Introduction. It has been confirmed by a number of empirical studies that the outbreak of coronavirus disease (COVID-19) significantly affected the psychological well-being and mental health of the world population. Timely and effective psychological and psychotherapeutic support in this special period is in high demand. Therefore, the analysis of an actual experience of practitioners, their requests and difficulties in the patients’ management is needed.
Goal. To analyze the requests and challenges faced by psychologists and psychotherapists in the early stages of the COVID-19 pandemic, and to review strategies on how to address based on the global experience.
Methods. According to the purpose, an anonymous online survey for mental health professionals from Eastern Europe was conducted on March 14-16 2020 and analyzed. Based on the obtained results, a literature review and systematization of practical recommendations for psychologists and psychotherapists regarding the COVID-19 pandemic were conducted.
Results. Respondents (n = 145), predominantly women (90.3%), with work experience from 1 to 27 years (M = 8.1, SD = 6.02), were psychologists and psychotherapists in private practice (77.9%) or employed and in professional organizations. The majority (75.2%) reported that they were considering what modifications in their professional practice organization due to coronavirus disease should be implemented, and 35.9% had already implemented some changes. These were 1) a readiness to change the therapeutic setting (frequency of sessions, on-line); 2) reconsider the financial arrangements; 3) and request for additional knowledge, practical recommendations or supervision.
Conclusions. The inevitable changes due to the pandemic situation cause corresponding modifications in the organization of psychological and psychotherapeutic support. The main task of these modifications is to maintain the stability of therapeutic setting and to guarantee the availability of necessary assistance to patients in such difficult conditions as quarantine, financial losses, inability to meet face-to-face etc. Practitioners rely more on their own experience in the implementation of necessary changes, but highlight the urgent need for additional training and guidance from the professional community, including in the supervision.
The outbreak of coronavirus disease (COVID-19) in China in December 2019 and its rapid spread to other countries of the world in the following months have become fateful for many areas of life. Researchers from different countries provide evidence of a significant impact of the COVID-19 pandemic on the psychological state and mental balance not only of infected people and their families , but also representatives of the contamination risk group , residents of areas with confirmed cases , medical employees [4-6] and volunteers . Considering the published data confirming moderate and high levels of stress among the population [1,3-5], high levels of anxiety in general [4-6] and due to contact with a probable carrier of the virus , high level of depression [4,5], sleep disorders [4,5,7], low level of trust in the competence of doctors due to a lack of reliable information about the virus , exacerbation of psychopathological symptoms and psychological difficulties, which may persist after recovery , the authors rightly emphasize the urgent need for timely psychological assistance and mental health during this period [5,8-13].
A number of publications also offer new methods, approaches and models of practice designed to work in the current environment, such as: online services of psychological help and self-help , "Structured letter therapy" , crisis model of help online , remote version of the method of First Psychological Assistance , risk management model and individual stress management plan for health professionals "The Anticipated, Plan and Deter (APD)"  and others. However, what is partially kept out of these studies is the needs of the practitioners themselves, which arise during the direct provision of psychological or psychotherapeutic care in the context of the rapid development of the COVID-19 pandemic in the region.
The aim of the article is to highlight the results of an empirical study of the needs and difficulties faced by specialists in providing psychological and psychotherapeutic care in the early stages of the COVID-19 pandemic, as well as to propose a strategy to overcome them based on the world experience.
Materials and Methods
The empirical study was based on an online survey developed for psychologists and psychotherapists with the possibility of further quantitative and qualitative analysis of the data. Respondents of the survey were Ukrainian-speaking and Russian-speaking specialists from Eastern Europe, who practice in various psychological approaches, both in private practice and those who advise in professional institutions (mental health centers, educational institutions, etc.).
Development and Polling Procedure
The survey was held from 14 to 16 March 2020. An invitation to take an anonymous survey online for research purposes was posted on the Internet (ads on social networks and closed professional web pages, e-mail invitations). In Ukraine, the survey period can be described as a period of uncertainty, when quarantine was already applied to schools, kindergartens and universities (March 11), but general quarantine had not yet been introduced, and restrictions were applied only to mass events.
The questionnaire included a short cover letter at the beginning, where the objectives of the study were presented, and consisted of open-ended and closed-ended questions, which can be divided into four groups:
- professional data: country of professional assistance, experience of a psychologist or psychotherapist in years, specifics of employment (in an institution or private practice), the usual format of practice (live or online), psychological approach;
- observation over the subject of discussion and change in the behavior of patients as a result of reaction to the pandemic COVID-19 on session: whether patients speak about the dangers of coronavirus; whether new complaints or symptoms appeared, that made patients suffered; how experts interpret this;
- self-reflection on changes related to the coronavirus pandemic: whether the professional style or management of patients during counseling has changed; whether the pandemic has affected the number of new patients in psychological practice, what problems psychologists or psychotherapists face;
- further changes in practice: what temporary changes in setting or work are acceptable to practitioners.
As the respondents, who participated the survey are in practice in different countries the question "Are there any cases of coronavirus infection in your region (city, region)?" with answer options: "No", "Yes", "Yes, there are fatal outcomes", "I do not have enough information" was added to find a possible link between the location of the psychologist / psychotherapist and their answers.
Analysis of the study data included descriptive statistics, calculation of frequencies, percentages, and rankings using IBM SPSS Statistics 22 software. The chi-square independent sample test was used to assess whether categorical variables were related to the sample. Analysis of variance (ANOVA) was used to compare three or more groups (categories) on metric variables (years of practice).
Responses (n = 145) were obtained from 131 women (90.3%) and 14 men (9.7%), with experience as a psychologist / psychotherapist from 1 to 27 years (mean M = 8.1, standard deviation SD = 6.02, mode Mo = 5, median Me = 6).
Usually, psychologists and psychotherapists indicated one country in which they practice, especially in the case of private practice, mainly Ukraine (53.1%), Russia (19.1%), Poland (5.7%). However, some noted a whole list of countries, adding remote places where their patients live, with whom specialists work online: USA (4.1%), Germany (4.1%), Italy (2.6%), Belarus 2.1%), Israel (1.5%), Finland (1%), England (1%), and other countries (5.7%).
Respondents said that they usually practice live face to face (42.1% exclusively in the office), and 57.9% work with clients both in the office and on the Internet (8.3% only remotely, online).
Almost a third of them are employed in certain institutions, psychological centers or mental health organizations, 77.9% work with patients in private practice. Some of them combine (7.6%) and work in both areas.
Those professionals who work in private practice more often combine online and face-to-face counseling (59.4%), by contrast with those who are employed in organizations that mostly (75.5%) work face-to-face (χ2 (4) = 23.17, p = 0.000).
Among those who work privately, the psychoanalytic approach was more common (35.6%). And within organizations, cognitive-behavioral therapists (24.2%) and those who combine different psychotherapeutic methods predominated (eclectic approach, 21.2%) (χ2 (16) = 25.71, p = 0.005).
Regarding the peculiarities of practicing during the pandemic, among specialists in different areas of work 40% of CBT therapists reported that their technique and style have already been partially modified due to the situation with COVID-19, while Gestalt therapists (35%) and psychoanalytic psychotherapists (42, 9%) answered that the effect was insignificant (χ2 (32) = 47.64, p = 0.03). The most experienced specialists (more than 9 years of practice) noted that their work style was partially influenced (M = 9.58 years, SD = 7.3) or was not influenced at all (M = 9.61 years, SD = 5.8). Slightly less experienced practitioners (M = 7.82 years, SD = 6) indicated that the impact was insignificant, and the least experienced (M = 5.65 years, SD = 3.9) answered that it was difficult for them to assess (F = 2.7, p = 0.03).
Almost half (46.2%) of specialists reported that there were no cases of COVID-19 in their region (city, region), 37.9% reported existing cases of coronavirus, and 11.0% of them confirmed cases of death from COVID -19. The remaining (15.9%) respondents said they did not have enough information about the pandemic situation in their region. It is interesting, that respondents who reported fatalities in their area of residence were more likely to think about further changes in the format of practice, or had already implemented certain modifications (χ2 (3) = 13.76, p = 0.003).
According to psychologists and psychotherapists, in the week before the survey, 50.3% of their patients talked about the coronavirus and its effects on health during consultations. In addition, 23.4% of them discussed this quite often, 12.4% of patients periodically initiated this topic. Among the probable causes, 44.8% of experts said that such behavior was caused by a real danger, 52.4% believed that it was somehow related to certain personality traits or psychopathological symptoms (for example, anxiety disorder or paranoid aspects of personality). Regardless of the answer to this question, the majority (75%) of specialists considered how the format of practice would change due to the current situation.
The more often the topic of the COVID-19 pandemic was discussed in the sessions, the more often it affected the style and technique of the specialist (χ2 (16) = 45.84, p = 0.000), and prompted psychotherapists not just to think about change but to modify the format (location, frequency of meetings, etc.) (χ2 (4) = 14.01, p = 0.007).
According to an empirical study, at the time of the survey with the first cases of COVID-19 75.2% of practitioners in the field of psychology and psychotherapy somehow ponder on possible changes in the organization of their work in the region in case of deterioration of coronavirus disease around. And 35,9% have already tracked or implemented some changes. By systematizing the short answers provided by respondents to the open question about the changes in practice that they observe, several key aspects were identified:
Preference for a remote format of psychological support
To continue their work, psychologists and psychotherapists had to change the format of live sessions for online or by phone when possible. Some reported that psychological training and group therapy also adapted the format to online meetings. Psychological educational lectures online on the situation with the global outbreak of COVID-19 have become in great demand.
Cancel therapy, reschedule appointments and / or change of settings
Due to the risk of infection with COVID-19, some specialists or their clients canceled live meetings: consultations, individual and group therapy sessions, psychological classes with children, community projects, etc. Due to the inability to organize online sessions for some clients (for example, lack of space in their home where other family members are present due to quarantine; due to limited method that cannot be reproduced remotely), this work was suspended for the quarantine period. Moreover, quarantine in educational institutions for children has made practice almost impossible for those professionals who are parents of preschoolers or schoolchildren. For the same reason, the psychological assistance to children, schoolchildren, their parents and teachers, that has already begun within the framework of school psychological services has become temporarily impossible. Practitioners noted that some patients were unable to continue their regular online sessions due to financial difficulties: the economic impact of COVID-19 and quarantine reduced the client's usual income. One of the expected risks was that the initially stable schedule became much more chaotic.
It is noteworthy that specialists from institutions and private practice tended to report different difficulties: restrictions on practice due to quarantine measures (closure or limited operation of institutions, difficulties in moving around the city) were more common for the first group, and difficulties with setting (including financial reasons) were more frequent for the second (cancellation of consultations, change of the schedule, financial questions).
Uncertainty, anxiety and fear are the main topics in the sessions
Experts have reported an increase in anxiety, panic and stress associated with the new coronavirus, both in patients who have been in psychotherapy or psychological support for a long time, and in those who have just applied. These experiences are most often associated with feelings of uncertainty, anxiety, fear of infection and fear of death.
The goals of psychological support are focused on overcoming
Improving a sense of security and coping with limitations, accepting the limits of personal responsibility and taking care of oneself have come to the fore in order to help clients. Ways to overcome psychological stress in a situation of possible isolation, work with a sense of alienation and exclusion in reality have become more meaningful than the analysis or exposure of these experiences. Because of these psychotherapeutic targets and goals, some experts have noted that their practice has become more proactive, using positive thinking ("What are your benefits of quarantine?") and drama methods (psychodrama, sociodrama), "CBT-like", which previously was not common to these specialists.
Emergency, urgency as an inherent characteristic of requests
Practitioners have noted an increase in urgent requests when current, past, or new patients ask for an urgent or additional counseling, which often sounds like a "matter of life and death." This may be due to a lack of resources to continue psychotherapy due to financial difficulties, lack of time and the risk of COVID-19 infection, which encourages patients to seek advice only in emergencies.
Three-quarters of respondents (75.2%) said they were considering further changes in practice that could occur if the situation with COVID-19 in their region worsens (Figure 2). The answers can be divided into three sections: changes in the setting (temporary suspension of practice in case of insufficient security, increase in the number of sessions, temporary change of consultations (for example, in a hospital, subject to safety measures), change of duration of consultations if necessary, items 1-4), revision of financial arrangements (deferred payment, charitable format of work with certain categories of the population, temporary reduction of the standard amount of payment for sessions, payment for goods or services, paragraphs 5-8) and the need for additional knowledge or supervision (paragraphs 9-10).
Analyzing the possible further changes in practice, noted by psychologists and psychotherapists, if the situation with the pandemic of the new coronavirus worsens (Fig. 2), we should pay attention to the following categories:
- changes to the setting that would provide greater security and compliance with quarantine requirements, on the one hand, and allow for further work, which is essential for certain categories of the population on the other hand;
- revision of our financial arrangements during the pandemic, which would allow clients to continue to receive stable and guaranteed psychological or psychotherapeutic assistance;
- the need for additional knowledge and supervision.
As can be seen from Figure 2, one of the top-3 trends expected by professionals is the demand for additional training on effective interventions for COVID-19 victims and their families. Today, a number of recommendations from professional mental and health organizations are widely disseminated through open web sources (American Psychiatric Association, APA) ; Center for the Study of Traumatic Stress, University of Unified Services ; Psychological Center of the International Federation of Red Cross and Red Crescent Societies RemotePsychologicalFirstAid ; World Health Organization, WHO , etc.). However, few of them have been translated into Ukrainian and Russian and, therefore, are not yet sufficiently known for the study area. However, in general, such a request from specialists can be interpreted as a critical recognition of the lack of knowledge, experience and specific recommendations for working in new conditions of uncertainty, it also indicates the high readiness of psychologists and psychotherapists for further professional development. Taken together, the need for additional training and the desire to increase the number of supervision hours can signal the need for clear instruction, support and guidance from professional communities in addition to individual development and innovation of specific professionals on how to deal with anxiety and other symptoms in a pandemic situation. In our opinion, this should be taken into account by the professional communities that regulate the activities of practitioners in a particular approach, and the heads of institutional psychological and mental health services in the country.
Regarding the experience of other countries, the Center for the Study of Traumatic Stress (Ursano R. and Morganstein J. and colleagues) published online a list of scientific articles and current reports with practical experience and recommendations under the general title "Coronavirus and EmergingInfectiousDiseaseOutbreaksResponse". In our opinion, the proposed English-language materials will be useful for professionals who provide psychological support and mental health, for families in quarantine, and community leaders. They include advisers  concerning:
- support of patients during quarantine and isolation;
- assistance to patients, who are concerned about coronavirus, for psychiatrists, clinicians or other staff;
- support of military families;
- self-support and self-care for health care workers;
- support of families and children at home;
- public communications on health risks and crisis messages to the population;
- preparing for and responding to mental health challenges.
However, since it may be impossible for the average Ukrainian practitioner to get acquainted with the cited materials due to the language barrier and the lack of currently translated materials in sufficient quantities, here are some particularly valuable positions from the studied advisors.
Thus, the chairman of the Committee on Psychiatric Care in Disasters of the American Psychiatric Association Morganstein J.  proposed a list of recommendations useful for patients and their families during an outbreak of infectious diseases:
- to give preference to reliable sources of information (information channels of the Ministries of Health, WHO);
- to teach and share basic information on how to reduce the spread of the disease in accessible and understandable language for children or the elderly;
- to correct misinformation and misperceptions;
- to restrict the viewing the media, turning to them only to make well-considered decisions;
- anticipate exaggerated reactions due to stress and resolve conflict situations.
The author also offers direct steps to minimize and overcome stress:
- to follow the usual routine procedures every day;
- to participate in activities that bring pleasure;
- to focus on the positive aspects of life and things that are out of control;
- to seek support from others;
- to engage in regular physical activity.
Morganstein J.  emphasizes that health care workers must also take care of themselves: meet basic needs (food, sleep, etc.), take breaks and rest, stay in touch with colleagues, friends and family, rely on to reliable information, to monitor their own level of stress, to understand the importance and honor of their work.
We suggest that, in addition to relying on the international experience of coping with the COVID-19 pandemic, local research would also be valuable in assessing local culture, mentality, and the effectiveness of specific methods and practical guidelines for maintaining psychological well-being. An analysis of crisis interventions in the experience of practicing certain psychological and psychotherapeutic approaches can also be useful: psychoanalysis, CBT, Gestalt therapy, positive psychotherapy, etc. Inter-theoretical discussions of practice and research of psychological and psychotherapeutic phenomenology during the pandemic of a new coronavirus disease are also relevant. However, the direct connection to researches, reviews and developed strategies of work with direct providers of psychological care and psychotherapy is expressly important in response to their educational and supervisory needs.
The inevitable changes due to the pandemic situation pose a challenge for the creation of appropriate modifications in the organization of psychological and psychotherapeutic support. The main task of these modifications is to maintain the stability of the therapeutic setting as much as possible and to continue providing the necessary care to patients in such difficult conditions as quarantine, financial losses, impossibility of face-to-face meetings and adherence to the schedule, etc. At the time of the study, it was found that practitioners rely on their own ingenuity and past experience in implementing the necessary changes, but both psychologists and psychotherapists note the urgent need for additional training and support from the professional community, including in the format of supervision and intervision. The results can be useful for professional organizations that regulate the activities of practitioners in a particular approach, as well as the heads of institutional psychological and mental health services in the country.
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