Never has the old cliché of “we are in it together” been more true. The problem with a pandemic such as Covid-19, is its predictable unpredictability. Even statisticians (very clever people, who are usually correct) could and still cannot predict the trajectory of this pandemic. The South African Centre for Epidemiological Modelling and Analyses with the Institute for Communicable Diseases estimated that between 87900 and 351 000 deaths are to be expected. Should the infection rate be 20% at least 500 000 people will have to be hospitalized. Should the infection rate be 40% this will lead to the hospitalization of 1 000 000 000 people. In South Africa 1500 infections so far have been reported.
But, we don’t know where we are going. We don’t know if lockdown will flatten the curve. But already, the pandemic has had far reaching effects on medical, social, financial and psychological level. It could either be individualistic or collective. According to Strong (1990) a pandemic actually causes two parallel epidemics: the epidemic of the disease, as well as a psycho-social epidemic.
Psychologists were to my mind ill- prepared for this pandemic. But then, who wasn’t? The science of epidemic psychology is not in the forefront of our minds, and there is a lack of knowledge regarding the impact of such a pandemic. Obviously in terms of Covid-19 specifically, there is a paucity of research. Strong (1990) says that the underlying assumption of epidemic psychology is that “Its underlying micro-sociology may well be common to all such diseases – or so shall I hypothesize- but is manifested in its purest shape when a disease is new, unexpected, or particularly devastating” (p. 250).
Our generation of South African psychologists has no personal or professional experience of a pandemic like this. Literature refers to epidemics like HIV in the 80’s; the H4N1 flu epidemic in 2005 and the Ebola outbreak in March 2015. But how many of us were affected by the last two epidemics? How many of us had to “accommodate” clients with H4N1 or Ebola?
But, Covid-19 has been uniquely disruptive. The U.N Secretary-General said that Corona is the greatest challenge that the world has faced since the Second World War – and this generation of psychologists didn’t experience the Second World War.
In December 2019 -with most of us on holiday- we heard something, very vague about a virus in China. There were more pressing things on our minds, like the weather, the new year, school fees, the Scope of Practice that still seems vague (is there one?), the economic situation in the country, the new car we may buy, the conference in Prague – should I or shouldn’t I? But by February things became more threatening. Then on 5 March 2020 (exactly a month ago) the first case was diagnosed in South Africa. In a matter of a month, our personal and professional lives have been turned upside down.
The pandemic amply supports Bronfenbrenner’s ecological theory (1994). The diagnosis of the 55 year old Patient Zero in China led to changes in the world. It had a profound effect not only on him, but also on his microsystem (his family, parents, siblings and work environment). The spreading of the virus then impacted on the mesosystem which surrounds the microsystem and indicates interactions between different role players in the microsystem, thereby playing a role in influencing the individual. The patient’s medical care, or work environment becomes relevant as the individual influences those contexts, but they also impact on the individual. The excosystem forms the third concentric circle. This system incorporates aspects such as mass media, community and welfare systems, extended family and even legal systems. The dynamics in the micro and mesosystems influences the excosystem, but obviously the decisions and interactions in the ecosystem have a reciprocal influence on the micro and mesosystems. The last system in the concentric circles is the macrosystem, which incorporates aspects such as societal beliefs, cultural aspects, laws and customs. The chronosystem indicates the patterns and events in the other systems and how reciprocal influences and transitions take place. The diagnosis of an individual therefore had severe impact, not only in his own context, but played a role in the functioning and dynamics of individuals and societies in a world- wide pandemic.
In the past week, from reading the news, Whattsapp and Facebook and yes, even a bit of scientific literature, I came to subjective conclusions of the challenges SA psychologists currently face.
Inaccessibility to our Health Professions Council/Statutory Board
The relationship between us as professionals and the Health Professions Council of SA has been precarious for a number of years. The need for guidance and communication, and even protection has during this past month been more crucial than ever. Psychologists in private practice as well as those in state organizations have been bewildered by questions such as “What is my responsibility?”, “Am I allowed to keep my practice open?”, “Is face to face therapy justifiable where there is a risk for spreading the disease?”; “Should I wear protective clothing?”; “What are the guidelines in terms of telemedicine/telepsychotherapy?” (Which is contentious in itself); “Does the welfare of the individual or society matter more?” and “What is an “emergency?”. Professionals would have appreciated more guidance, more directives and clearer answers from our statutory organization that claims to “guide the profession”.
In “Mental Health Protection and Psychosocial Support in Epidemic settings” the Pan American Health Organization (2016) acknowledges that epidemic preparedness focusses on the development of national plans, the necessary medical apparatus and surveillance of the disease and the economic impact of the disease. Psychosocial and mental health aspects are “conspicuously absent from such plans” (p.1). But, it is interesting that the PAHO’s Mental Health Unit already prepared guidance for mental health professionals in terms of psycho-social interventions during epidemics in 2011 (PAHO, 2016). The 2016 PAHO document (which is available online) provides a well-integrated synopsis of these guidelines. To my mind, the absence of guidelines -contributes to the bewilderment, anxiety and potentially consequential inability to manage this pandemic on psycho-social level. It seems that each practitioner does what s/he deems best in hospitals, psychiatric settings and that the plan of action depends on the individual manager or department. Psychologists need to hear the voice of their statutory organization more clearly in navigating the psycho-social consequences of this pandemic.
Catch 22- for academics
Staff at universities is currently in a catch-22 situation. The training of Masters’ psychology students is an important focus but currently the university has to take care of the safety of their students, staff and the management of academic and organizational matters. The Masters’ programs need to be re-planned. The fact that the pandemic “hit” South Africa basically at the start of the university recess complicated matters further. Academics are now consumed by attempts to work out when and how the second term should proceed; how to manage meetings and whether to implement Skype, Zoom and other forms of e-learning for lectures.
But “What about practicals?” Even though this may be an excellent opportunity for practical work by Masters-1 students, this also poses many ethical problems such as whether the students are academically and emotionally equipped to do frontline community work in high- risk areas, or in areas with a severe lack of psychological services. Who is responsible for the safety and welfare of these students? How does supervision take place? Can universities compel Masters’ students to do practical work in potentially dangerous situations?
On a research level, there are also more questions than answers. The current situation is fertile ground for much- needed research, but it is time-consuming to plan and execute ethically-accountable research. Some academics are therefore experiencing inner conflict and a catch- 22: assistance on community level, versus academic responsibilities.
Lack of training:
Most universities include crisis intervention in their Masters’ training, but it usually focuses on natural disasters, accidents, suicide-attempts, acts of terrorism or humanitarian emergencies. There is very little focus on crisis intervention in pandemics. Although intervention strategies may be similar, the dynamics of fear, attempts of explanation and moralization with the subsequent actions and reactions of individuals and societies as postulated by Strong (1990) need to be understood. The lack of research on epidemic psychology (and practitioners’ inaccessibility to scientific journals) poses serious problems for evidence-based practice during pandemics. One of the pillars of evidence-based practice is the scientific understanding of the phenomenon and/or context in which you work (Goodheart et al., 2006; Haynes et al., 2002). The Pan American Health Organization coined the term “Psychological First Aid” in 2009 and evaluated the evidence around Psychological First Aid and psychological debriefing concluding that “the former, rather than the latter, should be offered to people after a recent and severe exposure to a traumatic event” (p. 6) (PAHO, 2016). It is therefore questionable whether our training is 100% relevant in the current crisis.
Individual versus community welfare
Still using Bronfenbrenner’s model, it is evident that we have different systems at work within the pandemic. What is interesting to note, are the perspectives of all these systems. The individual feels s/he should protect themselves or that their needs must be met (walking the dog/cigarettes/being able to shop) and worries about his/her finances. The principal of the school that the individual’s children attend, is concerned about children’s welfare, but actually must also figure out how the curriculum will be met during a shortened school year. The individual’s line manager is concerned about financial loss and the economic burden and in the exco sphere the leaders of the country where the individual resides, need to negotiate and trade off the best interest of the country, and promulgate laws and regulations that impact on the individual in order to protect society, but that also protect the individual. The interactive roles of all these systems are therefore demonstrated.
I find it interesting that there is somehow at times an inability within the different systems to understand or to try to comprehend the point of view of the other systems. For examples: teachers may expect learners to do work at home, but some learners cannot access email, wifi or even computers; company managers demand a certain amount of time for employees working at home, but suddenly mommy/daddy also needs to take care of the children at home due to the schools being closed; individuals may experience the government regulations draconian and grudges it with a political flavor.
Even closer to home: Psychologists who are of the view that it should be ” business as usual” by means of Skype or Zoom (for which HPCSA has granted permission) find that some professional- indemnity companies are reluctant to provide coverage should there be claims against psychologists. Furthermore, some psychologists feel that they act in the best interest of the client by continuing to consult one-one with clients – and in the process they may exacerbate the spreading of the disease, or put their clients -and their own families- at risk. The question then becomes: in a situation like this, is the welfare of the individual supreme, or the welfare of broader society? And how is this balanced against our responsibility towards our clients.
Let’s face it: we are all going to lose financially – whether you are employed by the state (which will probably have to cut its budget severely), or a private practitioner (facing medical aids either unwilling to pay for telehealth or paying a reduced fee for practitioners using telepsychotherapy) or an academic (whose annual salary increase is being negotiated at this very moment). It seems as if the only companies that are benefitting are Netflix and manufacturers of sanitizers!
Even before Covid-19, SA’s public finances were unsound according to Financial Mail (12 March 2020). During the past two weeks panic selling on international markets saw the JSE all-share index to crash by 9.7%. It would be naive for us to think we will not be severely impacted financially by the pandemic.
While it must be welcomed that medical aids have approved telehealth, (even by the HPCSA, albeit temporarily), the approved tariffs are shocking. Psychologists still have their regular overheads (salaries, rent, electricity bills and all that). In response to the approved tariffs for telehealth, psychologists accuse the medical aids of targeting them, or unethical business practices, or not regarding psychological intervention as an essential service and not taking the best interests of clients into account. But we need to face reality: fifteen to twenty percent of patients who need to be treated for the disease will have to be hospitalized – anything from 500 000 to 1 000 000 000 people. Financial Mail (19 March 2020) indicates that 5% of Covid-19 patients will require ICU treatment and ventilation. In an interesting article by Mahomed and Mahomed (2018) in the South African Medical Journal, it was indicated that for the 2015/2017 financial year ( 4 years ago) costs in an ICU ranged between R 17 021 and R 26 954 per day (or higher) depending on the type of ICU facility care required. The implication for medical aids is obvious. At this stage it is unclear what the daily cost for a Corona-19-patient will be. Reality is that medical aids will have to work from a strict business principle in managing finances – with managing and containment of patients with Covid-19 as high priority. This includes the cancellation of all elective surgery. Medical schemes are legally compelled to have reserve funds, but if an outbreak continues for too long, they may need to dip into reserve funds. A second corona-remains a concern.
Private practitioners argue that medical- aid patients are entitled to psychological treatment. While that may be so, another question must also be asked: what psychological treatment is really needed at this point? Is it really necessary to do a school readiness evaluation now? The problems that little Margaret has been experiencing with her friends who are nasty towards her – does it justify telepsychotherapy? Peter and Sarah who has been unhappily married for 20 years – should telepsychotherapy commence now? Obviously there are clients who desperately need help. But other clients are not in desperate need. Should we consult with clients who are not emergency cases? What do you usually do with these clients when you go on holiday? Yes telepscyhotherapy can be justifiable – but we as psychologists we need to contemplate the consequences, risks and long-term implications. How do we continue post-Covid -19? What will the consequences be? How do we treat clients within a family system if we use telepsychotherapy? Telepsychotherapy and small children? What are possible ethical considerations?
This brings us to the concept of emergency services. The definition of emergency services in medical terms is actually quite easy. It can be seen as a life-threatening situation. The same definition in psychological terms is also valid, except we can add that an emergency constitutes when a client/patient’s symptoms place him/her at such a risk that should it not be attended severe mental health problems should result. Legal advice obtained by ReLPAG indicated that face-to-face contact would only be appropriate in highly exceptional circumstances. Emergency services to people in distress are therefore allowed, but the practitioners will be responsible to prove the extraordinary nature of the distress (ReLPAG newsletter, 3 April 2020). Yet, a lot of psychologists are still seeing clients at the practices with “business as usual”. Practitioners are therefore faced with the dilemma of the viability of telepsychology versus direct contact – and both these methods of delivery can possibly have negative consequences. ReLPAG also warns that practitioners can bring the profession in disrepute if a perception arises that the profession is used during the state of disaster to secure a flow of income. But, psychologists also need to financially maintain themselves and their families. It is a double edged sword.
Implications for the psychologists as mere human beings
We can use Bronfenbrenners’ model again, but putting the psychologist in the middle of the system. Amid of all this, psychologists are still individuals, spouses, parents, grandparents, brothers and sisters and friends. We need to manage our own anxieties, concerns, finances and responsibilities as being members of families. And also protect ourselves from the virus, and heed the national call of lockdown orders. We need to negotiate ourselves in our own micro, meso, macro and exco systems.
Psychologists working in the frontline in hospitals are naturally more exposed and in more vulnerable positions. More than 75% (some literature state 80%) of South Africa’s 56-million individuals rely on state hospitals, where there will probably be a shortage of beds or available ICU’s. This is where our colleagues will be severely exposed to contamination and to spreading the disease to close family members.
What is the point of these musings? The point is: Think ecologically. Think about the interaction between the different systems and remember that we as psychologists are part of a system, – on both an individual and collective level. Act ethically. Act responsibly. We have a responsibility towards our clients, but also to society, our families and ourselves.
So maybe, just maybe, the saying of “we are all in this together”, is not a cliché after all.
Take care of yourself and of the ones you love.
Esmé van Rensburg
(Academic, counselling psychologist and ordinary person in lockdown)
Disclaimer: The author wishes to confirm that this is her own opinion. It is not an academic article, but merely reflections and musings during a Saturday afternoon after a week of lockdown.
Bronfenbrenner, U. (1994). Ecological models of human development. Readings on the Development of children 2(1), pp. 37-43
Bronfenbrenner, U., & Cesi, S. (1994). Nature-nurture reconceptualized in developmental perspective: A bioecological model. Psychologial Review, 101(4), pp. 568-586.
Financial Mail (12 March 2020). How your pension, your business and SA’s economy are being infected by Covid-10. (available online).
Finanacial Mail (19 March 2020). Corona virus lockdown to leave SA’s poor high and dry (available online).
Goodheart, C.D. (2006). Evidence, endeavor, and expertise in Psychology practice. In Goodheart, C.D, Kazdin, A & Sternberg, R.J. (Eds). Evidence-based Psychotherapy, ( pp. 37-61), Washington: APA
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Mahomed, S. & Mahomed, O.H. (2018) .Cost of intensive care services at a central hospital. South Africa Medical Journal. Open access.
Strong, P. (1990). Epidemic psychology: a model. Journal for Sociology of Health & Illness, 12 (3), pp.249-258.
WHO. (2012). Psychological First Aid: Guide for Field Workers. WHO/War Trauma Foundation/Vision Global Internasional: Geneva. http://apps.who.int/iris/bitstream/10665/44615/1/9789241548205 eng.pdf
PAHO. (2012). Mental Health and psychosocial Support in Disaster Situations in the Caribbean. Washington. (available online).
PAHO (2016). Mental health protection and psychosocial support in epidemic settings (available online).