Crisis Counseling, Not Therapy, Is What's Needed in COVID-19

In the wake of the attacks on the World Trade Center, the public mental health system in the New York City area mounted the largest mental health disaster response in history. I was New York City's mental health commissioner at the time. We called the initiative Project Liberty and over 3 years obtained $137 million in funding from the Federal Emergency Management Agency (FEMA) to support it.

Lloyd I. Sederer, MD

Through Project Liberty, New York established the Crisis Counseling Assistance and Training Program (CCP). And it didn't take us long to realize that what affected people need following a disaster is not necessarily psychotherapy, as might be expected, but in fact crisis counseling, or helping impacted individuals and their families regain control of their anxieties and effectively respond to an immediate disaster. This proved true not only after 9/11 but also after other recent disasters, including Hurricanes Katrina and Sandy. The mental health system must now step up again to assuage fears and anxieties—both individual and collective—around the rapidly spreading COVID-19 pandemic.

So, what is crisis counseling?

A person's usual adaptive, problem-solving capabilities are often compromised after a disaster, but they are there, and if accessed, they can help those afflicted with mental symptoms following a crisis to mentally endure. Ensuring safety and promoting return to functioning, as well as being informed about immediately available resources, are the central objectives of crisis counseling, thereby making it a different approach from traditional psychotherapy.

The five key concepts in crisis counseling are:

It is strength-based, which means its foundation is rooted in the assumption that resilience and competence are innate human qualities.
Crisis counseling also employs anonymity. Impacted individuals should not be diagnosed or labeled. As a result, there are no resulting medical records.
The approach is outreach-oriented, in which counselors provide services out in the community rather than in traditional mental health settings. This occurs primarily in homes, community centers and settings, as well as in disaster shelters.
It is culturally attuned, whereby all staff appreciate and respect a community's cultural beliefs, values, and primary language.
And it is aimed at supporting, not replacing, existing community support systems (eg, a crisis counselor supports but does not organize, deliver, or manage community recovery activities).

Crisis counselors are required to be licensed psychologists or have obtained a bachelor's degree or higher in psychology, human services, or another health-related field. In other words, crisis counseling draws on a broad, though related, group of individuals. Before deployment into a disaster area, an applicant must complete the FEMA Crisis Counseling Assistance and Training, which is offered in the disaster area by the FEMA-funded CCP.

Crisis counselors provide trustworthy and actionable information about the disaster at hand and where to turn for resources and assistance. They assist with emotional support. And they aim to educate individuals, families, and communities about how to be resilient.

Crisis counseling, however, may not suffice for everyone impacted. We know that a person's severity of response to a crisis is highly associated with the intensity and duration of exposure to the disaster (especially when it is life-threatening) and/or the degree of a person's serious loss (of a loved one, home, job, health). We also know that previous trauma (eg, from childhood, domestic violence, or forced immigration) also predicts the gravity of the response to a current crisis. Which is why crisis counselors also are taught to identify those experiencing significant and persistent mental health and addiction problems, because they need to be assisted, literally, in obtaining professional treatment.

Only in recent years has trauma been a recognized driver of stress, distress, and mental and addictive disorders. Until relatively recently, skill with, and access to, crisis counseling—and trauma-informed care—was rare among New York's large and talented mental health professional community. Few had been trained in it in graduate school or practiced it, because New York had been spared a disaster on par with 9/11. Following the attacks, Project Liberty's programs served nearly 1.5 million affected individuals of very diverse ages, races, cultural backgrounds, and socioeconomic status. Their levels of "psychological distress," the term we used and measured, ranged from low to very high.

The coronavirus pandemic now presents us with a tragically similar, catastrophic moment. The human consequences we face—psychologically, economically, and socially—are just beginning. But this time, the need is not just in New York but throughout our country.

We humans are resilient. We can bend the arc of crisis toward the light, to recovering our existing but overwhelmed capabilities. We can achieve this in a variety of ways. We can practice self-care. This isn't an act of selfishness but is rather like putting on your own oxygen mask before trying to help your friend or loved one do the same. We can stay connected to the people we care about. We can eat well, get sufficient sleep, take a walk.

Identifying and pursuing practical goals is also important, like obtaining food, housing that is safe and reliable, transportation to where you need to go, and drawing upon financial and other resources that are issued in a disaster area. We can practice positive thinking and recall how we've mastered our troubles in the past; we can remind ourselves that "this too will pass." Crises create an unusually opportune time for change and self-discovery. As Churchill said to the British people in the darkest moments of the start of World War II, "Never give up."

Worthy of its own itemization are spiritual beliefs, faith—that however we think about a higher power (religious or secular), that power is on our side. Faith can comfort and sustain hope, particularly at a time when doubt about ourselves and humanity is triggered by disaster.

Maya Angelou's words remind us at this moment of disaster: "...let us try to help before we have to offer therapy. That is to say, let's see if we can't prevent being ill by trying to offer a love of prevention before illness."

Dr Sederer is the former chief medical officer for the New York State Office of Mental Health and an adjunct professor in the Department of Epidemiology at the Columbia University School of Public Health. His latest book is The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs.

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