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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 36-39

Technology-based psychosocial management for psychological distress due to stigma associated with COVID-19: A case study from North Karnataka


1 Department of Psychiatric Social Work, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
2 Department of Clinical Psychology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
3 Department of Psychiatry, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India

Date of Submission26-Dec-2020
Date of Acceptance01-Mar-2021
Date of Web Publication30-Jul-2021

Correspondence Address:
Suruchi Sonkar
Department of Clinical Psychology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_225_20

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  Abstract 


COVID-19 is associated with a significant distress and stigma. Due to the nature of the disease, it is difficult to conduct counseling and therapy without taking significant precautions such as wearing a complete personal protective equipment kit which impedes with rapport and dampens the speech which is quite essential for therapy. Herewith, we present a case where we used technology-based interventions, course, and outcome. Although the results of this case study cannot be generalized, few factors clearly stand out in the treatment of psychological distress among COVID-19-positive clients – psychoeducation, supportive therapy components of Cognitive Behavioral Therapy (CBT), and management of expressed emotion may play a key role in dealing with rural population. Family interventions were used to facilitate healthy family communication pattern (using technology) toward healthier involvement, connectedness aid client's recovery in the aftermath and acceptance of COVID-19 diagnosis. Intervention should also equip and empower client and family to deal with stigma and helplessness through clarifying misconceptions, providing knowledge, and enhancing agency or mastery over circumstances. These can serve as guidelines during treatment of psychological distress among COVID-19-positive clients and their families.

Keywords: COVID-19 positive, family intervention, management of stigma, psychoeducation for rural population, treatment of psychological distress


How to cite this article:
Shetty KV, Sonkar S, Mahadevaiah M. Technology-based psychosocial management for psychological distress due to stigma associated with COVID-19: A case study from North Karnataka. J Mental Health Hum Behav 2021;26:36-9

How to cite this URL:
Shetty KV, Sonkar S, Mahadevaiah M. Technology-based psychosocial management for psychological distress due to stigma associated with COVID-19: A case study from North Karnataka. J Mental Health Hum Behav [serial online] 2021 [cited 2021 Nov 28];26:36-9. Available from: https://www.jmhhb.org/text.asp?2021/26/1/36/322822



The COVID-19 pandemic has adversely impacted people's mental health. Subsyndromal mental health concerns are common response to the COVID-19 pandemic. Depressive and Anxiety symptoms (16%–28%) and self-reported stress (8%) with associated disturbed sleep are reported frequently.[1] Rajkumar (2020) suggests “novel methods of consultation, such as online services, can be helpful for these patients” and highlighted the need for research in vulnerable populations. In line with this perspective, the present paper is a case study examining the online psychosocial management for psychological distress due to stigma associated with COVID-19.

A 43-year-old widow, of middle socioeconomic status, from rural area, living with son and daughter-in-law contracted COVID-19 and was admitted to taluk Government Hospital, Dharwad. Consequently, she developed psychological disturbances namely, sleep disturbances, lack of appetite, excessive worries, fear of stigma, and social withdrawal.

The family members had little knowledge about the illness. They exhibited poor coping skills, with varied expressed emotions; mainly criticality and blaming. Perception of social support and care from family members was reported to be inadequate as they blamed the client, admitting in hospital but never visiting, giving rise to feelings of neglect and invalidation. Constant criticism increased the guilt and worries and did not help or encourage her to accept her illness.

The client's perception of family was unfavorable and felt neglected right from her teenage years. For instance, while her brothers were supported to study up to graduation, she was forcefully stopped from going to school. Discontinuity of education left her with little options, compelling her to work as a maid in nearby town far away from home. She was dependent on others family members even for minor decisions. She struggled to have a satisfying job throughout her life because of poor education, poor work skills, and self-doubt about her competence. At the early age of 17 years, she was married to a relative and gave birth to a son within the 1st year. However, unfortunately, the husband died due to accident soon after.

When client was admitted to hospital, district administration had sealed her house, thus, information about her illness was known to the entire village. Consequently, the family faced social stigma in the form of negative comments, criticism, rumors, and gossip, leading to being excluded from social functions, which triggered anger outbursts in the family members toward the client and persistently blaming her reason for humiliation at the hands of the community. The apprehension of being shunned due to illness was found to be one of the main fears and concerns. Stigma associated with COVID-19 poses a serious threat to patients and survivors of the disease.[2],[3] This implied the lack of adequate knowledge and the urgent need for Psychoeducation about the illness. Diagrammatic representation of social diagnosis is represented in [Figure 1].
Figure 1: Diagrammatic representation of social diagnosis

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  Psychosocial Management Top


Interventions (5 sessions lasting 35 min) were carried out over telephone and WhatsApp video calls. The goals of interventions with client were facilitation of insight, Supportive Counseling to foster agency and autonomy, Relaxation techniques training, Behavioral Activation using Activity Scheduling with client and self-monitoring to enhance self-mastery, and components of CBT for cognitive appraisal.

Building therapeutic alliance for treatment compliance

Building rapport with the client is paramount.[4] The client, being her first hospital admission, felt uncomfortable as she was alone without family members, having no idea about the treatment protocol. This uncertainty led to feelings of guardedness and apprehensiveness with the treating team which transformed into trust when therapist made her comfortable by validating her concerns.

Addressing denial through insight facilitation

Cognitive re-appraisal has been shown to lead to positive therapeutic outcomes in CBT, one of the most effective treatments in Depression. Attempts were made to make the client come out of her vicious thought processes of negative automatic thoughts. Insight facilitation was necessary, not only intellectual insight, which is more verbal or cognitive (like: “I know I should change.”) but also emotional insight, which is more experiential (for instance: “I want to recover, I must now take responsibility for my health”). Due to criticism from family, stigma from relatives; hopelessness, negative thinking and worrying about future, the client experienced severe distress. Building hope was one of the first humble steps in reducing the position of helplessness she was in.

Handling poor knowledge about illness using/through psycho-education

The level of knowledge about illness was assessed by the therapist revealed that client appeared to have no knowledge nor was she updated about the COVID-19 news being in denial. The nature of illness, common symptoms of COVID-19 and psychological disturbances were explained to her. The nature of COVID-19 treatment, the need for short term hospitalization (2–3 weeks until recovered), and reasons for not being permitted physical contact with family members were explained to her. The therapist differentiated between what were controllable factors versus what were the uncontrollable factors and asked her to focus on what was in her control by regulating her diet, sleep, and medicine through cooperation and compliance with the treatment team. The need for regular sleep at night and keeping oneself active and constructively engaged (within limited resources at hospital) during daytime were explained to her. Corresponding emotional sequalae of psychological distress in many forms such as shock or denial, uncertainty, worries, fears, or shame, anger were explained as possibilities, with acceptance being the healthiest and constructive one which is the last stage of emotional recovery post critical loss.[5]

Addressing fears, shame, and guilt due to stigma

The client's fears and doubts were explored. Fears of judgment and exclusion due to taboo associated with illness was the predominant fear.[2],[6] The reason for social distancing was clarified as not related to her personality or self but in response to precautions taken by one and all. Social distancing was explained as being done and strictly followed even with politicians and celebrities made her feel more confident about herself as she was tending to personalize that social distancing as a sign that people were judging her (as untouchable). Such taboo due to being socially distanced due to being ill were overcome by clarifying her misconceptions as COVID was a transient illness and not a chronic one.[7]

Facilitating coping through supportive therapy

Supportive therapeutic approach has been efficacious in dealing with depressive symptoms.[8] The client was provided encouragement throughout the sessions. The therapist aimed to provide supportive framework to foster autonomy. With the supportive framework and guidance client felt more confident to face others and her socialization improved. First, she was encouraged and facilitated to talk to son and other relatives and even neighbors. Her plans for the future were also discussed with the client, during the termination phase and independence was rewarded with appreciation. The family wished to keep her in a home isolation for few days; this plan was discussed with the client and her opinions were taken which made her respected increasing confidence. She was explained as to how separation from the family members temporarily would help them to start anew and improve the emotional bonding. She understood and expressed that she was willing to stay in a safe hospital and home isolation. Thus, the client due to renewed sense of hope, was now willing to venture out of the comfort zone, embracing growth, and this was one of the first steps toward autonomy.

Confronting negative thoughts through cognitive behavioral therapy

Client's negative beliefs were explored. In spite of the initial phase of denial, however, finally after the 4th session, she was comfortable and safe enough to accept the possibility for having an illness. Hope generation, facilitating rational acceptance through identification of cognitive errors, and cognitive reappraisals increased her level of comfort to deal with negative thoughts. Gradually, client could challenge her irrational negative automatic thoughts (“I am not okay” position in response to family criticism). Confronting the evidence for her depressive cognitions was used to help her understand illness. Behavioral experiments proved her fears about judgment and exclusion as disproportionate, greatly helping in improving her socialization.


  Intervention with the Family Top


Goals of interventions at the family level were first to psychoeducate the family on the nature of illness and treatment and second, to address the high expressed emotion and their response to perceived stigma.

Facilitating understanding about illness through family psycho-education

Family psycho-education is well-proven intervention for families of persons with psychological distress.[9] Assessment of level of knowledge revealed that the family had no knowledge about the COVID-19 and psychological problem of the client. The family members were called by the therapist and had telephonic counseling session. The health status of the client, various aspects of COVID-19, and importance of emotional support of family members were discussed. Their doubts and misconceptions were clarified.

Empowering family to deal with stigma through knowledge

Feelings of stigma was discussed and their concerns were validated, not minimized. Self-care for caregivers was suggested an emphasized the need to delegate responsibilities and share chores. They were encouraged to express their emotions with each other rather than displace any frustration onto client and to feel free to approach therapist in future for follow up if they felt burn out in management of client.[10]

Motivating involvement and healthy connectedness

In terms of closeness, the client reported that she was neglected by her family. The family were contacted over phone and explained the prognostic factors and their role in client's recovery, which motivated them to involve themselves in her care. The benefits of reciprocity were explained. They were appreciated for the microgains in improvement shown by client after the first call. Her perception about her family became more favorable. Her feelings of shame reduced, with reduced her social withdrawal, aiding recovery.

Family communication patterns and management of expressed emotion

It is well known that addressing the expressed emotion from the family members toward the clients is an important component of therapy.[11] The family members were explained how expressed emotions play a role in the prognosis of the client. The various expressed emotions such as warmth, positive regard, emotional over-involvement, hostility, and criticality were explained to them. The psychosocial assessment revealed the presence of high negative expressed emotion toward the patient. The importance of reducing negative expressed emotions, especially criticality (blaming) and more support from them toward the client was emphasized. They understood the need for self-care themselves to take their time off for themselves as they were quite burnt out, which led to displacing negative emotions by blaming client.

Behavioral contingencies of different types of communication patterns were discussed. Attempt was made to make them mindful and consciously aware about potential consequences of their communication pattern. Importance of positive reinforcement was highlighted. Alternative ways of saying the same thing were demonstrated through role play.[12]


  Outcome of Intervention Top


The family got to understand the nature of COVID-19 and comorbid psychological problems. Over a period of few weeks of hospitalization, client recovered from COVID-19 and psychological distress reduced significantly. Importance of compliance to treatment and benefits of timely follow-up was explained. Family members were encouraged to seek the help of the local and district COVID-treating team and helplines at any time they wanted.


  Conclusion Top


Online psychosocial management has utility in the treatment of psychological distress among COVID-19-positive clients. Few factors such as psychoeducation, facilitating healthy family communication (using technology), management of stigma, and expressed emotion may play a key role in dealing with rural population. There were some challenges faced during intervention, which could be overcome, like comfort with technology and clarity of sound and video as it was online-based interventions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066.  Back to cited text no. 1
    
2.
Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis 2020;20:782.  Back to cited text no. 2
    
3.
Chopra KK, Arora VK. Covid-19 and social stigma: Role of scientific community. Indian J Tuberc 2020;67:284-5.  Back to cited text no. 3
    
4.
Austin LN. Trends in differential treatment in social casework. J Soc Casework 1948;29:203-11.  Back to cited text no. 4
    
5.
Moreno C, Wykes T, Galderisi S, Nordentoft M, Crossley N, Jones N, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry 2020;7:813-24.  Back to cited text no. 5
    
6.
Harrison CA, Dadds MR. Attributions of symptomatology: An exploration of family factors associated with expressed emotion. Aust N Z J Psychiatry 1992;26:408-16.  Back to cited text no. 6
    
7.
Earnshaw VA, Brousseau NM, Hill EC, Kalichman SC, Eaton LA, Fox AB. Anticipated stigma, stereotypes, and COVID-19 testing. Stigma Health 2020;5:390-3.  Back to cited text no. 7
    
8.
Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom management and supportive care of serious COVID-19 patients and their families in India. Indian J Crit Care Med 2020;24:435-44.  Back to cited text no. 8
    
9.
Kulhara P, Chakrabarti S, Avasthi A, Sharma A, Sharma S. Psychoeducational intervention for caregivers of Indian patients with schizophrenia: A randomised-controlled trial. Acta Psychiatr Scand 2009;119:472-83.  Back to cited text no. 9
    
10.
Hart JL, Turnbull AE, Oppenheim IM, Courtright KR. Family-centered care during the COVID-19 era. J Pain Symptom Manage 2020;60:e93-7.  Back to cited text no. 10
    
11.
Devaramane V, Pai NB, Vella SL. The effect of a brief family intervention on primary carer's functioning and their schizophrenic relatives levels of psychopathology in India. Asian J Psychiatr 2011;4:183-7.  Back to cited text no. 11
    
12.
Holley JM. Expressed emotion and psychiatric illness: From empirical data to clinical practice. Behav Ther 1998;29:631-46.  Back to cited text no. 12
    


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