The response of the behavioral health system to the COVID pandemic has been rapid and remarkable. But it is, of course, imperfect and incomplete. What are the challenges still to be met? And what will happen after the pandemic, hopefully, ends and we move on to a new normal?
What Has Been Done to Address the Psychological Fallout of the Pandemic
Over just a couple of months, governments, charities, local communities, volunteers, and behavioral health providers have stepped up to respond to the widespread psychological fallout of the pandemic. This has included addressing the needs of people with pre-existing behavioral health conditions, who are at risk of exacerbation and relapse as well as the needs of people who develop new mental and/or substance use disorders during the pandemic. It has also included efforts to address the emotional distress that many people, with and without diagnosable disorders, have experienced—fears regarding illness and death, isolation and loneliness, loss of a sense of control, hopelessness, family tensions, grief, and more.
Living through the pandemic has been challenging and emotionally charged for most people, but especially for people who are without adequate income, food, and shelter; for those who are at highest risk of sickness and death; for racial and ethnic minorities; and for the healthcare providers and other essential workers who are on the frontlines of this massive struggle to survive.
Responses to the pandemic that can help to contain the psychological fallout have included:
- Governments and charities have mounted relief efforts that address “social determinants” of mental health, i.e. income, food, shelter.
- Federal and state laws and regulations have been changed to permit and pay for tele-mental health
- Providers have used tele-mental health not just for standard therapies but also for innovative approaches to psychiatric rehabilitation, support groups, mutual aid meetings for people with substance use disorders, and even for mindfulness exercises.
- Much effort has gone into preventing contagion in residential settings, in the hopes of protecting both clients/patients and the staff bravely providing care for them. Sadly, these efforts have not been entirely effective. Nursing homes have high rates of illness and death as, to a lesser extent, do psychiatric hospitals, shelters, jails and prisons, etc. To some extent this reflects failures to provide adequate testing, screening, and protective equipment.
- Governments have intervened to some extent to support the financial survival of providers with loans and changes in reimbursement criteria. Providers continue to struggle nevertheless.
- Training initiatives have been developed by professional organizations, trade associations, , professional schools, and continuing education programs to help providers learn how to use tele-mental health, to make use of emergency financing, to understand new regulations, and more.
- Providers have developed mutual aid groups to figure out how to deliver services when programs are closed, staff is in short supply, funding is problematic, etc.
- Governments, providers, professional organizations, and more have provided public information about how to cope with increased emotional distress.
- Helplines and hot lines have been beefed up for people seeking compassionate interaction, professional health, or immediate crisis intervention.
- Some professionals have come out of retirement to provide clinical services in volunteer corps that help to address the limited capacity of the behavioral health system in the best times and the more limited capacity now that some providers are out sick or with family responsibilities.
- Volunteers have been organized in neighborhoods, states, and even nationally to provide social connections and assistance to people who are isolated. In some of these initiatives, clinicians train the volunteers and provide backup when they connect with people who need professional help.
- Workplace programs, such as employee assistance programs (EAP’s), have provided work site interventions ranging from yoga groups to enhanced treatment services to help workers survive the stresses of their jobs.
As remarkable as these responses have been, there is still much that needs to be done to meet behavioral health needs during the pandemic. This includes:
- Vigilance and modifications of laws and regulations are necessary to make sure that relief promised for individuals and families and loans for businesses that are on the edge of bankruptcy (including behavioral health agencies) actually are delivered.
- New efforts are necessary to address racial and ethnic health disparities that have become increasingly apparent in the rates of sickness and death due to the pandemic.
- Regulators and accrediting bodies need to set and enforce standards and provide adequate resources to avoid contagion in congregate care settings such as nursing homes, inpatient psychiatric units of general hospitals, state hospitals, adult homes, community residences, supportive housing, etc. Standards should include routine testing/screening of workers and clients/patients, adequate protective gear, and more. Efforts should be redoubled to get tests and protective equipment, and failures to provide them due to cost avoidance should not be tolerated.
- Tele-mental health has unquestionably been a savior for many people. But it has limitations, not the least of which is lack of universal access to computers or even smart phones.
- It is important to identify and continue to remove regulatory and fiscal barriers to behavioral health service provision. For example, there continue to be problems paying for service for people with both Medicare and Medicaid (dual-eligibles) as well as problems funding outreach, psychiatric rehabilitation, and non-medical model services.
- Behavioral health services are now threatened by cuts in funding because states have had tremendous losses of income. It is critical for the federal government to provide additional emergency funding to fill the emerging gaps.
- It is also important to address workforce shortages. This ongoing problem has been compounded by the cancelation of licensing exams due to the pandemic. As a result, newly graduated social workers, for example, cannot enter the workforce at a time when they are desperately needed. In addition, immigrants who have professional credentials in their home countries but are not licensed here could be available for service if licensing rules were changed.
- Appropriate utilization of psychiatric inpatient services has become a critical issue. If admissions are reduced in order to be able to maintain safe environments vis a vis COVID, what will happen to people who otherwise would be hospitalized, especially those who are homeless, potentially suicidal, etc.?
- Frontline healthcare staff are under tremendous psychological stress as they face severe illness and death daily, work long shifts, and manage anxiety about their own health and the health of their families. In addition, other essential workers, who risk their health daily, also experience great emotional distress. All of these heroic workers need special attention and care.
- People with physical, developmental, psychiatric, or cognitive disabilities who need predictable routines are also at increased risk during this time of sheltering-in-place.
- Their caregivers need supports to avoid burnout and to continue to provide care in the home.
- Alcohol and perhaps other substance abuse is on the rise. For example, alcohol sales in liquor stores—regarded as an essential business—are up over 50% and on-line sales are up over 250%. It is important to monitor and address rising risks of substance abuse, especially of deaths from overdoses and alcohol-related disease.
- Generally, suicide rates rise as the economy declines. The disastrous near collapse of the American economy, the associated job loss and struggle to survive contribute to what has been called “a perfect storm” for suicide. This will need to be monitored carefully, and if rates rise as many expect, extra efforts will need to be devoted to suicide prevention.
- As noted previously, tremendous efforts have been made to provide public information including remarkably good advice about how to weather anxiety and stress. However, there are important questions about who the tip sheets and public service announcements reach. Is it only the educated population? Do there need to be different approaches to reach poor, disadvantaged, socially estranged populations, who are particularly hard hit by the pandemic? And does the good advice being offered need to be more tailored to particular populations taking into account different developmental stages, lifestyles, levels of education, regular sources of information, etc.?
- It has become entirely clear during the pandemic that the closures of schools, houses of worship, senior centers, social service provider organizations and more create mental health challenges. Joint efforts between the behavioral health system and other services systems are needed to identify cooperative ways to contain the psychological and spiritual fallout of the pandemic.
- It is particularly important to find ways to help people deal with death and/or in grief without traditional ceremonies—bedside vigils, funerals, graveside gatherings, comforting social events, and the like. Are mental health professionals prepared to provide help? Enhanced partnerships with spiritual leaders would probably be beneficial.
- This unique pandemic and the responses to it create a broad range of research needs and opportunities. How much relapse takes place? Do the prevalence and incidence of mental and substance use disorders increase? How much and what forms of emotional distress do people experience? How extensive is resilience and adaptability? Do the programmatic initiatives work? What are the benefits and shortcomings of tele-mental health services? Are there implications regarding the integration of behavioral and physical health? Do alternative reimbursement models created for this emergency contribute to continued service and the survival of service providers?
Getting Ready for the New Normal
Hopefully, the stringent public mental health measures that are designed to contain COVID will phase down in the next few months. What then?
The pandemic has revealed—once again—the social fault lines and the consequences of economic, racial, and health disparities in America. An enormous proportion of the American population—most of whom are not officially poor—lives from paycheck to paycheck; they do not have enough in savings to cover necessities for even a couple of weeks. Many live on the edge of homelessness. And a very large number of Americans do not have adequate health insurance and have no coverage at all if they lose their jobs. Obviously, this makes their lives difficult. It also affects their behavioral health negatively and may contribute to rising suicide rates, drug overdoses, alcohol-related deaths (the so-called “deaths of despair”).
Unquestionably, a major social task of the recovery from the pandemic will be to tackle disparities and the social determinants of behavioral health in a serious way.
With regard to behavioral health specifically, we can expect that the psychological fallout of the pandemic will not suddenly come to an end when sheltering-in-place stops. Some psychological effects will linger, and some will emerge when people are able to shift from the struggle to survive to an effort to re-establish normal lives. There may well be increased need, and demand, for behavioral health services.
Will behavioral health providers be able to meet the demand? Lack of capacity in America’s mental health system and shortages of qualified behavioral health personnel are longstanding problems. They may get worse.
Funding of behavioral health services will certainly be a problem going forward. Behavioral health providers rely heavily on Medicaid—a political football before the pandemic that is likely to be so again especially with a presidential election coming up. They also rely heavily on funding from the states, which are all going to move to cut their expenditures as the pandemic slows down, if not before. Cuts in funding to providers that are already at risk of bankruptcy will put the entire system in jeopardy.
There have been some remarkable changes made to the behavioral health system so as to preserve services that have been perceived as exceedingly important. Will these changes be carried forward? Will there be a greater appreciation of the importance of behavioral health services? Will changes in regulations—especially regarding telehealth and the assurance of financial viability—be carried forward or will government revert to reluctance to pay for tele-mental health and to suspicion that behavioral health providers don’t really need the funding they claim is vital?
The use of volunteers to provide social connections for people who are isolated has also been a very positive development. Hopefully, these initiatives will be sustained after the sense of urgency passes.
The private sector will also have an important role as people come back to work. Workplace behavioral health programs will probably be under increased pressure to address mental and substance abuse issues that affect productivity and personal life satisfaction.
Research about behavioral health during the pandemic has the potential to illuminate future developments as well as to provide the basis for preparing for the next pandemic. It should be used to guide the system forward.
Mental health advocates should begin now to identify the changes that ought to be preserved and be prepared to advocate for the fiscal and regulatory leeway that is needed to move forward.
Hopefully, after the pandemic ceases to be an emergency, the behavioral health community will be able to join forces to advocate for the overall system and the needs of the people it serves. Even in good times, behavioral health providers fight over the bones of governmental funding, each seeking to meet its own needs. And even in good times, mental health advocates have made themselves dysfunctional by engaging in ideological disputes that pit personal freedom against social protection. Hopefully, these disputes can be set aside and united action can be taken to progressively meet the behavioral health needs of the American population as goes on.
ABOVE ALL ELSE: PREPARE FOR THE NEXT TIME!
Michael B. Friedman, LMSW was Founder and Director or the Center for Policy, Advocacy, and Education of MHA of NYC until he retired in 2010. He continued to teach at Columbia University School of Social Work until he moved to Baltimore to be closer to his very special grandchildren. Now he serves as a volunteer behavioral health advocate with AARP of Maryland. He can be reached at firstname.lastname@example.org.