knew. Many of the parents attending us have echoed similar narratives and the knock on effect of strengthening relationships and giving parents a greater opportunity to influence change behaviours is greater as a result. For many this time of connection has positively impacted co regulation and increased attachments. Families are describing simple things like baking together, playing games, singing songs, many of the things we might recommend in therapy but the block always seemed to come back to time. Now the removal of this block has facilitated the opportunity for families to do what they may have liked to do but couldn’t because of time and pressure.
The second type of response observed are the communities where there is less adherence to the Covid-19 recommended restrictions, parents in these communities appear to have less community cultural supports that support adherence to not just the Covid-19 prevention criteria but traditional pro social norms generally. This has left these families further disempowered where their children are out roaming in clusters. These parents report back that they feel embarrassed, they recognise that it’s wrong, they hear other parents on the radio and TV talking about such parents who let their children do what they like. The silent, embarrassed voices of these parents tell a different story. Not one which is happy to see their children do as they please but one of upset and frustration and in some situations acceptance that they are powerless. One parent said to me that she was trying really hard to keep her children in but when she looked out the window “the whole estate was out and not a Garda (Police) in sight, sure what hope would you have?”
We as once very social society are asked not to shake hands, or have any physical contact with those who may have always greeted with a warm hug or firm handshake. We are confined to our homes and in the majority of cases trying to utilise home space available to work from home. This has changed our definitions of working spaces, we now work from austere clinical spaces or spaces where we invite clients in to our home offices. We are also invited virtually to work in our client’s kitchens, gardens, cars and bedrooms.
We have seen drastic changes in society within a very short space of time in Ireland. Things we once took for granted are no longer an option or available to us and it is surreal to say the least. The lockdown or restrictions on personal movement has impacted on clients ability to source and access substances, these factors along with the peer and community reinforcement factors of substance using have been shown in our service as having a real impact on young people’s choices during Covid-19. Health and safety is now the top priority in our lives and the health service is trying to safeguard as best if can with our help of course. We feel lucky to apart of a team that have had to courage to respond differently to meet the needs of our service users during this time. It is our duty to try and reassure those we are caring for and working with to reduce their anxiety and support each other as best we can. We will get through this eventually but it will be difficult.
Zinberg, N.E. (1984) Drug set, and setting the basis for controlled intoxicant use. New Haven. Yale University Press.