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In this stressful climate of fear, uncertainty, challenge, survival, and a sense of being overwhelmed or stretched to the limit, GPs and mental health professionals need novel approaches to help them explain the complex plethora of feelings, symptoms and behaviours resulting from the COVID-19 earthquake.
Rather than re-invent the wheel, the GPs at Penshurst Gardens Surgery are utilising the established Kübler-Ross stages of grief° in an innovative way to help diagnose COVID mental health problems and explore the available options to guide personalised, compassionate care.
COVID ‘grief’ stages based on the Kübler-Ross model:
1. COVID Denial. The myths: “It’s an impeachment hoax!”. Or: “I am young, so COVID will not affect me and the mask that I am wearing will protect me, therefore is it really necessary to wash my hands?”
2. COVID Anger. Lockdown measures may increase anxiety, provoke anger and ignite civil disobedience: “Why are my doctor colleagues still not being provided with adequate PPE to protect them from this deadly virus that scares the hell out of me?” Or: “My liberties are slowly being taken away. Why can I not go to pubs and clubs anymore or walk my dog in the park?”
3. COVID Bargaining. “Can I travel abroad to Antarctica or a country free of COVID-19? Or maybe my second home?”
4. COVID Depression. Vulnerable elderly and COVID-19 high risk groups are most at risk of loneliness/isolation from social distancing and shielding. But so are the chronically mentally-ill already at risk of suicide or recently-bereaved by the tragic loss of loved ones to COVID-19 and other patients with learning difficulties or disabilities.
5. COVID Acceptance. “We are all in this fight together so I will comply with the lockdown measures and do anything to reduce disease transmission and help humanity to survive this plague”.
As previously described by Kübler-Ross, we can expect our patients to move up and down the various stages in a fluid manner until they finally reach acceptance.
Practitioners should also be alert to the possibility that they too may be suffering from COVID grief from patient transference of emotions/feelings and take appropriate steps to debrief, discuss traumatic cases with colleagues or if necessary seek professional help for themselves. Self-awareness, critical reflection/or feedback from supportive colleagues are very helpful at a time when clinicians may themselves be in COVID Denial and hold on to their stoic mantra of ‘physician heal thyself ‘.
Penshurst prescriptions for the COVID ‘grief’ stages:
1. COVID Denial. Public/patient education should be tailored to the underlying health beliefs of COVID deniers, however GPs should be mindful not to provoke COVID anger when challenging such beliefs but to understand that denial in itself may be the patient’s only coping strategy.
2. COVID Anger. Allow enough time for listening, empathy, counselling in your telephone consultations and offer the option of referral for anger management if appropriate.
3. COVID Bargaining. Acknowledge where the patient is in their grief and provide reassurance that is normal to flit back and forth between the stages.
4. COVID Depression. Patients may benefit from bereavement support/ or counselling. Mindfulness therapy and CBT may be required to break the vicious cycle of negative thoughts/anxiety and avoidance behaviour (eg. social isolation) and help promote resilience. Consider psychotropic medications and adult psychiatry or CAMHS referral if and when appropriate.
5. COVID Acceptance. Regularly reinforce the benefits of compliance for ‘the greater good’ in saving the lives of the vulnerable and use motivational interviewing to empower the patient to carry on with their normal lives.
We at Penshurst hope that by applying the Kübler-Ross model in your consultations relating to COVID-19, this simple tool may provide deeper insights/understanding of where the patient is in their grief and guide appropriate mental health support at this very difficult, unusual and challenging time for families and communities.
On Death and Dying. Elisabeth Kübler-Ross. New York: The Macmillan Company (1969)