Introduction
The COVID-19 pandemic has led to substantial psychological impact in the United States and worldwide [
1‐
3]. For many individuals, mental health needs have been rising throughout the pandemic’s progression [
4], with adjustment-related impacts of quarantine, health anxiety, economic and financial stressors, social isolation, and more [
5,
6]. Aligning with preexisting epidemic and outbreak-related studies [
7‐
9], the COVID-19 pandemic has prompted greater anxiety and depression [
10], social isolation [
11], and risk for suicide [
12]. While the pandemic’s impact on mental health has been increasingly investigated, greater understandings of its impact on mental health services and delivery are needed from the perspective of mental health providers. Furthermore, and importantly, less is known to date about challenges providers community mental health (CMH) face in remote assessment and treatment of psychosis and suicide risk in the United States.
Suicide is a critical public health problem and leading cause of preventable death among individuals with schizophrenia spectrum and other psychotic disorders [
13], Bornheimer, 2020) [
14]. Data estimate the risk for suicide among individuals with schizophrenia spectrum disorders is over eight times greater than the general population [
15]. It is predicted that short- and long-term impact of the COVID-19 pandemic may disproportionately affect individuals with psychosis [
16] and given the potential for worsening mental health symptoms [
6], there are rising concerns of suicide risk within this population [
17]. As a result, it is essential that mental health providers gain skills to effectively conduct comprehensive suicide-risk assessments, formulate levels of risk, and deliver treatments and services to reduce risk and prevent death. Furthermore, CMH settings are well-positioned to engage in suicide prevention efforts as they are among the largest providers of outpatient behavioral health in the United States, and particularly so for clients with serious mental illness and psychosis [
18].
Service delivery has increasingly shifted to telehealth and virtual formats throughout the COVID-19 pandemic with notable impact on individuals seeking care, mental health providers adjusting to remote service delivery, and an increased need for mental health services [
19,
20]. In the United States in particular, the demand for mental health services have remarkably increased [
21]. Across the globe and within numerous individual contexts, there are varying perceptions about and experiences with virtual healthcare services among providers and clients. For some clients, virtual services increase accessibility to care, and for others, technology barriers have made care more inaccessible when face-to-face services are not an option [
22]. Among providers, there is a similar spread of virtual services being experienced as acceptable and effective in practice, yet also challenging given technology access and clinical barriers (e.g., not being able to observe certain nonverbal cues and less privacy) that may arise [
1,
23,
24]. One qualitative study exploring healthcare provider experiences during the pandemic yielded themes of a prevailing sense of helplessness, overwhelming workloads for providers, and increased mental health decline among clients [
25]. It is evident that providers have been impacted throughout the onset and progression of the COVID-19 pandemic. While the pandemic’s overall impact on mental health services is increasingly investigated, greater understandings are needed from provider perspectives regarding the impact on service delivery in United States CMH settings, such as perceived challenges of clients receiving treatment and provider challenges in workload, engagement, assessment, and treatment. The CMH context in the United States is particularly important, given many clients engaging in community-based mental health services reside in low-income, underserved, or rural areas with less access to technology [
22]. Additionally, there are gaps in knowledge about the pandemic’s impact on provider assessment and treatment of both symptoms of psychosis and suicide risk. In particular, the remote nature of service delivery likely poses complexities in client engagement, assessment of mental status and symptoms, and delivery of behavioral interventions.
Given ongoing changes in mental health service delivery and increased need for care, emerging research from the perspective of providers in CMH is particularly vital to inform clinical practice and future research aiming to disseminate mental health services in mental health service systems. The current study explored provider perspectives of mental health services and delivery challenges in relation to the COVID-19 pandemic with specific focus on providing services to individuals with psychosis symptoms and at risk for suicide.
Discussion
Literature of the evolving COVID-19 pandemic highlight an impact on mental health service need, utilization, and delivery (Ardebili et. al, 2020; [
25,
10,
19], Vizeh et al., 2020). Given the prediction that COVID-19 may disproportionately impact individuals with psychosis [
16], a population that is at greater risk for suicide in comparison to the general population (Adyin et al., 2019,Bornheimer, 2020) [
14], it is critical that mental health providers can effectively engage, conduct suicide-risk assessments, and deliver services to individuals with psychosis. As a result, greater understandings of the COVID-19 impact on services and delivery are needed from the perspective of providers in CMH with specific attention to challenges in assessing and treating psychosis and suicide risk. Data of the current study indicate CMH providers observed a greater need for suicide prevention, clients facing challenges with telehealth and virtual services, an increase in workload, and challenges with remote engagement, treatment of psychosis, and suicide assessment since the COVID-19 pandemic began. Provider responses to qualitative questions further underscore and expand upon the logistic, engagement, and clinical challenges emerging within the pandemic context.
Logistic challenges emerged as a theme including provider observations of clients facing technology barriers in remote service use, clients reaching out less to providers, some services not being offered remotely due to the need for technology, and provider challenges in engaging with clients due to limited technology. These technology challenges further reinforce the disparaging impact of COVID-19 with technology access for remote engagement with mental health services presenting an inequality gap [
33]. While many may have access to smart phones, computers, and reliable internet connections, clients engaging in community-based mental health services often reside in low-income, underserved, or rural areas with limited access to technology that is now needed for virtual services [
22]. Some providers shared that they tried to increase access by allowing clients to use their device to meet virtually with psychiatrists and primary care providers. Though providing a device for clients as a method of problem-solving aligns with social work values of compassion, justice, and beneficence, this is also unlikely a standard practice due to resources (e.g., availability of technology and cost) and provider time (e.g., increased caseloads due to greater service needs and staffing challenges). Beaunoyer and colleagues (2020) propose a multi-layer strategy to mitigate digital inequalities involving government, organizations, corporations, and communities. It is suggested that offering alternatives to technology (e.g., allowing a phone call visit instead of a teleconference visit which requires a camera and internet), increasing coverage and capabilities of networks, public funding for increased network access, and donating technology devices to low-income households may increase access to technology. It is also recommended to increase digital literacy with household, family, and community support for device use, tutorials and trainings, and adding digital literacy to public school curriculums.
Limited technology access also serves as a foundation for the rapport and engagement challenges that providers noted. This engagement theme includes provider observations of clients engaging less in services, clients facing challenges in remote engagement due to psychosis symptoms, and provider challenges in remotely building rapport with clients. Findings align with recent literature client and provider engagement challenges since the COVID-19 pandemic began due to technology and service access [
25,
34]. These engagement challenges are likely influenced and exacerbated by increased levels of social isolation during the pandemic, already an extant problem for individuals experiencing negative symptoms within psychosis (e.g., reduction in emotional experience and loss of volition; [
35]. It is also possible these challenges are influenced by variations in digital literacy, and service delivery organizations may benefit from offering training to their clients in how to engage with providers via smartphones and computers as they navigate online service system portals, audio and video telehealth sessions, setting up calendar reminders for virtual appointments, and more [
36]. If the technology gap can be improved by increasing access to remote services (e.g., offering both telephone and videoconferencing options for care) and training for clients to engage in remote services, providers could integrate greater opportunities for individual and group virtual engagement to foster a sense of community and belonging.
In addition to logistic and engagement themes, findings also revealed clinical and service delivery challenges. Providers described clients having increased agitation and anxiety, provider challenges with remote assessment, new tasks of assessing for COVID-related symptoms, and increased caseloads due to greater mental health needs in the community and provider staffing challenges. Assessment was a common theme in which providers shared difficulties in conducting mental status exams in relation to suicide risk and symptoms of psychosis, administering the Abnormal Involuntary Movement Scale (AIMS), and assessing for Activities of Daily Living (ADLs). For example, providers described challenges in assessing affect without seeing facial expressions, client experience and response to internal stimuli, and overall noted greater question evasion by clients. The challenges of assessing a client without being able to observe them are also echoed in recent literature [
24], and for those treating psychosis, observation of symptoms is an essential component [
37]. Related to service delivery, it was apparent that provider shortage was common due COVID-19 symptoms or illness, quarantine, and using sick time to manage stress and mental health,all of which increased workloads and caseloads.
Beyond troubleshooting technology barriers, findings point towards the need for support and training among providers who have been navigating challenges and practice unknowns in CMH settings and beyond. The COVID-19 pandemic arrived in 2020 with overwhelming demands for mental health providers and healthcare workers overall, raising concerns of trauma exposure, stress, and mental illness (i.e., depression, anxiety, and post-traumatic stress disorder) among providers delivering services [
38]. In the current study, providers shared that workload changes were challenging to manage and given it may not be feasible to hire more staff, strategizing for how to manage increased caseloads with bolstered support for providers to prevent burnout is essential. Burnout prevention approaches often involve self-care (e.g., sleep, breaks from work, movement), stress management (e.g., mindfulness, exercise), emotional support and professional mental health treatment [
39]. Such approaches can be integrated into service delivery settings like CMH, with the potential to improve provider support and quality of life [
40]. In addition to provider-focused strategies to prevent burnout, it is also imperative for agencies and organizations to foster supportive environments for staff. For example, establishing health and safety protocols with monitoring for mental health, efforts to de-stigmatize provider mental health, collaborating with providers and staff on what is needed to improve working conditions, and mindfulness of the disproportionate impact of COVID-19 on poverty-impacted individuals and racial and ethnic minority groups [
39]. For specific focus on mental health and trauma, Psychological First Aid for mental health providers may be beneficial to implement in CMH settings as suggested from prior pandemic-related studies (e.g., SARS) focused on healthcare workers [
41].
Though providers undergo training in educational programs, during licensure obtainment, and continuing education, most focus on in-person engagement and service delivery as opposed to telehealth and virtual forms of service delivery. An international survey (
n = 1206) across 100 countries revealed that approximately 49.1% of clinicians reported that they had not received any training in teletherapy (i.e., telephone and videoconference; [
42]. In the United States, studies prior to the COVID-19 pandemic show approximately 25% of clinicians used telehealth with a lack of available training being cited as a barrier [
43,
44]. Therefore, it is essential for trainings to be established and implemented for providers to gain skills and confidence in remote engagement, assessment, and service delivery including the nuances of mental status and emotion expression. Assessing for symptoms of psychosis and suicide risk, particularly of focus in the current study, are challenging to do remotely (e.g., AIMS) and likely require additional clinical training and skills. In addition to the shift towards virtual service delivery with clients, many providers have also navigated a shift to virtual supervision [
39]. Therefore, approaches to practice and supervision must be adjusted with space for real-time processing of changes and subsequent modifications as needed. Overall, new and additional training for clinicians both in the context of continuing education and also provided at service delivery sites like CMH may alleviate some of the clinical challenges faced resulting from telehealth and virtual service delivery.
Limitations
First, the findings emerged from a small sample of providers in a CMH setting of a northern midwestern region of the United States. Thus, social work provider perspectives in the sample may differ from providers of other disciplines, other mental health settings, and geographical areas across the world. It is essential for future investigations to examine a range of experiences and impacts of the COVID-19 pandemic among mental health providers across characteristics, contexts, and settings. Second, providers shared observations of client challenges within the pandemic context who were reportedly engaged in CMH services, therefore emerging themes of pandemic-related challenges may differ for clients who are not engaged with services. Third, providers most often identified as female, White, and non-Hispanic/Latinx, thus the sample is not representative of all providers across the United States and the globe. Fourth, although themes did not emerge in the data about positive changes or outcomes in relation to the pandemic, our interview did not specifically ask or probe for positive aspects of the pandemic context. We did, however, have an open-ended question asking for any additional observations or experiences at the end of the interview, with no positive responses emerging. It is important to be mindful that while many challenges emerged, it is also very possible that there are benefits to the pandemic context and virtual service delivery for providers (e.g., some people may enjoy working remotely from home or not having to drive to work). Lastly, data were qualitative, cross-sectional in nature, and collected between November and December of 2020. As a result, statistical investigations of findings did not occur and fluctuations or patterns of provider experiences were not examined across various points of time and waves of the COVID-19 pandemic.
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