Using guidance from disaster psychiatry to frame psychiatric support for cancer patients during the COVID-19 lockdown.

From the field of disaster psychiatry, five principles for mass trauma intervention are safety, calming, connectedness, self‐efficacy, and hope.

COVID‐19 is an extreme event for cancer patients.

Concurrent threats of cancer diagnosis and community spread of COVID‐19 create significant stress and distress.

The five principles provide a useful framework for helping cancer patients cope with stress in the era of COVID‐19.

The five principles may also apply to crisis inflection points along the cancer care trajectory.

SAFETY, CALMING, CONNECTEDNESS, SELF‐EFFICACY, AND HOPE FOR CANCER PATIENTS DURING COVID‐19

Providing effective psychiatric support for cancer patients during the COVID‐19 pandemic benefits from guidance developed in the past 20 years, following natural and anthropogenic disasters. In 2004, disaster mental health experts convened a symposium to examine the scientific underpinnings of early psychological support for communities exposed to extreme events. The product of their endeavors was a landmark paper entitled, “Five essential elements of immediate and mid‐term mass trauma intervention: Empirical evidence.” The five principles, each grounded on a breadth of scientific evidence, are safety, calming, connectedness, self‐efficacy, and hope.

Each of the five is psychologically beneficial. Collectively, they assist survivors to cope with the stressors of large‐scale, potentially traumatizing events. This framework was adapted for psycho‐oncology consultations with cancer patients at Sylvester Comprehensive Cancer Center during the initial online encounters with patients after shifting to telehealth delivery of care.

COVID‐19 AS AN EXTREME EVENT FOR CANCER PATIENTS

For cancer patients, the arrival of the COVID‐19 pandemic has been an extreme event. In addition to their cancer diagnosis, our patients tend to be older and frequently immunosuppressed, with multiple underlying conditions, the precise attributes that amplify risks for severe or fatal COVID‐19. COVID‐19 is easily transmissible through direct patient contact, touching contaminated surfaces, and airborne spread via bioaerosols and droplet clouds. , Viral spread from asymptomatic or presymptomatic individuals has been extensively documented. Cancer patients must take extraordinary, life‐changing precautions to prevent infection and illness. Understandably, many patients were highly distressed during the initial online consultation sessions, trying to adhere to their cancer therapy regimens and supportive lifestyles in a COVID‐19‐transformed world.

COVID‐19 STRESSORS AND A FRAMEWORK FOR COPING

Helping cancer patients deal with the compounding stressors of their cancer treatment and the overlay of COVID‐19 required a new framework—and the five principles provided the heuristic needed for devising a practical approach.

Reissman and colleagues envisioned the five principles as dynamic pathways. , Think of safety, calming, connectedness, self‐efficacy, and hope as desirable endpoints. When COVID‐19 arrived in the community, so too did danger, distress, physical distancing, helplessness, and despair. So, the mission of early mental health and psychiatric intervention is to move cancer patients along five pathways to help them cope with COVID‐19. Effective intervention places cancer patients who are grappling with COVID‐19 on a glide path (a) from perceived danger to perceived safety, (b) from fear to calming, (c) from isolation to connectedness, (d) from helplessness to self‐efficacy, and (e) from despair to hope. These principles are helpful in a practical sense as well as being psychologically beneficial.

COPING WITH COVID‐19: FIVE PRINCIPLES FROM DISASTER PSYCHIATRY

Here is how the framework was applied within a series of telehealth sessions. We began the session by identifying urgent patient needs and prioritizing these for immediate solution. At that time, we also gathered information regarding perceived sources of stress related to COVID‐19. During the first weeks using this framework, we compiled a list of stressors reported by the patients; the expanding list was used to provide examples and stimulate discussion about stressors with each subsequent patient encounter (Table 1).

TABLE 1

Stressors for cancer patients during COVID‐19 quarantine

Fears of acquiring COVID‐19 infection and illness

Fears about their own health

Fears about family members becoming infected with COVID‐19

Fears about being infected by family member who had to work during the pandemic

Fears that their physical symptoms (eg, cough, sore throat) might be COVID‐19

Fears about being at elevated risk for severe or fatal COVID‐19 (older age, cancer diagnosis, immunocompromise, other underlying conditions)

Fears about receiving treatments in hospitals or clinics due to perceived risk of contracting COVID‐19

Limited quantities of survival supplies

Lack of access to face masks and gloves

Not having access to nutritious food during the quarantine

Concerns about family members not having enough food or supplies

Information regarding COVID‐19

Distress related to excess time spent watching news about COVID‐19

Misinformation and disinformation/conspiracy theories

Insufficient information regarding prevention of COVID

Lack of trust in the media and politicians

Technology limitations

Limited access to internet, smartphones, tablets, PCs, and social networks

Difficulty navigating websites and applications (especially older adults who needed to use cellphone rather than laptops)

Difficulty connecting to loved ones in other countries

Financial concerns

Financial losses (eg, money lost in the stock market)

Job loss/unemployment

Loss of health insurance due to job loss

Confinement‐related stressors

Disruption of daily routines (physical inactivity, inability to attend PT, disruption of sleep wake cycle)

Reduced social interaction

Reduce physical contact with loved ones

Being enclosed

Disrupted access to health care

Concerns about accessing routine care (especially appointments in which a physical exam is required)

Concerns about access to cancer therapies

Concerns about access to home health care and PT

Concerns about their physicians being targets of discrimination, bullying or physical violence

A portion of the initial session used problem solving to identify, list, and triage patient concerns. Patients selected one priority solvable problem as a focus for the session, followed by brainstorming, identifying helpful strategies for managing the problem, and developing an action plan. Then, we embarked on the five principles.

Promote a sense of safety

Infectious disease outbreaks can challenge individuals' psychological sense of safety, leaving them worried about infection and death. Promoting a sense of safety and comfort can reduce distress and minimize psychological consequences. Strategies included providing education about how COVID‐19 spreads and actions that individuals can take to protect themselves. Science‐based information and resources were provided.

Promote a sense of calming

This principle was especially amenable to guided, participatory practice via telehealth. Calming strategies make a stressful time feel less turbulent. The psychiatrist guided patients in deep breathing and participated with patients in listening to a brief mindfulness podcast. Psychiatrist and patient practiced a “grounding” technique, redirecting their focus toward non‐distressing things in their environment that they can see, hear, or touch. Patients were advised to refrain from watching excessive media coverage about COVID‐19 and instead to stay informed through once or twice daily news updates.

Promote a sense of connectedness

Population‐level mitigation strategies—stay‐at‐home orders, physical distancing—are antithetical to social connectedness, but learning how to use available technologies can restore some aspects of social support. These include the online consultations with providers, telephone support groups, text messaging, web‐based chat rooms, and video calling. During the initial sessions, psychiatrists took on the unusual role of “tech coach” to their patients. As patients gained mastery over the new modalities of virtual communication, they reestablished connectedness—and connectivity.

Promote a sense of self‐efficacy

For many patients, COVID‐19's arrival into the community engendered a sense of vulnerability, helplessness, and lack of control. Self‐efficacy is the principle where a psychiatrist can be most proactive. Strategies focus on countering helplessness with “can‐do‐ness.” The mainstay here is the promotion of positive activities, tailored to the patient's physical capabilities and adapted to the constraints of limited mobility during lockdown. Problem solving was used to inventory the activities the patient enjoys, and adapt selected activities to current realities. All patients were encouraged to maintain daily routines, eat a healthy diet, and observe regular sleep/wake patterns. Keeping physically active is critically important, so session time was spent on how to adapt an exercise routine to the patient's environment. Patients considered, and then selected, enjoyable and edifying activities that could be done comfortably at home.

Promote a sense of hope

The psychiatrist can instill hope throughout each online encounter, reassuring the patient that professionals and caregivers are available and accessible. Patients whose survival horizon extends for several years could be assured that COVID‐19 vaccine development is progressing a peak speed and, as soon as late 2020, vaccines may become available for distribution. Conveying that the current COVID‐19 crisis is time‐limited is a hope‐filled message. Patients can be told about what their own medical centers are doing on the front lines to improve patients' lives. Clinicians can infuse the entire encounter with hope through their positive demeanor, capability for establishing rapport, and realistic reassurances that mental health support is readily available.

EXTENDING THE FIVE PRINCIPLES TO CRISIS INFLECTION POINTS ALONG THE CANCER CARE TRAJECTORY

This five‐principle framework was implemented with dozens of patients during the first months of telehealth consultation and seems to be a promising approach that can be flexibly adjusted according to the future progression of the COVID‐19 pandemic. Shifting to telehealth consultations and interventions was essential for patient and provider safety due to the ease of transmissibility of COVID‐19. , , Fortunately, recent reviews of studies conducted in the pre‐COVID‐19 era have found that digital interventions appear to facilitate patient‐provider communication in cancer care. At least throughout the remainder of 2020, until an effective and immunogenic vaccine is developed and widespread population vaccination is achieved, these approaches will need to be maintained for supportive cancer care.

As a possible offshoot of this exploration into using disaster psychiatry principles for supporting cancer patients during COVID‐19, it is possible that this approach may have more mainstream applicability in cancer care. The trajectory of cancer care is not uncommonly punctuated by a series of highly stressful crisis points, starting with the moment when the patient receives the initial cancer diagnosis. , Other inflection points that are fraught with distress, and may signal life threat, include being informed that the cancer has spread within an organ or metastasized, that a hopeful therapy has not worked, that remaining life expectancy is short, or that hospice care decision‐making is at hand. Handling stress, distress, anxiety, and possible depression at some of these crisis points might potentially benefit from problem solving and support using the safety, calming, connectedness, self‐efficacy, and hope framework.