Covid counselling

Guidance Document for Psychosocial Counselling for COVID-19 Positive Patients and their Family Members

Disclaimer:-

The advice and information given in this booklet is the best we can give based on current evidence based research and clinical experience in an Indian context. The advice offered is to aid counsellors in working with individuals in primary care settings to provide psychological education and to enable the family member or primary contact of the COIVD Positive patient to make an informed choices about protecting themselves and caring for the patient if he / she is at home/ Hospital. Group counselling or individual counselling can be taken as and when required.

ICMR, New Delhi

Guidance Document for Psychosocial Counselling for COVID-19 Positive Patients and their Family Members

1st edition-2021

© Indian Council of Medical Research
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How to use the manual?

The psychosocial counselling manual has been commissioned by the Indian Council for Medical Research (ICMR). The manual has been prepared by experts in the area of mental health from across the country. With COVID-19 being declared a pandemic and with more and more people being affected directly or indirectly, there is a need to provide psychological first aid to relieve their distress and prevent them from developing more serious mental health issues. As a first step, this manual outlines the counselling that can be offered to individuals diagnosed with or awaiting tests results for COVID-19, the family members of these individuals and frontline workers involved in the care of these individuals.

This manual is meant to serve as a guide to counsellors trained in MSW, MA/ M.Sc.Psychology, Anthropology, Health Sciences and have been trained in basic counselling skills. The manual outlines the minimum work that needs to be done with each group of individuals, and the counsellor can tailor these according to the needs of the individual.

The objective of this manual is to guide the counsellors in understanding and addressing the mental health needs of the individuals, who are awaiting results of COVID-19 tests, confirmed COVID-19 individuals, health care workers working in COVID hospitals and their family members. The counsellors can aid these individuals in getting reliable information and alleviate their distress. This manual gives a framework and an algorithm about responding to people when they are distressed and supporting them during these difficult times. In addition, it has details on how the counsellor can take care of themselves during the COVID-19 pandemic.

The manual has different sections that cater to different sets of individuals outlined above, including a general section on counselling skills. It is recommended that the counsellor read the relevant sections of the manual before meeting individuals, e.g., general counselling skills, plus the section addressing distress in healthcare workers. The counsellors need to be familiar with and prepare information about the COVID-19 pandemic from authorised websites like World Health Organization (WHO), Ministry of Health and Family Welfare (MoHFW) and Indian Council of Medical Research (ICMR) and can recommend the same to the individuals being counselled.

This manual must not be treated as an alternative to professional help. Whenever the counsellor identifies a serious mental health condition, they need to refer such individuals for professional help.

We hope you find the manual useful.

Guidance Document for Psychosocial Counselling for COVID-19 Positive Patients and their Family Members

TABLE OF CONTENTS

S. No. Title Page No.

Introduction

Basic Psychosocial Counselling Principles

Specific Principles to Provide Psychosocialcounselling for COVID-19 Positive patients

Specific Principles to Provide Psychosocial Counselling to family members of COVID Positive patients

Annexure-I

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ICMR’s Guidance Document for Psychosocial Counselling

Section I: Introduction

Background:

COVID-19, a communicable disease, has instilled fears in the minds of the community because of severe morbidity, mortality and efficacy of high transmission. Therefore, anxiety to self-infection and passing the infection to friends, families and co-workers emerges as an emergency. The constant fears of getting the infection also lead to the development of mental stress. People with an already existing mental health condition may feel even more distressed, and there can be an increase in their problems.

Need for Psychosocial counselling in current scenario:

Certain stressors are particular to a different group of people within communities, suchas families of vulnerable individuals and frontline workers. It is expected for affected (both directly and indirectly) individuals to feel stressed and worried. Some of these fears and behaviours are realistic,while many are just borne out of lack of knowledge, rumours and misinformation. Steps are needed toprevent social stigma and discrimination associated with COVID-19. Care has to be taken to promotethe integration of people who have been affected by COVID-19 without over-targeting.

While preventive and medical action is the most important, emergencypsychological crisis interventions for people affected by COVID-19 are also critical. This includesdirect interventions for patients and indirect for relatives, caregivers, and health care professionals. It will be essential to make a family member or primary contact of a COVID positive patient aware,provide correct scientific knowledge and provide psychosocial first aid in the form of emotional andmental support in a culturally appropriate manner.

Additionally, since large-scale Intervention is the present goal of guidelines rather than just enhancing clinical care of few mental health professionals, a feasible and straightforward intervention was realised. To deal with all the issues discussed, present guidelines were designed. The module adheres to some of the basic principles of psychosocial care as defined in previous chapters. In addition to that, a professional must be deliver counselling services informed and guided by five essential principles of psychosocial care, depicted in the figure below (Hobfoll, 2007).

Who can counsel or provide support?

Professional Counsellors
Masters in Psychology or Social Work with some counsellingexperience
Health care workers trained in counselling.
The trained individuals who wish to volunteer their services to support patients of COVID-19

2. Sense of Calmness

3. Buildin

1. Sense of Safety

Principles of Psychosocial Support

5. Connected

–

4. Self & Collectiv eEfficacy

ICMR’s Guidance Document for Psychosocial Counselling

Section II: Basic Principles of Psychosocial Counselling

The counsellor can use strategies to establish a good rapport with contacts and increase their motivation to change in terms of protective behaviours and providing home-based care.
Counselling should not be conducted in silos, and it should not be very structured because no two persons are identical. A client-centred approach should be used to address each person’s needs individually.

1. Goals of Counseling

Successful counselling aims to enhance the client’s coping skills by bringing change in the decision- making and behaviour changes specific to the crisis like the COVID-19 pandemic.

i. Encouraging safety, health and hygiene: There is a lot of confusing information available to the public right now. As a part of counselling, the counsellor can check what some measures of safety the client is taking are and help them with correct and reliable information along with its rationale. Secondly, the counsellor can emphasise the client focusing on taking care of the health of all family members by exploring first the methods the family is adopting and suggesting some options if needed.

ii. Reducing immediate distress: The clients might come to the counsellor with high distress levels.It is helpful when a counsellor is calm, patient, introduce self and the purpose for counselling,listen attentively, paraphrases and summarises the concerns to the client. A counsellor can alsouse active listening and ask open-ended questions to explore the concerns more. In high distresssituations, refrain from quickly jumping to provide a solution or moving away from the topic.

iii. Normalise the worry and developing healthy ways of addressing worry: Help clients understand that feeling negative emotions are natural and that they are not alone in this can help normalise the worry. Few statements like “Understandably, you are overwhelmed with the situation”, “I can see that you have been dealing with many worries about safety. Counsellors can help clients identify healthy ways of addressing these worries in the followingways:

a. Identify what are some specific aspects of life when they worry more and see what makes other aspects less worrying

b. Explore if there are times when worry is more than during other times and what brings the difference?

c. Help them identify some steps they have taken to deal with worries and which ones have worked more than others. Also, explore if they know of some methodstheir loved ones use to take care of worrying

d. Highlight that all emotions like worry are transient and that they shall pass

e. Suggest them to practice methods that have worked for them and create more ways that
are possible for them in their life context and based on their belief system

ICMR’s Guidance Document for Psychosocial Counselling

f. Suggest some research evidence-based methods like deep breathing, relaxation, mindfulness.

iv. Take constructive steps towards solving life problems: Clients who come with worries about life problems can also be helped with identifying more realistic, doable strategies that can help them solve the problem. Identifying the problem, some possible solutions, testing the pros and cons of each, and identifying the most probable option can be effective.

v. Increase supportive communication in relationships: Help clients identify the importance of open and supportive communication methods in the family. Encourage them to acknowledge efforts over outcomes to reduce critical feedback and help them use more supportive words.

vi. Help individuals cope better with their life challenges and suggest some appropriate ways to enhance coping.

vii. Generate a sense of realistic hope: This can be done carefully without silver-lining any conversation. It helps when a counsellor is realistic, calm and supportive, especially during difficult conversations.

2. COUNSELLING SKILLS

Counselling is a helping approach that highlights a client’s emotional and intellectual experience,such as how a client feels and what they think about the problem they have sought help for. Effective counselling would need the following skills:

i. Attending: It is beneficial for a family when they are attended to patiently. Their concerns are heard and spoken to gently and with respect. Statements like “I am here to listen to you”,”I would like to know more about what your concerns are”

ii. Active and carefully listening, “what person is saying” listen first to understand theirchallenges holistically.

iii. Using open-ended questions like “What is going on in your mind?”, “What about this situation brings worries to you?”, “What are some things that you find helpful in dealing with this situation” help elicit client’s information in a more detailed manner and helps them express themselves well. Additional close-ended questions with yes or no responses can be asked to seek clarity on specific issues.

iv. Demonstrating empathy: Helping clients feel supported in these difficult and isolating times is essential in counselling. A counsellor can demonstrate empathy through statements like “I notice that this is an extremely challenging time for you and your family”, “I notice your care and concern for your family through these steps you have taken”. Through this, the counsellor can connect with the clients and provide emotional support.

v. Assuring confidentiality: Providing clear idea to the client about confidentiality and their conversations will stay confidential. It helps clients to open up about their worries. It must be explained to the client that their conversations will not be shared, recorded or used for any purpose with anyone by the counsellor. Only in times of risk to their life or the life of another personwill the counsellor, with the client’s consent, share only the required details to an emergencycontact person or required authorities.

vi. Using simple language: Counselling is more effective when the counsellor can communicate in a simple language with the client, use examples relevant to their life, provide strategies possible in exercise by the client and explain concepts in the language suited to the client.

xii.

xiii.

ICMR’s Guidance Document for Psychosocial Counselling

vii.

viii.

ix.

xi.

Psycho-educating: This involves providing basic facts, information and reliable resources to the clients regarding their concerns. For COVID related information, they can be directed to resources like WHO, CDC, United Nations and Government of India. Ensure that you share information clearly, without any conflicting messages and politely check if the client has understood the information.

Assessing risks to safety and crisis management if required (through referral): Assessing if the client is experiencing any thoughts about harming themselves, wishing that things were over, or has any suicidal ideations or plans, also checking if there are risks due to violence or abuse, any use of substances that might put the client in the way of risk in any way. Based on the risk assessment, ensuring that the safety of the client is prioritised.

Addressing issues of stigma and discrimination, if any

a. Identify what kind of response do the neighbours have towards the person and their family members

b. Provide them with correct information about COVID spread and resources that they can take home and show to relatives and friends

c. Provide them with emergency contact numbers in case of incidence of attack or violence from the neighbourhood

Making suitable referrals and connecting with other support services: Counsellors can keep contacts of the following authorities in case of emergency and provide them to clients if needed:

a.Police /Medical / Women / De-addiction Support Centre/ Child /Geriatric Helpline Number /Mental Health Helpline Numbers

b.Counsellors can also identify specific needs of the clients and support them in identifying local support services for the same. These could include medical and grocery delivery numbers.

Problem-solving: Clients reach out to counsellors with many different problems. Counsellors can take them through a process of problem-solving through the following steps:

a. Identification and creating a problem statement.

b. Explore when the problem has existed and how severe it is

c. Identify who all are a part of the problem

d. The different steps that the client took to solve the problem before coming for therapy

e. Identify which steps were most effective

f. Assess the pros and cons of those steps and provide additional steps from your side if
needed

g. Explore how the client wants to try the steps again by focusing on the pros and reducing
the cons

h. Identify what the expected and realistic outcomes of these steps are

i. Help the client visualise the expected and realistic outcomes

Generating realistic hope and bolstering strengths: Every individual has an inherent ability to deal with life’s challenges and cope with them. Providing false hopes can do more damage to a person than a difficult reality. Counsellors can also help clients identify their strengths, resilience and help them tap into their support systems. Statements like-

a. “We can try our best to stay safe and take all precautions to keep ourselves healthy”,

b. “I am not sure of the answer to your question, but I can look up reliable resources and get
back to you”,

c. “What are some things you do or remember when you feel very low or beaten down” are
hope generating yet realistic statements.

Activity scheduling: Counsellors can help clients create a healthy routine by mapping their day. Following aspects can be ensured in the day:

ICMR’s Guidance Document for Psychosocial Counselling

– Sleep hygiene- ensuring time for an adequate routine sleep cycle of 7-8 hours.

– Avoid using electronic devices such as mobiles, laptops at least 2 hours before bedtime. The blue light from screens can interfere with melatonin (sleep producing hormone) production–making it
difficult to fall asleep. If the use of the device is unavoidable, work in ‘night light’ mode.

– De-stress before bed by taking a relaxing bath, reading or deep breathing.

– Physical activity in the form of exercise or yoga

– Deep breathing or progressive muscle relaxation

– Fun family time and connecting with loved ones over phone calls

– Scheduled time for work
The counsellors (or their supervisors) need to liaise with the medical officers / local authorities in charge of these hospitals to ensure the amenities mentioned earlier.
3. WHAT SUPPORT WILL BE PROVIDED

• Confidential and safe space to share one’s story: Counselling is a safe space where a counsellor listens and understands a client’s story from their perspective and makes an effort to help them move in the direction they desire. Safety is provided by being calm, respectful, confidential, non- judgmental, patient and supportive. A counsellor must attempt to provide an equitable position to the client in this relationship.

• Emotional support: Clients come to the counselling service with high distress. Providing them with emotional support helps clients feel less distressed and begin focusing on important aspects of their lives. Emotional support is provided through active listening, reflecting feelings, extending empathy and support.

• Connection to reliable information: Help client’s access information that is reliable and well represented. Based on the level of knowledge, educational background, language preference, nature of the concern, etc., the counsellor can choose and provide resources that will be most helpful to the client.

• Referral to medical and mental health services: As a part of the counselling process, the counsellor can perform a quick mental health screening and refer to adequate services if more intensive support is indicated.

• Referral to other support services: A counsellor must also be mindful of other kinds of support that a client might need and provide adequate referrals if needed, along with an explanation for the referral.
4. QUALITIES OF AN EFFECTIVE HELPER
Effective counselling occurs only when there is a mutual understanding between the counsellor and the client, which is brought about by sharing and exchanging ideas. The qualities of a goodcounsellor as following go hand in hand with good counselling skills:

i. Warmth: Being able to offer a nurturing environment is essential for clients to sharetheir deepest fears and worries about what is happening outside and within.

ii. Acceptance: Offering complete acceptance is needed to create a space of unconditional positive regard and take in a person’s whole story without passing anyneed for requirements or judgments on it.

iii. Flexibility: The ability to adapt to a client’s needs and requirements from the session and shift their perspective is essential to understand the frame of reference fully.

ICMR’s Guidance Document for Psychosocial Counselling

iv. Updating oneself: In the specific circumstances of this counselling requirement, a counsellor must be aware of the daily happenings, any medical or psychological research or resources that could support the client and any events they should know about.

v. Contextual understanding: The location of a person’s socioeconomic, cultural and present- day background changes their needs in counselling, without which the work can often feel disconnected or removed from the immediate need.

Basic rules:

i. Asking open-ended questions that require an explanatory response would be helpful. This encourages the contact to do most of the talking while the counsellor listens and encourage furtherdialogue.

ii. It would be important to affirm and support the contact’s statements of understanding and intention to change and sustain protective and hygienic behaviours.

iii. Focus on the contact’s strengths, efforts, patience, and other attributes. Subsequently, link and summarise the discussion that would help the contact to realise his/ her strengths to cope with quarantine, protection, test and care.

iv. Discuss behaviours and situations that he/ she would find difficult during this period.

v. Develop a strategy that helps guide the contact towards change by eliciting and reinforcing his/
her statements about it and helping in resolving uncertainties.

vi. Work towards change: Once rapport is established, attributes are understood, using the theory
of change; take a step towards desire, ability, reasons, and need to change.

vii. The counsellor reinforces these statements through reflective listening and supportive
statements.

viii. Finally, the counsellor is careful to communicate acceptance and reinforce the contact’s self-
expression throughout the session.

5. PRINCIPLES OF COUNSELING

Counselling is an iterative process, and the counsellor has to necessarily determine at every point in the client encounter whether it is vital to re-address and emphasise a given principle:

i. The counsellor will adopt and communicate a non-judgmental attitude, respecting that every individual has their views and perspectives and can make their own choices. Avoiding imposing personal beliefs, views and evaluations on the person seeking help.

ii. Confidentiality and safe space: The counsellor will attempt to provide a space where an individual is not worried about the possibility of any distressing information or their identity being shared with another party or with anyone outside the counselling space. Anylimitations to confidentiality will be shared with them.

iii. Empathy: The capacity to understand the feeling experienced by the client and communicating that is essential to establishing a counselling relationship and facilitating the counselling process.

6. DON’T FOR COUNSELLORS

i. Being inattentive and distracted in the session: A counsellor must ensure minimal distractions in conversations by talking in a quiet space, with no other people around, focusing only on the client and taking notes. Some ways to communicate attentive listening is through frequent nods, gestures and eye contact.

ICMR’s Guidance Document for Psychosocial Counselling

ii. Using medical jargon: Counsellors must ensure that they use simple and straightforward language to explain things. They will ensure that the client feels respected, understood and the counsellor’s message is received well.

iii. Misinforming the client (by providing wrong information): It is always better for a counsellor to say that they do not know and will find out that they provide half or wrong information. The counsellor must also ensure that their sources of information are valid and reliable and should not depend upon hearsay, popular opinion or inauthentic sources.

iv. Giving false hope or making false promises: A counsellor must refrain from providing assurances for aspects beyond their control or knowledge to minimise immediate distress. Statements like “everything will be fine”, “things will fall into place”, “I am sure you will be okay and all the troubles will go away” must not be used.

v. Imposing personal views or decisions on the client: The counsellor can tentatively provide hypothesis and options, but exercising them lies with the client. The counsellor mustnot reprimand or show upsetness to the client in case their suggestions are not followed.

7. CONSIDERATIONS FOR PHONE COUNSELLING

The section below throws light on special considerations for providing counselling services over the phone and also for adapting counselling skills to suit the medium of the telephone.
Before initiating the telephone counselling service:

✓ Laying out the scope of the service

✓ Design protocols for issues such as call duration and call back and follow up policy

✓ Develop protocols for sharing client confidentiality within the team members or within the
supervisory context

✓ Develop protocols for breaching confidentiality in crisis cases

✓ Develop formats for documenting call details

✓ Ethical framework for the service (confidentiality, anonymity, call recording, boundary
management, counsellor competence. crisis management, counsellor self-care etc.)

✓ The design flow of the call elaborates upon the entire process of telephone counselling, starting from picking up the call to ending the call. Develop appropriate verbiages for different stages of
this process

✓ Prepare referral directories and referral policies
Considerations for providing counselling services over the telephone:

✓ Familiarise yourself with the technology and its features before offering counselling services. Assess if the client needs familiarisation with the phone, he/she is using

✓ Clarify the scope of the help-line and your role to the caller

✓ Assure the caller of confidentiality of the service

✓ Practice two-way confidentiality with the client and counsellor identities being anonymous and
confidential. Do not share your contact details with the clients.

✓ Inform the client about norms of shared confidentiality

✓ Learn about assessing risks in case of clients who present with crises and also about protocols
for crisis management and referrals

✓ Be knowledgeable about the laws that apply to client concerns presented over the help-line

✓ Learn to adapt your skills of offering face to face interventions over the medium of technology

ICMR’s Guidance Document for Psychosocial Counselling

✓ In case of prank, sexual or nuisance calls, politely clarify the scope of the service and set limits with the caller

✓ Do not offer diagnosis or medical advice

✓ Follow ethical guidelines

✓ Watch for signs of fatigue, stress and burn out and practice-self care
8. ALGORITHM FOR COUNSELLORS
This algorithm is intended for Counsellors/Volunteers to be followed with clients during the pandemic.
Step 5: Clarify the myths about COVID-19
9. SELF-CARE OF THE COUNSELLOR/VOLUNTEER

• Centring: Prioritise own physical, mental, and social-emotional health through COVID-19

• Reflection: A counsellor/Volunteer holds a similar space to the client and is affected by the situation. He/she needs to take the time to process. Take the time to reflect on where they are, what theyneed,
and how to adjust to find the equilibrium.

ICMR’s Guidance Document for Psychosocial Counselling

• Self-awareness: It is the crucial first step before you can intentionally practise any other aspect of self-care.

• Routine: A semi-structured schedule allows people to make space for themselves, maintain time boundaries, and avoid burning out due to overwhelming responsibilities.
• Relaxation: Resting is a critical component in exhausting COVID-19 like emergencies to replenish and practice ethically and effectively.

• Support & Counselling: Overwhelming situations like the COVID-19 pandemic may lead to an increase in intense stress. Counselling may be a great choice in self-care. Be creative and utilise various ways, including digital platforms, to remain connected to family, friend, mentors and colleagues.

Conclusion:

As the pandemic wanes in the months ahead, these symptoms will subside some but may persist for others. To sustain and restore, continuous monitoring of the mental health outcomes of healthcare workers, individuals caring for patients with COVID-19 patients would be required. Counsellors/Volunteers will play a vital role in addressing acute symptoms such as depression, anxiety, and psychological distress during COVID-19 and in the post-pandemic phase.

Key Features:

• Build rapport: Greet and exchange introductions. Talk about prevention and thank them for their role in curbing the spread by reaching out to the health system. Explain the importance of isolation/ quarantine and how it is a service towards humanity because it will help in breaking the transmission.

• Give Brief Background about COVID 10 pandemic: COVID 19, a communicable disease, has instilled fears in the minds of community because of severe, morbidity a, passing the infection to friends, families and co-workers emerges as emergency.

• Responsive Services that can be imparted: Individual counselling, small-group counselling and referral

• Setting: Clinic / telephonic

• Target: Family members/ primary contact: Adults, Elderly, Children, Pregnant Woman, andPerson with special need

• Frequency of sessions: Multiple sessions might be required especially psychosocial counselling.

• Counsellor: MSW, MA/ M.Sc. Psychology, Anthropology, Health Sciences

• Expected Quality: Active listener, non-judgmental, empathetic

ICMR’s Guidance Document for Psychosocial Counselling

Section III: Specific Principles to Provide Psychosocial counselling for COVID Positive patients

1. INTRODUCTION

People diagnosed with COVID-19 may experience a range of distress during their course of illness varying from shock, fear, denial to anger, irritability, frustration and many more. Though overcoming distress adaptively supports and accentuates the recovery of the patients with COVID- 19,sometimes, distress becomes so overwhelming for few that it has a deleterious impact on the patients’ mental health, impeding recovery in many cases. Thus, an urgent need was realised for providing psychosocial care to the patients to optimise their mental health and well-being. Though psychosocial Intervention for managing disaster and other traumatic life events pre-exists, the global pandemic of COVID-19 has posed unique challenges to people, requiring reconsiderations to its effective management. For example, the difficulty in accepting the diagnosis, uncertainty about the course and progress of the illness, feeling ofloneliness resulting from being quarantined etc.

Establishing a Therapeutic Relation: The patient may meet a counsellor with a varied mindset (apprehensions, anxieties, misconceptions, fear etc.) which can be overcome by initiating a strong therapeutic relationship. An excellent way to build such a relationship is by counsellor introducing themselves to the patient and clarifying the specific reason for their visit or the goal of counselling, followed by initiating an open communication with the patient about their life in a manner they want to outline. For those who find it difficult to talk about themselves initially, the counsellor may introduce a variety of neutral topics to begin the conversation and gradually progresses on to the details of the patient’s life, which they would want to talk about. The aim is to create a safe therapeuticenvironment based on trust where the client achieves a sense of comfort in expressing their concernsopenly to the counsellor without fear of being judged or evaluated. Counsellor’s ability to be empathic, congruent, and accepting of the client unconditionally is considered essential but sufficient conditions for bringing any therapeutic gains in sessions (Rogers, 1951,1957).

Since counselling may be tailored based on the needs presented by the patient, it would be beneficial

o Quick Assessment: Pre-Requisite to Intervention
for them to perform a quick assessment, if the condition allows, on the following grounds.

a. Mental health needs include assessment of predominant mood state of the patient (sad, anxious, anger and so on), asserting severity of the mood state (mild, moderate or severe), estimationof one’s ability to deal with it (high or low self-efficacy) and perception of psychological support in life (present or absent).

b. The phase of recovery For this, we can classify the stages of the disease and its recovery into three broad phases (figure); unique needs of each phase may be incorporated sensitively into the counsellor’s Intervention. The assessment will be crucial in determining the extent and nature of psychosocial Intervention, varying across the three phases, each having its own goal and techniques.

ICMR’s Guidance Document for Psychosocial Counselling

1. Patient has just come to know about the onfirmationof COVID-19

Phase I Intervention
Achieving Stabilization and Psychoeducation

Phase II Intervention
Enhancing Coping & Addressing Specific

Adjustment Issues

Phase III Intervention Moving Towards Recovery

3. 4.

Patient is still dealing with the diagnosis and may or may not have resulting emotional turmoil

Patient is in the initial process of adjustments with changes brought by the condition

Patient in the later stage of adjustment process Patient is awaiting recovery followed by discharge

2. STEPS OF COUNSELLING

Phase I Intervention: Achieving Stabilisation & education

The chief goal of this phase is to assist the patient in dealing with some of the immediate emotional turmoil and distressful thoughts experienced due to the diagnosis of COVID-19. Additionally, this phase also intends to assist patients in dealing with uncertainty (primarily related to the nature of the illness, being quarantined and management of the same) by providing detailed health education. Chief techniques employed can be described as follows:

a. Validation of Feelings refers to recognising and accepting another person’s thoughts, feelings, sensations, and behaviour as understandable. Emotional support in the form of acknowledgement of feelings. Efforts can also be made to let patient self-validate by accepting theirthoughts, feelings, sensations and behaviour as humane and a normal process of adaptation to changesin life.

b. Acceptance of Feelings: The process of acceptance begins here with the counsellor listening out and validating the concerns/distress of the patient thoroughly. A counsellor can reduce the self-blame here by explaining that so many people worldwide deal with the same crisis and show hope by discussing the high recovery rate of COVID-19 than mortality and providing examples ofrecovery stories.

c. Management of Initial Emotional Turmoil: Patient with COVID-19 may feel emotionally overwhelmed at many points during recovery. However, the initial emotional turmoil can be frequent and severe, which can be dealt with in the following way:

– Letting it go: It can be explained that trying to push the emotion away has a rebound effect in
increasing the same and magnifying suffering.

– Emphasising its Phasic Nature: It is helpful to emphasise the phasic quality of emotion and its
temporary significance. Similarly, emotional upsurges may also appear very distressing at one point, but they will run their course and eventually be replaced by some other emotion. Thus, the patient can simply learn to ride with its flow rather than considering it as a permanent state of mind or acting on it with immediate impulse.

– Expressing Emotions helps an individual to be relieved of its impact. The patient can be encouraged to express themselves to their loved ones (virtually while maintain social distancing), writing about difficult emotions or channelising it through painting or other activities are also perceived to be helpful for many.

– Practising Relaxation: Deep breathing exercise can be introduced and practised. In this, a patient will be instructed to sit straight in a comfortable position with eyes closed and are instructed to take deep, slow breaths for 4 seconds, hold it inside for another 4 seconds, and exhale in 6 seconds through the mouth. Repeating this simple exercise for 10-15 minutes daily calms down the nervous system and relaxes a person significantly.

– Accumulating Positive Emotions: A step forward approach will encourage patients to engage
in activities that can bring them joy and happiness in life (within the premises of the hospital stay).
It could be as simple as talking to someone they love over the phone or video call,reading

– –

No Future Telling: Since the future is unpredictable by its very nature, it would non-productive, tiresome and excessively stressful to keep estimating it. Instead, a helpful approach would be focusing on going through each day one by one with the utmost vigour as possible.
Cope Ahead: This is for those patients who cannot remain preoccupied with future worries despite every attempt to deal with the same. A counsellor can introduce the skill of coping ahead. It simply means imagining the most future stressful situation and then trying to cope with the situation adaptively. The patient can rehearse in their mind what exactly they will do to cope effectively with those problems.

Fear of Death: With the rise in the mortality rate of patients with COVID-19, people are often surrounded with an intense fear of dying, which may further perpetuate the feeling of helplessness, can lead to significant anxiety, fear and typically reduces one’s willingness to invest in treatment. When faced with such concerns, it would be essential for a counsellor to validate their feelings of fear first and foremost. Given the pandemic situation, fear and panic are some of the most common people’s worries, and it is essential to acknowledge their feeling than deny it in any sense or distract self from the fear. Then the attitude of “neutral acceptance” should be propagated towards death, i.e.., death is a universal fact outside of one’s control, and therefore is neither good nor bad. A counsellor thus helps the person to acknowledge their feeling and accept it. Thereby, a person can be encouraged to further classify their death anxieties into those within their control and those outside control.

“What situations will lead to death?”;
“Will it happen soon?”;
“How the family will be devastated due to this?”

These are some of the examples of questions or anxieties for which there is no absolute answer. However, one can always choose to focus on what is within their control, i.e., trying their best to take treatment, keeping courage, hope, and willing to work towards the betterment of their condition. Such a stance helps a person to regain control and keep the hopefulness.

In mild to moderate disease condition, when counsellors can ascertain that there are good chances of recovery, it would also be beneficial to help patients understand that their death anxiety is the “worst-case scenario” and move the discussion towards all the factors that predict a good prognosis.
However, this approach should not be used in severe cases where there is a high possibility of death. Sharing “recovery narratives” is also a highly effective way to help patient instil hope.

ICMR’s Guidance Document for Psychosocial Counselling

humorous stories etc.
d. Health education: According to the patient’s level of acceptance, disease and the epidemic situation,

time for recovery, quarantine stay facilities, the treatment process will be objectively and truthfully explained so that the patient is well informed. Misconceptions will be handled at this stage. Adequate information will also be made available to the family members so that they also learn to deal with the situation and keep realistic expectations.

Phase II Intervention: Enhancing Coping & Addressing Specific Adjustment Issues

Towards the end of Phase-1, patient with COVID-19 comes well in terms of their diagnosis and are completely aware of the challenges associated with it and various ways of working through it. However, effective translation of discussed changes into day-to-day functioning becomes the main focus of Phase-II. Intervention at this stage is thus aimed at helping them deal with various adjustment issues due to COVID-19 and enhancing their coping skills. Descriptions of techniques are as follows:

a. Reducing Psychological Impact of Being Isolated: By strengthening physical health, creating new routines, virtually connecting to the loved ones, limiting information consumption onCOVID- 19 online, accepting the uncertainty of the situation while focusing on what is within thecontrol (like routine, habits) and doing as best as they can to handle the situation.

b. Dealing with Anticipatory Anxieties: Patient may often find themselves surrounded with concerns about the future by imagining a worst-case scenario which can escalate distress many folds. A counsellor can tackle this by:

Supportive Counselling: Throughout the recovery process, there could be many points when the patient losses hope and is emotionally overwhelmed to use any coping strategy. This can especially be the case when the condition of the patient is deteriorating. At such times, it is significant to provide supportive counselling to the patient so that they continue to make efforts to better the condition. Chief ways of doing this would be:

adverse outcomes. A counsellor can elicit some such unhelpful cognitions frompatients by simply

Praise Efforts till Now

ICMR’s Guidance Document for Psychosocial Counselling

This can be done by either providing such examples or letting the person watch such videos online where people have successfully coped with death anxiety and are fully recovered. Gradually, the counsellor may help people focus on their control box, encourage them to intensify efforts at what can realistically be done in a situation, and show a willingness to participate maximally in their recovery.

d. Managing Concerns towards the Well-Being of Family Members: Often, patient in isolation ward have realistic worries related to the well-being of their family members. Patients can be explained that they always make calls to their family members and be assured of coping with the separation and the pandemic. Additionally, talking about this concern to fellow patients also provides relief through shared support.

e. Enhancement of Coping Mechanism: This includes discussing the range of stress inoculation techniques. Here counsellor can simply introduce the types of coping mechanism people employ to deal with stress. It can be adaptive (like exercising, virtual socialising, performing pleasurable activities, actively seeking emotional support, positive reframing of the situation, using humour, practising religious prayers), leading to multiples benefits while it becomes maladaptive, it poses mental health challenges. For example, by self-blaming, denying the situation, avoiding the conflict, or socially isolating oneself. Based on discussion with the patient and a quick assessment ofhow he/she copes usually, a counsellor can elicit how and when the patient can replace maladaptive strategies with adaptive ones. Collaboratively, they can chart the outset of such helpful techniques and write somewhere as their coping toolkit, which can keep referring to whenever stressed out.

Note: If the patient has not taken vaccination and there are anxieties encircling vaccination, it would also be essential to address it in this phase.

f. Vaccination Related Anxiety: Counsellor may come across people’s inhibition to get vaccinated and any associated misconceptions. It is crucial to clarify the misconceptions by furnishing them with factual data. The technique of probability estimating can be used here where on a pie, a counsellor can assist a person in identifying the significant percentage of the reduced risk due to vaccination and the minor percentage of risk with which one decides. The person is encouraged to look at the brighter side of the picture than only dwelling on the disadvantages of vaccination. The person can further be redirected towards websites or appropriate knowledge/information, which show how many people in India and across the world have chosen to decide for greater health benefits. Some of their foremost anxieties on side-effects can be clarified, and if required, the help of a treating doctor can be taken in doing the same. In addition to motivational enhancement, it would also be essential to lay down the action plan of when and how they will complete their vaccination.

Phase III Intervention: Moving Towards Recovery

As the name suggests, the patient is prepared to continue their journey towards recovery, and counselling terminates at this phase. Core techniques employed are as follows:

–
– Reassurance
– Encouragement
– Reframing: Often, the way patients interpret the situation under distress is biased towards anticipating

ICMR’s Guidance Document for Psychosocial Counselling

asking, “how they are thinking or feeling about the situation?” Patients come up with a range of unhelpful cognitions. For example, saying that “I am doomed to die“, “I am completely helpless“, “I will never feel better“, “This is the end of the world“. Such thoughts can escalate existing anxieties and sadness. Thus, the counsellor can reframe the statements that reflect reality and are not biased towards anticipating adverse outcomes.

– Advice: Advice can be limited to reasserting techniques mentioned in core intervention for optimising mental health. However, offering advice to a dependent person can be gratifying but may deprive the patient of the opportunity to grow.

b. Practising Self-Compassion: Isolation in the COVID-19 ward brings a considerable time to the patient where they can endlessness engage in thinking about self. Often when in a low mood or anxiety, self-evaluations are quite severe and harsh. One may feel frustrated that the situation is not what he/she imagined, which may further build a sense of isolation – as if “I” were the only person suffering or making mistakes. It is beneficial for the counsellor to introduce here the ideaof self- compassion, which simply involves recognising that suffering and personal inadequacy are part of the shared human experience – something that we all go through rather than somethingthat happens to “me” alone. Thus, the patient can be asked to be more kind to self by knowing thatthey are doing as best as possible, and so is everyone, including doctors.

c. Building Hope: As discussed in the principles above, hope building can be a continuous process counsellor must engage in. It includes discussion on positive aspects of life which appears unacknowledged otherwise, discussing new perspectives on the distress, a best-possible scenario that still lies ahead and may eventually be reached after overcoming this critical phase.

d. Termination: Ways of bringing out the changes discussed in the sessions are summarised and drafted as an action plan. Ways of dealing with relapse and stigma associated with COVID-19 is discussed. The patient is encouraged to follow through with the action plan whenever distressed. Their self-efficacy is strengthened towards recovery. However, they are also provided with details of all the local health emergencies if they find any distress too overwhelming to deal with. On this note, the session can be terminated.

3. CONCLUSION

To summarise, current guidelines aim to support the recovery of the patient in such a way that their immediate distress is normalised ad managed, their specific concerns are addressed, coping skills are enhanced, and hope perspective is instilled. To help counsellors remember the core techniques easily and quickly, the following acronym can be used: SPARC, which stands for Stabilisation, Psychoeducation, addressing Adjustment issues, Coping skill enhancement, and recovery.

It is important to emphasise that the techniques mentioned in the present guidelines under each phase constitute the Intervention’s core elements; the module does not follow a rigid sequential approach. A counsellor/volunteer may often find cross-over between techniques such that few techniques are more frequently used than others, few are simultaneously clubbed, or few may be reversed in order.

Thus, health care professionals are encouraged to modify, adapt and tailor their preset intervention approach based on guidelines described below to fit the ecology of the culture, place, type and severity of distress of the patients with COVID-19.

ICMR’s Guidance Document for Psychosocial Counselling

Section IV:
Psychosocial counselling for Family members/primary contact of COVID Positive patients

• Person-to-person transmission most commonly happens during close exposure to a person infected with the virus that causes COVID-19, primarily via respiratory droplets produced.

• Older adults or those with underlying chronic medical conditions may be most at risk for severe outcomes, and therefore anxiety for and among the elderly members of the family surfaces. Also, not having the opportunity to grieve also adds to the stress.

• The purpose of this chapter is to make a family member/ close contact of COVID Positive patient feel prepared and informed in facilitating their response role. It would be crucial that they know of local resources and services available for the sick person.
1. Introduction
Emotional distress and anxiety are common during pandemics such as the COVID-19 outbreak. There is an understandably increase in concerns of the family member/primary contact about contracting the virus due to its highly contagious nature. It is important to ensure that the patient and other household members are techniques, limiting its spread. If you are counselling a caregiver for someone with COVID-19 at home or in a non-healthcare setting, follow this advice to protect yourselfand others. The focus of counselling should be to enhance self-care in overcoming accumulated stress and grief in providers and practice self-awareness.

2. Concerns to be addressed: there is a need to

• Provide clarity on who is the contact and the level of risk

• Explain the importance of contact tracing

3. Definition of contact of COVID+ person

A contact can be any person (family/ friend/ co-worker) who, by the following definition, is involved in any of the following (MoHFW, 2020):

✓ Providing direct care without proper personal protective equipment (PPE) for COVID-19 patients

✓ Staying in the same close environment as a COVID-19 patient (including workplace, classroom,
household, gatherings).

✓ Travelling together nearby (1 m) with the asymptomatic person who later tested positive for
COVID-19.
Based on risk, there are two types of contacts:
i. High-Risk Contact

• Touched body fluids of the patient (Respiratory tract secretions, blood, vomit, saliva, urine, faeces)

• Had direct physical contact with the patient, including physical examination without PPE.

• Touched or cleaned the linens, clothes, or dishes of the patient.

• Lives in the same household as the patient.

• Anyone nearby (within 3 ft) of the confirmed case without precautions.

• Passenger nearby (within 3 ft) of a conveyance with a symptomatic person who later tested

positivefor COVID-19 for more than 6 hours.

ICMR’s Guidance Document for Psychosocial Counselling

ii. Low-Risk Contact

• Shared the same space (Same class for school/worked in the same room/similar and not having a high-risk exposure to a confirmed or suspect case of COVID-19).

• Travelled in the same environment (bus/train/flight/any mode of transit) but not having high-risk exposure.
4. Issues faced by that a COVID+ family member (CFM) or primary contact (CPC)
Make it motivational interviewing so that strengths/ weaknesses can be identified. Probe on following and prioritise what makes him/ her more anxious and what are the facilitators.

• Perceived self-risk and anxieties: Regardless of their health status, CFM/ CPC are likely to report distress due to fear and risk perceptions and fears about COVID 19

• Social distancing related: Physical distancing, self-isolation and quarantine and many times working from home are triggering reactions of isolation, loneliness, and loss of social contacts among the large number of people worldwide. A need to provide support, reassurance, providing valuable and adequate information, and solving practical issues will be required.

• Family Care Giving related: From care provision to the patient at home, there can be loss in empathy or what may be termed as compassion fatigues.

• Stigma &Discrimination related: There are mental health and psychosocial consequences of discrimination towards persons who have been infected and their family members, and there is a social stigma towards them

• Myths, Misconceptions, information seeking and getting correct information Identify needs on issues where information or counselling may be required

1. Knowledge about CORONA Virus, transmission, prevention (Use information from MOHFW website)

2. Caring for the patient at home

3. Psychosocial counselling to reduce distress and mental stress

4. Referral for expert opinion in case required

5. Steps of counselling:
The counsellor needs to encourage family members or contact the patient to identify the issues

and the support system. There will be a need to plan. The plan should consider

family members, their ages, co-morbidities and pets. Planning will be about protecting oneself and other family members and caregiving for the COVID patient. Counsellor isolation of the patient but with care and empathy.
There are three tasks for the contacts

The coronavirus has entered your home as someone living with you might have COVID 19. So you have three tasks:
Task 1: Help the member who might have COVID 19
Task 2: Protect yourself: at home: protecting yourself and other members

Task 3: Psychosocial Counselling

ICMR’s Guidance Document for Psychosocial Counselling

Imparting COVID situation knowledge: Aspects of isolation, being non-patronising about isolation, health, health condition, keeping active, maintaining a schedule
Psychosocial support: Networking-having digital connections and presence, connecting with near and dear ones, surprises, relaxing activities, keeping daily communication with friends, co-workers

Sleep Cycles: For sleep cycle changes, not sleeping well, provide psychosocial support.
Referrals: Refer to the expert in case of –Not feeling well, not responding to counselling, continued fear, thoughts of self-harm, uncontrolled anger, continued self-harm thoughts, family members informed about significant changes in behaviour.

1. Information on COVID- 19 and measures to strictly adhere for prevention of the spread of infection

2. Support and empower to connect to the hospital staff for regular updates on patient health and in cases not possible to be assured that the hospitalised person is in charge of the care and will intimate any information that the family may need to know.

3. Advise to regularly talk over the phone to the affected family member and share lighter moments and update of the family

4. Advising on preparedness towards measures to be followed once the family member comes back home from the hospital.

5. Advice on proper care and support and possible help-line numbers to address any concerns relating to patient care in case the patient is advised to be home quarantined

6. Advice on designating an individual for taking care of the responsibilities of the patient if possible and in cases not possible complying with all preventive measures

7. Minimising the interaction and maintaining physical distancing of the vulnerable group from the patient.

8. Advice on regular monitoring of their or other family members health for any symptoms related to COVID and referral to help-lines for support in case of any symptom for diagnosis and treatment

9. Support on dispelling any misconception and providing support against any possible stigma or
discrimination that they may be facing

10. General counselling on apprehensions related to the future of the family and referral in case specialised counselling is required to address anxiety or any other concerns that they may have.

Note: It is important that counsellors, patients, families and healthcare workers should familiarise themselves with:

I. local and national guidelines on safety precautions (as some of them may be asked by a treating physician to counsel a patient in person or visit the ward directly, even where this is not appropriate)

II. Materials distributed by the Government of India on handling emotional distress during COVID-19 are available in many languages on the respective State official health department’s website.

ICMR’s Guidance Document for Psychosocial Counselling

6. Conclusion
As of now, in March-2021, India currently has approved (EUA) two vaccines to prevent coronavirus disease,i.e. Covaxin and Covishield. Apart from vaccination, the best way to prevent illness is to avoid being exposed to this virus. The fear, spreading misinformation and grief about the disease creates mental health issues and anxiety amongst the close contacts. Hence systematically adhering to protective measures shall mitigate fear and anxiety. Understanding the complexities of anxiety and grief can be important for supporting patients, families, colleagues, and ourselves.

***

Annexure-I

How to prepare PowerPoint for Training of Trainers

The training module should be developed in the form of PowerPoint slides, which can be accessed by the trainer electronically or as flipcharts (depending upon the location of training).
To prepare a PowerPoint presentation that contains the summary of each chapter of the Psychosocial Counselling Manual.

The PowerPoint presentation must contain minimum words on the slide (preferably illustrated with pictures) and relevant text in the notes section below. The text information should be such that the trainer must cover that. Additional information may be provided as necessary.

A total of 10 slides can be prepared for each chapter
The general principles of the counselling should not exceed more than three slides. These slides are common for each chapter, with some customisation if needed.
The core message of the text of each chapter of the manual is to be presented in the remaining 5-6 slides.
The last slide should be a summary slide.
An official ICMR logo may be applied at one of the corners of the PowerPoint slide.

List of contributors:

Chairperson

Prof. B.N. Gangadhar

Ex-Director, National Institute of Mental Health and Neuro-Sciences, (NIMHANS), Bangalore

Co-chairperson

Prof. Shalini Bharat

VC & Director, Tata Institute of Social Sciences (TISS), Mumbai

Members

Prof. Rajesh Sagar

Department of Psychiatry, AIIMS, New Delhi

Prof. K Muralidharan

Dept. of Psychiatry & Deputy MS, NIMHANS, Bangalore

Dr Bontha V Babu

Head, S.B. & HSR, ICMR Headquarters, New Delhi

Dr Seema Sahay

Scientist G, ICMR-National AIDS Research Institute, Pune

Dr Janardhan N

Addl. Professor, Dept. of Psychiatric Social Work, NIMHANS, Bangalore

Dr Beena Thomas

Consultant, Social Scientist, ICMR-NIRT, Chennai

Dr Saritha Nair

Scientist-E, ICMR-National Institute of Medical Statistics, New Delhi

Dr Ravindra Singh

Program Officer, Division of NCD, ICMR Headquarters, New Delhi

Dr Vivek V Singh

Health specialist, UNICEF India

Dr Sumit Aggarwal

Program Officer, Division of ECD, ICMR Headquarters, New Delhi

Dr Atreyi Ganguli

National Program Officer, WHO India

Dr Heena Tabassum

Program Officer, Division of BMS, ICMR Headquarters, New Delhi

Dr Chetna Duggal

Associate Prof. School of Human Ecology, TISS, Mumbai

Dr Aparna Joshi

Asstt. Prof. School of Human Ecology, TISS, Mumbai

Dr K Chithra

Sr. Resident, Dept. of Forensic Psychiatry, NIMHANS, Bangalore

Mr Suhas.P. Shewale

Research Scientist, ICMR-National AIDS Research Institute, Pune

Dr Vandana Choudhary

Clinical Psychologist, Department of Psychiatry, AIIMS, New Delhi

Acknowledgement:

We gratefully acknowledge the following for their contribution in drafting the document: Administrative Work: Ms Aarti Chawla, Sh. Ved Prakash, Sh. Harish and Praveen Kumar, Ms Charmi Kohli, ECD-II