Challenges and recommendations for mental health providers during the COVID-19 pandemic: the experience of China’s First University-based mental health team

The first challenge was the lack of clear legal regulation regarding the scope of services, which increased the risk of becoming involved in legal and ethical dilemmas. The Mental Health Law of the People’s Republic of China is the only law that regulates mental health practice in China, and it endeavors to differentiate “psychological counseling” and “psychotherapy” [9]. The former refers to interventions conducted by counselors with individuals who typically have relatively minor or more developmental issues, while the latter refers to interventions conducted by medical professionals in a medical facility with individuals who have formal psychiatric diagnoses. Unfortunately, as referenced in the “Translator’s notes” in the English version of the law [10], nowhere is there a definition of what types of treatment are considered psychotherapy, or of what type of training is necessary to be qualified to provide psychotherapy. Nevertheless, the law’s intent is clear on the following points:

Psychological counselors shall not provide psychotherapy and shall not diagnose or treat mental disorders. (Mental Health Law of the People’s Republic of China; Chapter II, Article 23).

Further, it is explicitly stated that:

The second systemic challenge was related to the lack of standards for the regulation of professional qualifications. Since the cancellation of the counselors’ qualification exam in 2017, there has been no licensure that would standardize the qualifications of mental health professionals in China counselor [11]. Therefore, being a Counseling or Clinical Psychologist certified by the Chinese Psychological Society (CPS) is the only organizational approach that allows one to be considered a qualified mental health professional. When coupled with the lack of systematic clinical training in China in general, it was not an easy matter for us to assess applicants’ professional competence during the recruitment phase. In order to protect the quality of services, we therefore had to start small by primarily recruiting counselors who had received, at a minimum, systematic master’s-level training from BNU, with more than 300 h of direct service and over 100 h of supervision, or counselors who were trained abroad with similar requirements. Then, we expanded the recruitment to counselors referred by our alumni. We asked all the applicants to report their training background, including degrees, names of training programs, direct clinical hours, hours of receiving individual and group supervision, and experience in crisis intervention, and to provide one reference. While the desire of Chinese counselors to contribute was greatly appreciated, we ended up screening out approximately 61.5% of the applicants. All of the accepted counselors had a minimum of a master’s-level degree in Counseling or Counseling Psychology, with a mean number of clinical hours of 1153 and individual supervision hours of 140, as well as group supervision hours of 190. In addition, we provided intensive online group supervision to all counselors throughout the project, but especially during the first 4 weeks of service, not only to support the counselors, but also to monitor their performance through case discussion, role play, and other supervision strategies. We were able to identify problematic counseling behaviorss through supervision. For example, we communicated our concern and subsequently prohibited a therapist from providing services due to their lack of maintaining appropriate boundaries in hotline counseling. We also had to ask counselors to discontinue the provision of services when we detected that their personal issues were being triggered and interfered with their professional work.

Similar to the challenges in assessing counselors’ competence or possible impairment, it was difficult to recruit supervisors and assess their level of competence. We therefore only recruited experienced supervisors with whom we were already familiar. Such a recruitment strategy was able to provide reassurance regarding supervisors’ qualifications and competence, but it also limited the pool of supervisors. Due to the lack of standards in professional qualifications and regulations for supervisors, we only felt confident in collaborating with a very small number of supervisors, which was deemed necessary in order to lower the risk of unacceptably diminishing the quality of our services. A breakdown of our counselors and supervisors’ backgrounds and clinical experience is presented in Table 1.

Another significant systemic challenge was related to working with clients who were in imminent danger. All counselors recruited had been formally trained in suicide assessment and developing a safety plan, and had at least one course in crisis intervention. For the ones who participated in the hotline service or the crisis team, they additionally had to have some practical experience in dealing with crisis or suicide intervention. Identifying a person (typically a relative or friend) to serve as the client’s emergency contact is a widely accepted practice in regular counseling services. Usually, this information is collected before the first session. However, as is the case with almost all crisis intervention, when a client calls the hotline for help, the therapist does not have the opportunity to collect emergency contact information before the phone call. The therapist therefore needs to collect information from the client in crisis on the phone, which often is not an easy process. Given the nature of crises, the client’s sense of urgency makes it much less likely that they will be able to tolerate this sort of questioning [12]. When a hotline emergency occurs, a police or medical response is sometimes needed. This presented another challenge. The knowledge of the location of the client is critical, but the policy of employing mobile phone technology to ascertain the location of an individual might vary by country. In China, only in criminal cases can one get permission to use location technology. For mental health emergencies, a policeman usually goes to the listed home address when searching for a person who is posing a serious and imminent risk of suicide.

For example, there was one time our team received a phone call in the middle of the night, in which the help-seeker announced that she planned to kill herself in a few hours. We searched the caller’s location through the calling system, but later realized that the location only identifies the caller’s phone registration area, not her actual location at that moment. The hotline counselor was not able to get information regarding where she was right then, nor could the counselor get the caller’s name, personal id number, or emergency contact information. When the counselor sought guidance from the supervision team, the supervisor quickly called the local police emergency number and reported the imminent danger presented by the caller and consulted regarding how best to collaborate. The police collected as much information as possible to evaluate the emergency level, and the counselor at the same time continued talking to the caller, attempting to calm her and keep her on the phone until further help could be provided. Because the exact location of the caller was hard to identify, the police department had to collaborate internally, first to identity in which area the caller was located and then to allocate resources to implement the plan to rescue the caller, all of which took an understandably, but excruciatingly long time. Luckily, the counselor was finally able to calm that caller down and the caller agreed not to attempt suicide, and, in the end, the police no longer needed to search for the caller. This lesson taught us that hotline counselors should have knowledge about the national policy regarding the use of mobile phone location technology and the process of working collaboratively and effectively with law enforcement personnel, in case they find themselves intervening with a client in a potentially lethal crisis. We also recommend hotline counselors not to work alone; in case of emergency, they need to have some support already in place, so that the support system can help to contact other law enforcement or the hospital system staff.

The hotline services also encountered a few technical challenges. Due to the quarantine policy, counselors had to use their own cellphones, and work from home. The hotline system was designed to assign phone calls randomly to counselors’ cell phones. As a result, counselors’ cell phone numbers are only protected when receiving phone calls. If they spoke with a client in crisis and needed to call back, the callers would be able to see their personal phone numbers. To solve the problem, we employed a second hotline system provided by another telephone company, which can block counselors’ phone numbers under all circumstances. Additionally, it quickly became apparent that the telephone company would not always have enough workers or programmers to repair any technical failures that occurred during the quarantine. This led to some communication interruptions. Counselors on the hotline services team therefore had to inform callers at the beginning of every call that communication interruptions happen occasionally, so, should this occur, the callers would need to call back to continue the services. The person who receives the phone call, however, might be a different therapist. The caller can then decide whether to work with the new therapist or not. This was far from ideal. We found that communication interruption had some, perhaps obvious, negative influences on the therapeutic relationship. Both counselors and callers felt frustrated when they couldn’t get in touch after the interruption. Having to repeat their presenting problem was both tiring and irritating to some callers.

Working-at-home brought further difficulties related to documenting the overall workload. Some phone calls to the hotline were inappropriate for our counseling services, such as a request for a media interview, misdialing, or misunderstanding the purpose of the hotline. The resulting data generated by the hotline system consequently did not accurately reflect the real work of counselors. The same problem occurred with online counseling. To remediate these statistical errors, we chose to count the counselors’ work based upon the clinical notes that they generated.

Online supervision shared the same difficulties, but it also had its own unique challenges due to employing new technology. We used online video and audio conference software, like ZOOM or ZHUMU, to provide group supervision every day. Since ZOOM and ZHUMU do not have the function of providing statistics, we had to count the supervision hours manually. Moreover, the level and quality of engagement during the online supervision was difficult to ascertain. Initially, some supervisees chose to turn off the video camera to improve internet stability during supervision, but it was then difficult to distinguish a silent participant from someone who just turned off the video, and may have been doing something else, with only audio playing in the background. We therefore established a policy that required video, in order to address these concerns. Supervisees had to turn on the camera in the supervision in order to claim their hours. If a supervisee’s internet could not support video conferencing for the entire time, she/he had to inform the supervisor before the supervision session, and turn on the video at the beginning and toward the end, in order for the supervision hour to be counted.

The challenges we ran into in the systemic, resource, and technical aspects of our work highlighted for all of us of the issues related to social justice. According to our data through April 8th, 2020, 4.67% of hotline callers were under the age of 18, and 0.78% above 69; 10.54% of online counseling clients were under the age of 18, and only one client was above 69-years-old, comprising 0.58% of the total online counseling population. Access to and familiarity with computers, smart phones and the internet reflect privilege, both financially and educationally. Such privilege might also differentially impact an individual’s comprehension of mental health issues and related help-seeking behaviors. In addition, the availability of medical and referral resources differs significantly by region. When making referrals, we often ran into challenges in finding local referral resources. Help-seekers’ financial situation also limited their ability to access referral resources, even when they could be identified.

Clinically, we also faced challenges that are unique to this pandemic. A lot of help-seekers expressed practical dilemmas and a sense of helplessness due to the lockdown of public facilities and the dearth of resources. For instance, with the rapid increase of the rate of infection and the inadequacy of medical supplies (e.g., testing kits, hospital beds, medicines) at the outset of the pandemic, people were worried that they could not get the treatment they needed, especially the ones who were already experiencing symptoms. Patients with chronic illness who needed regular hospital visits could not get physical treatment in a timely fashion. With the COVID-19 infection spreading globally at this stage, some Chinese students and other Chinese nationals overseas who had made the decision to fly back were not able to do so due to the high cancellation rate of international flights. According to our clinical records, among the 150 callers from overseas, 30% of them felt isolated in their current situation, and 19% of them were worried about the frequently changing international regulations and policies regarding the pandemic. While working with individuals who were facing these practical dilemmas, our counselors consistently felt and expressed a strong desire to support them, but experienced a sense of helplessness at the same time. This trend was initially the anecdotal impression of the supervisors, but it was subsequently strongly supported by a review of the supervisory records. Consequently, supervisors were also found to have spent a substantial amount of supervisory time on their supervisees’ countertransference reactions. To support counselors when they had a sense of helplessness, most of the supervisors created a safe space during group supervision, and helped the counselors to process their feelings; supervisors not only acknowledged the difficult time we were all facing and therefore normalized their sense of frustration and helplessness, but also identified the appropriate and helpful counseling skills that the counselors had already utilized in supporting these callers. The supervisors also shared other techniques and resources that the counselors could use, and employed some relaxation exercises to help the counselors to increase their self-compassion and decrease their mental distress.

Another therapeutic challenge relates to the adjustment and limitation of using tele-media as a way to conduct counseling. During service provision, we encountered several suicidal calls and repeat callers who had severe mental health issues (e.g., bipolar disorder, clients with psychotic symptoms, and clients with long-term addiction issues). For counselors who were not specifically trained to deal with severe clients in a one session context, and who were also new to the hotline/online type of service, a lot of them felt a sense of incompetence, and worried that they were not effectively helping their clients. For example, 70% of the time in supervision, counselors were expressing doubts about their therapy skills (e.g., “Is it right if I respond in this way?”, “What else can I do to help?”, and “How should I respond when my client expresses very intense emotion”). We also fielded questions about how to get an accurate evaluation of clients’ current mental health status and form a comprehensive case conceptualization with limited nonverbal information and having such a brief time working with clients. For repeat callers, especially the ones who might have personality disorders or who were experiencing a manic episode, the call usually stirred up the emotions of the entire team. There was an inherent tension between providing sufficient support to these special help-seekers, while simultaneously protecting the emotional well-being of our counselors, including the need to address the potential for burnout.

The issue of protecting against counselor burnout emerged as a central concern in the therapeutic process. Research suggests that, after 3–6 h of uninterrupted work, a significant proportion of helpers report impaired functioning associated with elevated symptoms of psychological distress [13]. Large-scale surveys also suggest that helpers who experience elevated personal symptoms of psychological distress are unable to communicate or use their core skills effectively [14, 15]. These results are consistent with what we observed during our work on this project. We noticed that after receiving 3 to 4 intense calls over a 3-h shift, our counselors started to experience emotional exhaustion, and expressed more uncertainty about the interventions they provided. Not only did the intensive work in a single shift impact the counselors’ sense of well-being, the uncertainty of the overall duration of our work, the unpredictable amount of need, and the increased severity of the callers’ issues, all led to burnout and fatigue on our team, and made the work more difficult.

In the course of developing and delivering mental health services during the pandemic, we were also faced with several unique ethical challenges. The first challenge concerned issues regarding public media, which can be seen as both a blessing and a curse. As our service received more public attention, many from the media contacted our team for various interview requests. We considered this a great opportunity to increase public awareness of mental health issues related to COVID-19. However, when dealing with the media, many of them were overly interested in obtaining “in-depth” interviews with counselors that asked them to provide caller stories. Some even went so far as requesting us to film our counseling and supervision process. This revealed the public’s (and the media’s) general lack of awareness of the ethical boundaries regarding privacy and confidentiality issues within mental health services. In this process, our team had to repeatedly explain and emphasize the boundaries of privacy and confidentiality. We value the great opportunity to collaborate with the media to educate the public, but it was a struggle to find a balance between responding to the media’s wants and needs and protecting our clients by upholding important ethical standards. According to the Ethical Principles of Psychologists and Code of Conduct (“APA Ethics Code”) (American Psychological Association, 2017, [16]), ethical standard 4.07 makes it clear that psychologists do not disclose client information in public media unless “they take reasonable steps to disguise the person or organization,” and “the person or organization has consented in writing.” The team initially considered adding an item to the online informed consent form regarding whether or not the client would be willing to share their story. However, considering the vulnerable position clients are in when they seek help, this was viewed as potentially exploitative. Furthermore, because clients do not have the ability to view the final media product before it goes to the public, they would not have the chance to withdraw their consent if they were uncomfortable with it. Given these considerations, we had to turn down all the story-sharing requests, and ultimately felt confident that this was the right call. Despite this, some media tried to approach some of the counselors privately to solicit stories, and we had to make clear and repeated announcements to prohibit our volunteers and counselors from agreeing to such unethical interview requests.

The second ethical challenge concerned the practice of telepsychology. Due to the nature of our hotline service, we could not obtain written informed consent signed by both the counselor and the client. Furthermore, due to the lack of legal regulations, there is no equivalent in Chinese law to the Health Insurance Portability and Accountability Act (HIPAA), and therefore no platform has been designed to provide an encrypted communication environment for counselors and clients. This presents great threats to the security and transmission of client data with online counseling services, but, given the urgency of the circumstances and the implications for the Chinese public, and after considerable internal debate, we decided that we could not afford to allow this limitation to shut down our much-needed efforts.