Patient Counseling

Disproportionately Impacted Groups

Domestic Violence Victims

• NYC saw an uptick in reports of domestic violence during the COVID-19 lockdown, with some reports suggesting up to a 20% increase. Similarly, NYC HOPE, an organization providing resources for domestic violence victims, saw their website traffic nearly double. It is critical to screen all patients for domestic violence and feeling unsafe at home.
• More patient resources on this topic are linked HERE.

Minority Groups

• COVID-19 has disproportionately impacted socioeconomically disadvantaged populations, further revealing the extent of racial inequity, economic injustice and health care discriminiation in our society.
• Information on existing NYC resources to help people with housing, unemployment, food security and more can be found HERE.

Managing Stress and Anxiety

Patients may have anxiety or feel emotional distress from the COVID-19 outbreak; these are helpful techniques endorsed by NYC Well to reduce stress:

• Journal about, speak about, or think of positive aspects of your situation and your own personal strengths
• Connect with friends and loved ones (phone, text, video chat) who are supportive and adapt your daily routines to involve friends and family virtually
• Go outside and get exercise, if you are not sick
• Reach out to those in your community who need support
  • Volunteer to make phone calls to seniors
  • Write positive reviews for local businesses
  • If you are not sick and do not have any symptoms, offer to shop for essentials for those who need help
• Identify what you are feeling and give yourself compassion for feeling
• Be proactive about your needs and financial stressors
• Recognize that feelings of grief or loss are normal and shared by the wider community
• Prioritize sleep hygiene and improving sleep habits (i.e., establish a sleep routine, reduce blue light 2-3 hours before bed, drink less caffeine)

Helping Patients Navigate Uncertainty

Many patients can become overwhelmed in the face of uncertainty when it comes to COVID-19 prognosis and prevention best practices amidst changing guidelines.

Advice for patients overwhelmed by the uncertainty of changing guidelines

• Take regular and routine breaks from the news
• Stick to trustworthy news sources like the CDC and NIH
• Focus on the things you can control
• Practice tolerating uncertainty
• Draw on skills you’ve used before to navigate difficult situations

When talking to patients about prevention in the context of changing guidelines, emphasize these certainties:

• Wearing a mask, social distancing and outdoor activities reduce transmission
• Exercise caution around vulnerable populations (e.g. elderly, immunocompromised, etc.)
• Wash hands with soap and water, frequently and thoroughly

When speaking to COVID-19+ patients and family who are concerned about an uncertain prognosis:

• Never make up answers or speculate! It is okay to admit that you don’t know. In fact, there is a lot we have yet to learn about COVID-19
• Emphasize that, with every passing day, we are learn more about COVID-19 and how best to help affected patients
• Assure the patient and their family that the medical team is doing everything they can to help the patient and that they are in very good hands

Risk Assessment and De-escalation

In addition to its physical symptoms, COVID-19 can have significant impacts on a patient’s psychosocial factors and their mental well-being. In patients experiencing intense emotional distress, it may be appropriate to perform a risk assessment to gauge the possibility of self-harm. We describe useful techniques for evaluating risk and, if necessary, engaging in de-escalation techniques to minimize harm and refer out appropriately.

Establishing Rapport

• In order to establish risk or elicit indirect/direct cues that could lead you to believe that a risk assessment needs to be done, you need to establish rapport with the patient. Rapport is the quality relationship between you and the patient. When the patient trusts you, they are more likely to be honest and open.
  • Validation: expresses to the patient that you accept their reality and their feelings as legitimate. Validating the patient’s perspective allows them to feel comfortable expressing themselves and fosters good rapport.
    • “What you are going through is really difficult - it’s great that you were able to reach out for help”
    • “I hear you”
    • “Given what’s going on, of course you feel that way”
  • Open-ended questions: questions are a primary way of discovering information and focusing the conversations, open-ended questions can help patients communicate their needs freely. Use these questions to probe how you can help before asking questions with a “yes/no” answer.
  • Reflecting: repeat, re-state, and interpret what the patient says – using their words. It allows the patient to know that you were listening to what they are saying, while giving you a chance to check back and see if you heard and interpreted their content correctly.
  • Normalizing: affirm and validate the patient’s experience, letting them feel comfortable in their experience and assuring them that they are not alone. It can also be helpful to dispel myths or stigma about mental health resources.

Risk Assessment

• When talking to the patient, listen for direct cues (talk of death, dying, or suicide) and indirect cues (talk of hopelessness lack of meaning, disappearing, depression). If risk is identified, ask the following:
  • “When someone feels very upset or overwhelmed, as you have mentioned, they may have thoughts that life is not worth living. Have you had such thoughts?”
    • If YES: “Are you having thoughts of dying or of killing yourself?”
    • If NO: “Have you had such thoughts in the past 24 hours?”
  • If the patient answers YES to these two questions, contact your resident and a mental health provider. Say to the patient:
    • “I’m very concerned about you. You seem to be going through a very difficult time and I am worried about your safety and would really like to see you feel better. I can bring in someone who is professionally trained and can talk to you right now. They will be able to come up with some ideas for you to be safe and feel better, and I think they’ll be able to help you better than I can.“

De-escalation

• The goal of de-escalation is to help the patient get to a point where they are willing to engage with their provider and/or trained mental health professionals.
  • Ask if the patient would be willing to call NYC Well (1-888-NYC-WELL), with you on the line if necessary, to access trained mental health counselors who are available 24/7
  • If the patient is only willing to speak with you, focus on keeping them safe and de-escalating them with the goal of engaging with a provider using the following conversational tips
    • Exploring thoughts of self-harm
      • “Tell me more about what you’re thinking and feeling.”
      • “What is going on today that makes these thoughts come up now?”
    • Understanding past behavior
      • “Have you ever felt this way in the past?”
      • “What made feelings of hurting yourself come on at that time?”
      • “What made feelings of hurting yourself go away at that time?”
      • “Have you ever attempted to kill yourself?”
        • Further explore these mitigating/protective factors
    • Explore access to means of self-harm
      • “Have you thought about how you would harm/kill yourself?”
      • “Do you have [method described by the patient] available to you?”
    • Explore protective factors
      • “I’m very glad you told me about how you are feeling. That tells me that there’s a part of you that doesn’t want to die/hurt yourself. Tell me more about that.”
        • Pivot the patient towards discussing their safety
        • Explore what the patient needs to stay safe
        • Explore if they are willing to store their methods of suicide/self-harm in a separate room or location
        • Discuss friends, family members, roommates, or other social supports
    • Continue to explore the patient’s willingness to connect with trained mental health clinicians
  • If the patient is not at immediate risk and is not willing to engage with their provider or another mental health clinician, engage them in a Safety Plan (a digital template can be accessed via the free app MY3) that the patient completes on their cell phone
  • Inform the patient about 24/7 crisis resources like 1-888-NYC-WELL and the psychiatric ED at 212-241-5637