Managing a pandemic`s emotional toll

This article is written to assist addiction professionals and staff at treatment centers in addressing the psychosocial aspect of a pandemic flu outbreak. It is not intended to take the place of pandemic behavioral health training or to develop federal, state, local or agency policy. It is intended to be a quick reference guide to assist in meeting community needs and to remind providers to maintain good health and self-care for themselves and their families, as well as to acknowledge the anxiety, distress and grief that people experience during long-term, major public health events.

Additional information on how a pandemic outbreak can affect the delivery of inpatient and outpatient services is available from several federal sources. Most important is that during a pandemic, in addition to education and coordination for clients and staff on receiving H1N1 flu vaccine and on personal protection, plans need to include a disruption of direct face-to-face contact with clients. Proper hand-washing, covering your cough, not sharing personal items, and washing and disposal of personal items need to be reviewed with all staff and clients. In residential treatment and sober housing, adequate planning for providing appropriate care for those who become sick also needs to occur. Isolation, quarantine and social distancing are just three levels of protective factors that will directly affect patient care.
Information dissemination for the staff and general public is very important to mitigate the concerns of the community. Specific training, policy and access to current health risks and updates for spokespersons on public health crisis response and risk communications principles is an essential component of pandemic preparedness.
What is a pandemic?
A disease epidemic occurs when there are more cases of that disease than normal. A pandemic is a worldwide epidemic. An influenza pandemic may occur when a new influenza virus against which the human population has no immunity appears. With the increase in global transport, as well as urbanization and overcrowded conditions in some areas, epidemics due to a new influenza virus are likely to take hold around the world, and become a pandemic faster than before. The World Health Organization (WHO) has defined the phases of a pandemic to provide a global framework to aid countries in pandemic preparedness and response planning. Pandemics can be either mild or severe in the illness and death they cause, and the severity of a pandemic can change over its course.
Current epidemiological models project that a pandemic could result in 2 million to 7.4 million deaths globally. A pandemic that becomes severe and widespread over time would result in:

• Vaccines, antiviral agents and antibiotics to treat secondary infections being in high demand and potentially short supply;
• Medical facilities being strained with demands to care for both influenza and non-influenza patients; and
• Potentially significant shortages of personnel to provide essential community services.

A flu pandemic is an act of nature that, as of now, scientists cannot prevent. Because there is little natural immunity, the disease can spread easily from person to person. However, we can decrease the impact that a flu pandemic can have on our physical and emotional health. By taking action now, as well as during a pandemic and in the months that follow, both individuals and entire communities can better overcome the challenges that a flu pandemic might bring.

Special circumstances
Many of the recommendations we have to address the emotional and psychosocial aspects of a crisis are based on experiences with current disaster response preparedness for other hazards. They are considered evidence-informed, based on assumptions from previous health crises. Yet a pandemic also has some unique considerations that make it different from other disaster situations. The impact and duration can be more widespread and long-lasting than for other traumatic disaster events.

People might become quite fearful about the risk of becoming infected. They might worry about how they will manage their sickness, and about the potential threat to life if the condition is severe. Healthcare and treatment providers will have concerns about becoming infected themselves while caring for patients in residential settings. Providers also will have concerns for their family members. Social distancing, isolation and quarantine recommendations and possible mandates will also intensify emotional reactions. The severity of the pandemic combined with the anticipated number of lives lost will multiply provider and community reactions to the situation.

There are many emotional challenges that could face individuals and families during pandemic influenza. These challenges are not limited to the medical impact of a disease outbreak, but also include reactions to organizational and governmental response; the impact on society; personal and global economic disruption; pre-existing medical or mental health issues; separation from natural sources of support; and loss of and grief for friends and/or family members.

Experiences with disaster relief efforts suggest that enhanced workforce support activities help workers remain effective during emergencies. During a pandemic, the occupational stresses will likely differ from those faced by relief workers in the aftermath of a natural disaster. The severity and duration of illness along with potentially high numbers of deaths will add considerably to personal and social stress.

Public health crises also result in different responses that are not seen in natural or technological disasters. Those include multiple unexplained physical symptoms (MUPS); panic; a surge in healthcare-seeking behavior; and a greater mistrust of public officials. These reactions further complicate the public health and medical response to the situation.

Areas of concern specific to addiction professionals and the clients we work with, along with the larger recovery community, also will include:

• Staff and clients concerned about personal contact in individual, group and family sessions;
• Isolation and quarantine for affected and non-affected individuals;
• Restrictions on public gatherings, including self-help meetings and faith-based services;
• Continuation of care, and services/treatment interruption;
• Staff shortages due to staff sickness and caring for sick family members; and
• An increase in anxiety, fear, grief and loss as part of a relapse.

Learning from our past
The effect of a disaster situation goes far beyond its immediate devastation. It takes time to rebuild what has been destroyed. Communities are more than their infrastructure—they are people who live, work, study, play and participate in their recovery, people who raise families, who protect the disadvantaged, who share space and resources. Communities connect individuals. No one who lives through a crisis is untouched by the experience. It is essential to remember that not all that has been lost is physical. The emotional toll can have long-lasting effects.

The devastation of a pandemic outbreak affects the safety, security and sense of well-being of individuals and the community as a whole. Not everyone will be affected at the same level of intensity. Most people who are coping with the aftermath of a disease outbreak have normal reactions as they struggle with the disruption and loss caused by the crisis. Others can experience sadness, deep depression, emotional stress and mental exhaustion. Providing mental health services is often overlooked as a priority in complicated disaster situations.

Addiction professionals need to prepare for the psychological needs of the community affected by the situation, along with assisting with the medical and physical needs and safety of the public. While providing direct mental health services might not be within the scope of practice for some counselors, the need for coordination of resources must be included in pandemic emergency planning.

Anticipating and responding to a community affected by a health crisis requires an understanding of how stress and trauma can influence our thoughts, emotions and behaviors along with our physical health. Managing a disaster situation is the responsibility of an entire “community,” a composite that at a minimum includes fire and police; emergency medical services; the public health system; the community health system (federally qualified health centers); local municipalities and government authorities; and local hospitals and other healthcare organizations.

Providers can often be directly affected during a public health crisis situation. Providers’ families, friends, neighbors and co-workers can become sick, and some will die during a pandemic. Survivors will have additional stressors, providing for children and other family members of those who are sick or have died.

It is important for individuals and organizations to learn to recognize the symptoms of stress and ways to alleviate it. A valuable lesson learned from previous disasters is the need to have a personal disaster plan. All workers—counselors, doctors, nurses and support staff—need to be encouraged to develop a personal family disaster plan that includes a family communication plan. Providers have concerns about their families’ safety and health, and families have valid concerns about providers. To best meet the needs of the public, one first needs to meet one’s personal needs, and the needs of one’s family.

The impacts on individuals and communities include emotional reactions such as fear of exposure/infection; massive loss and grief; exposure to traumatic images; an inability to see loved ones; and not being able to say goodbye to those who may die in the hospital or while separated from family.

With so many powerful sources of stress striking world¬wide, it is no surprise that mental health experts expect millions of people to feel anxious about both the spread of the disease and the fear of the unknown. Because stress can weaken your immune system, experts recommend that you focus on sources of support and control before and during a pandemic. Your sources of support can help strengthen your body and mind so you become more resilient in the short and long term.

Relapse prevention plans also need to account for the reality of a pandemic’s emotional impact. Pandemic preparedness must include specific physical and logistical preparation. Individuals whose recovery work includes attendance at 12-Step meetings will definitely be affected if attendance at meetings is disrupted for an extended period. Recommendations for social distancing and possible restrictions on group gatherings will increase stress for those who attend self-help groups. Developing alternatives to face-to-face contact, in the form of both self-help and professional counseling sessions, will be required.

Phone calls, Internet chat rooms and videoconferencing all can be utilized. 12-Step presentations on tape or other prerecorded lectures, webcasts and presentations using technology will be extremely important, and need to be planned for now as part of pandemic preparedness efforts.

Philip T. McCabe, CSW, CAS, CDVC, DRCC, is a Health Educator at the University of Medicine and Dentistry of New Jersey School of Public Health, Office of Public Health Practice. His e-mail address is mccabept@umdnj.edu.