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Library of Congress Cataloging-in-Publication DataNames: Stebnicki, Mark A., author. Title: Counseling practice during phases of a pandemic virus / Mark A. Stebnicki, Ph.D., LCMHC, DCMHS, CRC, CMCC.

Description: Alexandria, VA : American Counseling Association, [2021] | Includes bibliographical references and index.

Identifiers: LCCN 2021008083 | ISBN 9781556204081 (paperback) Subjects: LCSH: Disaster victims—Mental health. | Disasters— Psychological aspects. | Psychic trauma. | COVID-19 (Disease)

Classification: LCC RC451.4.D57 S74 2021 | DDC 363.34/8—dc23 LC record available at https://lccn.loc.gov/2021008083

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Dedication

This book is dedicated to my mother Patricia, a COVID-19 survivor who continued to struggle with symptoms 4 months after her diagnosis.

She has dedicated her life to prayer and service to others. • • •

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Acknowledgments vii

About the Author ix

Introduction xi

Chapter 1 Theoretical Aspects of Risk and Resiliency

During a Pandemic Virus 1

Chapter 2 The Pandemic Risk and Resiliency

Continuum Theoretical Model 13 Chapter 3 What Is Healthy-Normal and Unhealthy-Abnormal Mental Health Functioning During a Pandemic Virus? 37 Chapter 4 The Medical Aspects of a Pandemic Virus 47 Chapter 5 The Psychosocial Aspects of a Pandemic Virus 69 Chapter 6 Fear and Anxiety: Predominant Emotions During a Pandemic Virus 91 Chapter 7 Mental Health Aspects of a Pandemic Virus 101 Chapter 8 Disaster Mental Health Counseling During Phases of a Pandemic Virus: The Phases of Pandemic Rehabilitation Model 121

Table of Contents

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Table of Contents

Chapter 9 Pandemic Risk and Resiliency Factors in Children and Adolescents: Considerations for School Counselors 137 Chapter 10 Identifying Risk and Resiliency in Adults During Phases of a Pandemic Virus 153 Chapter 11 A New Anthem for Coping With Extraordinary Stressful and Traumatic Experiences During Phases of a Pandemic Virus 163 Chapter 12 How Do Cultures and Vulnerable Populations Heal During a Pandemic Virus? 175 Chapter 13 Guidelines for Coping With Stress, Fear, and Anxiety During Phases of a Pandemic Virus 185 Chapter 14 Empathy Fatigue During a Pandemic 193

References 203

Index 229

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I want to offer my sincerest gratitude to the following individuals who reviewed the work I created for my pandemic risk and resiliency continuum theoretical model and to those who submitted a “Pandemic Perspective” for this book. I invited a review and comment from a panel of individuals who had expertise in the areas of disaster mental health and trauma counseling, counselor education, behavioral sciences, epidemiology, and public health and those who have worked with the medical, psychosocial, and vocational aspects of chronic illness and disability. I requested their critical review because of the respect I have for their impressive careers and body of work, which assisted me in developing a stronger book.

Stephanie F. Dailey, EdD, LPC, NCC, ACSAssistant Professor, Counseling and DevelopmentGeorge Mason University

Donna R. Falvo, PhDProfessor (Ret.) Mary Switzer Scholar Clinical Psychologist, Registered Nurse (Ret.)Southern Illinois University–CarbondaleUniversity of North Carolina–Chapel Hill

Debra A. Harley, PhD, CRC, LPCProvost’s Distinguished Service ProfessorEarly Childhood, Special Education, and Rehabilitation Counseling University of Kentucky

Michael E. King, PhD, MSWCaptain, U.S. Public Health ServiceRegional 4 Administrator, Substance Abuse and Mental Health Services AdministrationAtlanta, Georgia

Acknowledgments

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Acknowledgments

Hanoch Livneh, PhDProfessor (Ret.), Counselor Education ProgramPortland State University

Karen Pell, PhD, CVEApplied Social ScientistColumbia, Maryland

Tyra Turner Whittaker, RhD, LCMHC, CRCProfessor, Department of Counselor Education and Family Studies Liberty University

Noel A. Ysasi Jr., PhD, CRCAssistant Professor, Director of PhD ProgramDepartment of Addictions and Rehabilitation ServicesEast Carolina University

• • •

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Mark A. Stebnicki, PhD, LCMHC, DCMHS, CRC, CMCC, is professor emeritus and former coordinator of the Military and Trauma Counseling (MTC) certificate program in the Depart-ment of Addictions and Rehabilitation Services at East Carolina University. He developed the MTC certificate in 2015 and the Clinical Military Counseling Certificate program offered through the Telehealth Certificate Institute in 2016. Dr. Stebnicki is an active teacher, trainer, researcher, and practitioner with more than 30 years of experience working with the psychosocial reha-bilitation and mental health needs of adolescents and adults with posttraumatic stress symptoms, chronic illness, and disability. His primary areas of interest relate to the medical, psychosocial, vo-cational, and mental health needs of persons with chronic illness, individuals with disability, military service members, veterans, and their families.

Dr. Stebnicki has extensive experience in disaster mental health response. He is certified by the Washington, DC-based crisis re-sponse team the National Organization for Victim Assistance and North Carolina’s American Red Cross Disaster Mental Health crisis response team. He served on the crisis response team for the Westside Middle School shootings in Jonesboro, Arkansas (March 24, 1998), and has done many stress debriefings with private companies, schools, and government employees after incidents of workplace violence, hurricanes, tornadoes, and floods. His youth violence program, the Identification, Early Intervention, Prevention, and Preparation Program, was recognized nationally by the American Counseling Association Foundation for its vi-sion and excellence in the prevention of youth violence. Other honors include consulting with President Bill Clinton’s staff on addressing the students at Columbine High School after their critical incident (April 20, 1999).

About the Author

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About the Author

Dr. Stebnicki has served in many statewide and national profes-sional counseling associations and on several accreditation boards. He has written a total of 10 professional texts, most recently Clini-cal Military Counseling: Guidelines for Practice (2021, American Counseling Association), Disaster Mental Health Counseling: Re-sponding to Trauma in a Multicultural Context (2017, Springer), The Psychological and Social Impact of Illness and Disability (7th ed.; edited with Irmo Marini; 2018, Springer), and The Professional Counselor’s Desk Reference (2nd ed.; edited with Irmo Marini; 2016, Springer). He has written more than 40 journal articles and book chapters and has presented at more than 100 regional, state, and national conferences, seminars, and workshops on topics ranging from military mental health, traumatic stress, and empathy fatigue to the psychosocial aspects of chronic illness and disability.

• • •

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Introduction

Chasing plagues had never entered my consciousness as a mental health and rehabilitation practitioner, counselor educator, and researcher. However, those who work in the laboratory, out in the fields, and in bat caves to collect data on viruses that could potentially alter the history of humankind are champions. Who would have thought that spending months collecting samples of bat feces and saliva could be such important work? Indeed, viruses have existed on planet Earth since the beginning of humankind. The nature of viruses is that they change their genomic sequences and mutate into highly infectious diseases such as the novel (meaning “new”) coronavirus (COVID-19). The constant comingling of different genomic sequences globally has created dangerous new pathogens that have lethal consequences for humankind.

Counseling Practice During Phases of a Pandemic Virus was in-spired by my more than 30 years of experience as a mental health and rehabilitation practitioner, counselor educator, clinical supervisor, and researcher. My areas of interest are chronic illness and disabil-ity, disaster mental health response, and traumatic stress. My work has guided me to provide mental health and rehabilitation services to active-duty service members, veterans, veterans with disabilities, and military families. I have worked in hospitals, a physician’s office, nursing homes, outpatient clinics, and a variety of rehabilitation pro-grams. My interest in disaster mental health response was accelerated when communities where I lived and worked were at the epicenter of school shootings, workplace violence, hurricanes, floods, tornadoes, and earthquakes. Despite all these experiences, I am a student all over again studying a new type of natural disaster—a pandemic virus. So now I am chasing plagues.

Metaphorically speaking, the new anthem in disaster mental health response may not look like the old mental health hymnal. There are human casualties, restrictions on our freedoms, government mandates, and public health guidelines for protection and safety. We as Americans

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Introduction

have made multiple attempts to try and restore some normalcy in our lives. It requires a significant amount of psychological/emotional real estate to build a treatment center within our mind, body, and spirit to try and make ordinary sense out of an extraordinary stressful and trau-matic event. The operation tempo is relentless because the viral enemy combatant never sleeps or takes a day off. Thus, it is essential that we prevail on the COVID battlefield. Overall, the medical, physical, and psychological costs of fighting an unseen enemy such as COVID-19 and its mutant strains have been imprinted on our mind, body, and spirit.

The fields of psychology and counseling must cultivate new research and training opportunities for mental health and allied helping profes-sionals to work across all age groups and cultures during phases of a pandemic disaster. We must create pandemic identification, prevention, and therapeutic intervention programs. We should never again delay a disaster mental health response as we did during the summer and late fall of 2020. The current and predicted increase in anxiety, depression, posttraumatic stress, and substance use disorders is pervasive across all age groups. The COVID-19 pandemic has spawned an increase in suicidality that is the direct result of untreated, undertreated, and unrecognized mental health symptoms and conditions. Accordingly, the psychology and counseling professions are challenged with recon-ceptualizing disaster mental health programs and services for pandemic survivors using new technology (i.e., telebehavioral health) and other therapeutic interventions yet to be developed and implemented.

At War With a Pandemic Virus

We need to cultivate a fighting spirit in the COVID war as we enter the COVID Generation.1 Disaster mental health response through-out phases of the pandemic virus necessitates a high level of empathy and compassion toward individuals, groups, communities, and cul-tures who are COVID survivors. As a profession, we are challenged to reconceptualize disaster mental health response as we transition throughout phases of a pandemic virus that some experts project will kill up to 700,000 people in the United States. So how serious is it? The U.S. Department of Defense met the Federal Emergency Man-agement Agency’s request during April 2020 to ship 100,000 body bags to aid state and local governments in managing the growing number of COVID-19 fatalities (Entress et al., 2020). It is worri-some that some Americans still do not take coronaviruses seriously by not using good hygiene, rejecting the COVID-19 vaccines, and dismissing the overall positive effects of the federal government’s im-munization program on decreasing deaths related to COVID-19 and

1At the time of this writing in April 2021, the COVID Generation does not have a unified definition and has relational meaning in the literature primarily to children and adolescents.

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Introduction

its mutant variants. The rate of spread of the infection, accompanied by the severe illness, mortality, and mutant variants of COVID-19, has resulted in long-lasting aftereffects that will likely be with us for the next several years.

We have been at war since the start of 2020 with an unseen enemy combatant, COVID-19. New radical insurgencies of coronavirus mu-tations have emerged as a threat to humanity. One splinter cell first identified as VUI-202012/01 began its assault in England and moved to the United States in January 2021. By February 2021, this variant as well as South African and Brazil variants had spread throughout most states. The problem with these mutant viruses is that they can spread 50–70% times faster than the original COVID-19 virus. Worldwide, other coronavirus variants have been identified also. The enemy we are confronted with is invisible except to virologists, infectious disease specialists, epidemiologists, and public health experts.

The coronaviruses of the 2020–2021 pandemic have left scars within our memories and hearts, with more than 30 million infections and well more than 550,000 COVID-19-related deaths by early 2021. We have COVID fatigue that manifests as serious medical, physical, and mental health concerns. So how long can we sustain both the pandemic virus and mental health crisis in the United States? Now that the vaccine rollout and immunization have begun, we are try-ing to restore some normalcy and balance to our lives by reopening schools, businesses, the service industry, entertainment venues, and other areas. It is critical that we try and make ordinary sense out of an extraordinary stressful and traumatic event by adjusting and adapting our strategies on the COVID battlefield.

Will There Be an End to the Coronavirus Pandemic?

Infectious viruses and diseases have been with us since the beginning of time. They are a naturally occurring phenomenon. They can adapt and survive in a variety of conditions but must have a human and/or animal host to exist in their virulent and highly contagious state. It may be that viruses inherit the earth (Tyson, 2007). So is there an end in sight to COVID-19? This is much like asking “How long will it take before the sun’s fuel burns out?” It is helpful to understand that there is no beginning or end to a viral contagion.

The journal Nature explores what the science says about how COVID-19 will play out in the months and years to come. Scientists indicate that for the pandemic to end, either COVID-19 must be eliminated from the global population (which is near impossible) or between 50% and 80% of the world’s population must build up sufficient immunity through either infections or vaccinations (Scudellari, 2020). Public health officials and infectious disease experts have said it is very likely that COVID-19 will become an endemic disease. Essentially this novel coronavirus will always be present in our environment with

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Introduction

possible mutation in the human genome long after the government immunization program ends. If we are fortunate, COVID-19 will be classified as a low-level contagion. Thus, the medical, mental, and public health care systems as well as the world economy will have to learn how to survive this endemic virus.

The challenges in the COVID Generation are unlike any others. It would be naive to imagine that once the COVID-19 vaccines have been distributed and administered to most of the world’s population that a book such as this will no longer be relevant. In fact, rabies still exists today, despite Louis Pasteur’s development of a successful vaccine in 1885. Tetanus (vaccine developed in 1927), measles, mumps, and rubella (1971), hepatitis B (1982), and hepatitis A (1995) all have the potential to be public health crises in certain occupational settings and regions of the world despite the public perception that these diseases have been eradicated. Fortunately, the COVID-19 vaccines on the market have about 72–95% efficacy in treating COVID-19. However, we will need to continue collecting data on those who have been immunized given the new coronavirus variants.

The good news is that we are in a much better place now than Americans were during the 1918 H1N1 (Spanish flu) pandemic, when approximately 675,000 people in the United States died. The measures available in 1918 to mitigate the spread of a viral contagion were extremely limited. That pandemic predated antibiotics and did not involve epidemiology, highly specialized lab sciences for deciphering the genomes of infectious diseases, or the technology used today by the pharmaceutical industry in the research and development of vaccines. There were no diagnostic tests available to confirm infections and no antiviral medications that could significantly reduce symptoms of the virus. Thus, we have seen improvements coming out of the 20th century and into the 21st. This is evident by advancements in disease surveillance, diagnostic testing, situational awareness, community mitigation science, and a system of public health communication (Jester et al., 2018).

A Pandemic Virus and a Mental Health Crisis

In the past several years, there has been a resurgence of interest within epidemiology in infectious diseases. Data are available from past pan-demics (i.e., severe acute respiratory syndrome coronavirus 2, H1N1 flu, Ebola, Middle East respiratory syndrome, HIV/AIDS) to help guide medical practitioners in disease surveillance, medical evalua-tion, testing, prediction, preparation, and treatment. However, the same cannot be said of psychology, counseling, and disaster mental health response, which offer few guidelines to inform assessment, prevention, and mental health treatment during phases of a pandemic virus. Hence, the motivation for this unique work in mental health is to identify, recognize, prepare for, prevent, and apply therapeutic strategies for pandemic survivors. It is essential to have resources avail-

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Introduction

able to address issues related to the medical, physical, psychological, behavioral, and psychosocial impacts of a highly infectious disease in combination with a mental health crisis.

During the early phases of the 2020 COVID-19 pandemic, the refrain repeated in American popular culture was that “we are all in this together.” Also during 2020 were a rise in White nationalism, systemic racism, political divisiveness, the propagation of media-driven conspiracy theories, civil unrest, and economic disintegration, all interacting with this lethal virus to hinder the public health and safety of Americans. To complicate matters even further, there was an ongoing 20-year war on terrorism, cyberattacks on our homeland security infrastructure, and the insurrection at the Capitol on Janu-ary 6, 2021. Overall, it is my contention that we are not all in this together, because this statement assumes that all persons are living life at the same level of medical, physical, and mental functioning.

The statement that “we are all in this together” also implies that we all enjoy the same benefits and privileges in terms of socioeconomic status, access to quality health care, jobs, civil rights, as well as ad-equate support systems and other resources. Thus, we are not all in this together. Many Americans do not recognize the seriousness and lethality of the COVID-19 pandemic based on their questioning of the use of vaccines, wearing masks, social and physical distancing, and other virus hygiene protocols. Instead of “We are all in this together,” I would offer the reframe “We are all our own best support system.” It is only when we can come together in the present moment that good things will unite our communities and regions. Until then, many Americans are surviving at a basic level instead of thriving.

The medical, physical, psychological, behavioral, psychosocial, and economic impacts of viral contagions have catastrophic impacts on in-dividuals, groups, communities, and cultures. Pandemic viruses mimic other natural disasters, such as floods, hurricanes, tornadoes, wildfires, and earthquakes, all of which also occurred in 2020. However, a pandemic disaster involves other losses, such as the large-scale loss of life, health, jobs, careers, educational opportunities, social and entertainment activi-ties, as well as many other things. This pandemic disaster is not confined to one geographic location. Rather, this viral contagion has had a global impact. All the calamity of 2020 will be etched and mapped into the human consciousness in an infinite number of ways. The result will be a historical trauma that lives in the mind, body, and spirit of humankind, much like the Black Death of the 14th and 17th centuries in Europe and the Spanish flu at the start of the 20th century in America.

The New Anthem for Counseling Practice During a Pandemic Virus

The number of extraordinary stressful and traumatic events has grown worldwide since 2001. Anyone who watched the January 6, 2021,

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Introduction

attack on the U.S. Capitol in Washington, DC, by pro-Trump ex-tremists knows that this September 11th-style attack on the homeland has threatened psychological safety and security in an already tense COVID environment. Fears and anxieties over the war on terror-ism; catastrophic natural disasters prompted by climate change; mass shootings in schools and entertainment venues; and the spewing of toxic chemicals by large industries that poison our air, water, and food supply have become integrated with fears and anxieties associ-ated with a pandemic virus that has threatened humankind. Fueling our fears and anxieties are videotaped images that replay on 24-hour news stations and a daily dose of other frightening stories in print and electronic media. Thus, we are surrounded by a daily digest of trauma unfolding in real time. The only breaking news stories missing from this list are a zombie apocalypse or alien invasion. For some, planet Earth does not appear to be a safe place to live.

Today we are singing a new anthem because of the paradigm shift in disaster mental health response. There is a world full of sickness introduced by a highly infectious viral contagion. We are required to reconceptualize how to heal the mind, body, and spirit of individuals, groups, communities, and cultures affected by a new natural disaster: novel coronaviruses. The new normal in mental health is that anxiety and fear of the next pandemic viruses may have become integrated into our psychological and emotional well-being. For some, the idea of a deadly germ in our environment has sparked neurotic thoughts, feelings, and behaviors that have become chronic and persistent pat-terns leading to mental health issues. Thus, the anxiety and fear we feel around a continually present viral contagion has been integrated into our unconsciousness. Overall, the emerging COVID Generation requires an intensive research agenda to identify, recognize, and explore the unique mental and behavioral health characteristics of individuals, groups, communities, and cultures that have difficulty living optimally. It is paramount that mental health professionals facilitate new meaning and understanding with COVID survivors. Cultivating a perception and attitude of healing the mind, body, and spirit will teach us how we can thrive rather than just survive pandemic disasters.

Foundational Principles of a Pandemic Virus

Counseling Practice During Phases of a Pandemic Virus is a compre-hensive and foundational resource for mental health counselors and allied helping professionals. This work identifies, discusses, analyzes, illustrates, and differentiates characteristics of the COVID-19 pandemic from other natural disasters. It offers a compass to facilitate the use of pandemic disaster strategies with adults, adolescents, and children. A key asset of this work is the pandemic risk and resiliency continuum (PRRC) theoretical model, which offers mental, behavioral, and psy-

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Introduction

chosocial health benchmarks that can potentially be tracked through-out phases of a pandemic virus. The PRRC model has been critically reviewed by a panel of eight experts in disaster mental health response, epidemiology, medical and psychosocial aspects of illness and disability, and applied behavior science. Feedback from the subject matter experts was integrated into and is reflected in the PRRC theoretical model.

Counseling Practice During Phases of a Pandemic Virus is essential reading for members of the counseling, psychology, and public health professions. The ongoing public health crisis has created documented medical, physical, and mental health impacts on our overall well-being. We cannot watch from the sidelines: Failing to respond is not an option if we care to thrive, rather than just survive, during this pandemic virus. So how do we come out of the darkness and into the light and bring new meaning to such catastrophic and traumatic events? How do we facilitate good medical, physical, psychological, emotional, social, psychosocial, occupational, spiritual, and cultural healing during a pandemic disaster?

Most COVID-19 cases are identified and treated in health care settings by medical professionals who have little or no training in the assessment, diagnosis, and treatment of psychiatric conditions associated with mental, behavioral, and psychosocial health conditions. Thus, education and training regarding the screening of mental, behavioral, and psychosocial health issues would enhance patients’ overall medical, physical, and mental functioning. This work is a unique resource for mental health and other allied helping professionals who work in a variety of clinical, school, and community-based health care settings. The intention is to prepare professionals to meet the intense challenges of pandemic viruses in the 21st century. More specifically, this work

1. identifies children, adolescents, adults, and families who are at low, moderate, and high risk for mental, behavioral, and psycho-social symptoms related to pandemic viruses with the intention of triaging the most at-risk persons for follow-up services;

2. discusses the use of specific intake interview questions and ap-propriate functional assessments to assess low-, moderate-, and high-risk clients;

3. illustrates how risk and resiliency factors occur on a continuum during pandemic viruses using the PRRC theoretical model;

4. differentiates mental, behavioral, and psychosocial symptoms that are healthy-normal and unhealthy-abnormal as they relate to a pandemic virus;

5. appraises salient features of the assessment, diagnosis, and treatment of mental health conditions that interfere with daily functioning in multiple life areas;

6. explores the grief, loss, and psychosocial experiences associated with pandemic viruses;

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Introduction

7. describes the various phases and stages of pandemic viruses that should be anticipated for the application of prevention and treatment approaches;

8. illustrates specific adjustment and adaptation stages of a pandemic virus and how they impact mental, behavioral, and psychosocial functioning;

9. delineates through the phases of pandemic rehabilitation model the essential tasks of navigating and transitioning through criti-cal stages of a pandemic virus;

10. identifies coping and resiliency resources for persons that can serve as a means of prevention and treatment of mental, behav-ioral, and psychosocial symptoms during phases of a pandemic virus; and

11. discusses how to recognize and prevent the symptoms of empa-thy fatigue so professionals can function optimally and provide services to those in need during a pandemic disaster.

Overall, Counseling Practice During Phases of a Pandemic Virus provides a new paradigm for professionals dealing with the mental, behavioral, and psychosocial health of individuals, groups, communities, and cultures. The material presented is based on the opinions of subject matter experts; extensive research in disaster mental health counsel-ing; theories of trauma-informed counseling; and clinical applications in the fields of counseling, psychology, traumatology, epidemiology, behavioral health, and public health sciences.2

2The Centers for Disease Control and Prevention’s (CDC) guidelines for COVID-19 have been dynamic during 2020–2021 as they have offered interim guidance to healthcare professionals, businesses, educational systems, and the general public. Guidance on appropriate virus hygiene protocols such as use of masks in public schools and other settings reflects the current state of epidemiological concerns of COVID-19 infections, disease transmission, geographic hot-spots of variants, and mortality. Thus, the CDC guidelines for good virus hygiene have been adapted by some states, institutions, and organizations but dismissed by others based on their unique circumstances. Readers should consult the latest federal, state, and local health institutional guidelines for appropriate virus hygiene and disease containment issues in their area of the country.

Chapter

1

1

Theoretical Aspects of Risk and Resiliency During a Pandemic Virus

The purpose of this chapter is to discuss, analyze, recognize, and illustrate risk and resiliency factors that are of clinical significance in individuals seeking mental health and allied helping services during a pandemic virus. My theoretical model, called the pandemic risk and resiliency continuum (PRRC) model, is illustrated in Chapter 2. It offers a unique perspective, with two separate models: resiliency (excellent to poor resiliency) and risk (low to extreme risk), each assessed on a 5-point scale. The models of resiliency and risk each comprise four major categories of characteristics and traits: (a) mental health, (b) behavioral health, (c) psychosocial health, and (d) medical/physical health. The foundations for good mental, behavioral, and psychosocial health are explored in this chapter. The focus is on individual resiliency and risk factors observed during phases of a pandemic disaster. The intention is to enable helping professionals to anticipate, prepare for, and prevent adverse mental, behavioral, psychosocial, and health reactions.

Research generally suggests that during other natural disasters 30–50% of individuals will acquire adverse medical, physical, and psychological conditions. Short- and long-term consequences can negatively impact individuals’ overall medical, physical, and mental health and well-being. Reconceptualizing disaster mental health mod-els and applying the results to phases of a pandemic virus will assist practitioners in appraising risk and resiliency during a pandemic virus. Ultimately, clinical researchers and practitioners may want to develop pandemic disaster prevention and intervention approaches with the intention of decreasing the mental, behavioral, and psychosocial risk factors that predispose individuals to depression, anxiety, substance use, and posttraumatic stress disorders.

Chapter 1

2

The PRRC is based on extensive research in disaster mental health response; theories of trauma-informed counseling; and clinical thera-peutic applications in the fields of counseling, psychology, traumatol-ogy, grief, death, and dying, which is generally reflected throughout this work (e.g., Baker & Cormier, 2015; Biddlestone et al., 2020; Boss, 2006; Dong & Bouey, 2020; Echterling et al., 2005; Fiorillo & Gorwood, 2020; Garfield, 1979; Germani et al., 2020; Lopez Levers, 2012; Manderscheid, 2007; J. E. Miller et al., 2020; Morganstein & Ursano, 2020; Muratori & Haynes, 2020; National Center for Health Statistics, 2020; Ornell et al., 2020; Pappas et al., 2009; Razai et al., 2020; Reyes et al., 2013; Shigemura et al., 2020; Shultz et al., 2016; Steardo et al., 2020; Stebnicki, 2000, 2005, 2007, 2008b, 2016a, 2017, 2018b; Stebnicki & Marini, 2016; Updegraff & Taylor, 2000; Wind et al., 2020; Worden, 2009). Additional considerations have been given to a variety of clinical observations, documented case studies, personal testimonials, and experiences of disaster and trauma survivors. Overall, the theories expressed by the PRRC theoretical model are delineated throughout the chapters of Counseling Practice During Phases of a Pandemic Virus.

Shortcomings in Theories of Pandemic Disaster Mental Health Response

Natural disasters (e.g., floods, hurricanes, tornadoes, wildfires, earth-quakes), person-made disasters (e.g., school shootings, terrorist attacks, workplace violence), and technological/biological disasters (e.g., cyberattacks, toxic chemical spills, nuclear and industrial accidents) have distinct psychological stressors and clinical characteristics. Simi-larly, pandemic disasters have unique characteristics of their own that hinder mental, behavioral, and psychosocial functioning. Each type of disaster has its own separate theories, constructs, and strategies that underlie the mental health response that are typically attributed and generalized to individuals, groups, communities, and world cultures (American Counseling Association, 2020; Baker & Cormier, 2015; Echterling et al., 2005; Lopez Levers, 2012; Stebnicki, 2000, 2005, 2007, 2008b, 2016a, 2017; Substance Abuse and Mental Health Services Administration, 2020c).

However, few studies address the mental, behavioral, and psychoso-cial health concerns of pandemic viruses such as the novel coronavirus (COVID-19). During the past 30 years, the extensive research on disaster mental and behavioral health has focused largely on natural and person-made disasters (Boss, 2006; Lopez Levers, 2012; Muratori & Haynes, 2020; National Organization for Victim Assistance, 2020; Schneider Corey & Corey, 2021; Stebnicki, 2016c, 2017; Van Der Kolk, 2014). For example, in the United States, studies of pandemic viruses have primarily centered on AIDS and HIV, which were first

Theoretical Aspects of Risk and Resiliency During a Pandemic Virus

3

reported in 1981. There are four decades of research related to the HIV/AIDS epidemic and pandemic. Thus, there are a considerable amount of research related to the medical, physical, psychosocial, and behavioral aspects of these infectious diseases (Eaton & Kalichman, 2020). By 2006, the HIV/AIDS pandemic had resulted in an esti-mated 65 million infections and 25 million deaths worldwide (Centers for Disease Control and Prevention [CDC], 2006). The estimated number of positive cases of HIV/AIDS in 2018 had been reduced to approximately 38 million worldwide (UNAIDS, 2019). Thus, profes-sional education, training, and HIV/AIDS prevention and intervention programs have demonstrated effectiveness in reducing the incidence and prevalence of this pandemic. However, the same is not true for the COVID-19 pandemic disaster, as health care providers and the public health infrastructure are overwhelmed. In addition, there has been a significant increase in the number of Americans experiencing depression, anxiety, substance use, and posttraumatic stress disorders.

Early researchers suggested that personal psychological growth is essential for transcending adversity and cultivating coping and resiliency skills during extraordinary stressful and traumatic events (Csikszentmihalyi & Nakamura, 2002; Siebert, 2005; Tedeschi & Calhoun, 2004; Updegraff & Taylor, 2000). The construct of resiliency encompasses other concepts, such as hardiness, resourcefulness, and mental toughness, which serve as coping resources for individuals in crisis (Schneider Corey & Corey, 2021). In the aftermath of a crisis, disaster, or trauma, it is vital that survivors draw on strengths and coping resources that perhaps were not recognized by themselves and others before the critical event (Stebnicki, 2017).

Over the past several years in the United States, there has been a resurgence of interest in studying the mental, behavioral, and psy-chosocial aspects of pandemic viruses. Emerging infectious diseases remain a top priority and challenge for public health officials engaged in the business of human survival (Germani et al., 2020; Morens et al., 2008; Pappas et al., 2009; Reyes et al., 2013; Wang et al., 2020). Today’s epidemiological and psychological concerns with viral infec-tions may have arisen with the 2013–2016 outbreak of West African Ebola virus disease. A resurgence of the Ebola virus was observed in December 2013, when an 18-month-old boy from the rural forested region of southeastern Guinea was suspected of having been infected by bats. The Ebola pandemic was the largest, longest, deadliest, and most geographically expansive disease outbreak in the 40-year inter-val since Ebola was first identified in 1976 (Shultz et al., 2016). At the height of this disease outbreak in 2014, the Ebola virus spread globally. It coincided with the CDC training 6,500 U.S. health care workers and 24,655 other health care workers in West African countries of Guinea, Liberia, Sierra Leone, and Mali (CDC, 2019a). In 2014, the CDC reported 11 cases of travel-related Ebola virus in

Chapter 1

4

the United States. Fortunately, the spread and transmission of Ebola virus infection in the United States have not reached the levels of the COVID-19 virus.

The Ebola virus is one example of a virus with the potential to morph into a lethal viral contagion and become a pandemic. The pathways and transmission of Ebola and many other viruses, such as COVID-19, are of paramount concern for epidemiologists and world health care organizations tracing, tracking, and analyzing viral DNA to treat these highly infectious diseases and develop vaccines to prevent their spread. Unfortunately, the counseling, psychology, and disaster mental health fields have not kept pace with the virologists, epide-miologists, and other medical specialists who study viral contagions. Thus, it is essential that researchers gain a complete understanding of the mental, behavioral, and psychosocial risk and resiliency fac-tors associated with pandemic viruses. A greater understanding is needed to treat individuals affected by the unique characteristics of a pandemic disaster.

Coping, Risk, and Resiliency as They Apply to the PRRC Theoretical Model

The impressive research on coping, risk, and resiliency is worthy of a book on its own. However, these constructs have been sparsely ap-plied since the COVID-19 pandemic began. Thus, for the purpose of describing the PRRC theoretical model, I offer some key applications and definitions of these constructs.

Coping

Coping strategies and stress appraisal have been studied for decades by classical theorists and stress researchers (e.g., Frankl, 1959; Kabat-Zinn, 1990; R. S. Lazarus, 1999; R. S. Lazarus & Folkman, 1984; Sapolsky, 1998; Selye, 1950). The literature on how individuals cope with a variety of medical, physical, and psychological conditions is quite substantial. Coping, as it relates to persons with chronic illness and disability, is a psychological strategy used to decrease, modify, or diffuse the impact of stressful and critical life events (Livneh & Antonak, 2018). The defining characteristics of coping include how people (a) exhibit and experience coping as a state or trait; (b) con-trol or manipulate their coping strategies; (c) organize their coping style around a range of internal and external characteristics; and (d) respond affectively, cognitively, and/or behaviorally.

Individuals exhibit a range of healthy and unhealthy coping strategies to lessen the impact of extraordinary stressful and traumatic events. Some examples of coping strategies include denial, regression, com-pensation, rationalization, and diversion. Falvo and Holland (2018)

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described coping strategies in relation to persons with chronic illness and disability as subconscious mechanisms for dealing and coping with the stress of their medical/physical condition. Thus, the intention of coping is natural. It is a means for people to reduce their levels of stress and anxiety. Coping styles are particularly relevant for individu-als dealing with medical, physical, psychological, public health, and environmental impacts of the coronavirus pandemic.

Risk

It is difficult to provide a parsimonious definition of risk-taking as it relates to phases of a pandemic virus. This is because risk-taking is a multidimensional construct that involves thoughts, feelings, cogni-tions, experiences, and behaviors. It also involves risk-taking attitudes and behaviors that determine a range of decision-making strategies to safely navigate complex, uncertain, and dangerous activities (H. F. Chan et al., 2020). There is limited empirical evidence of psycho-logically based risk-taking behaviors measured during the COVID-19 pandemic. However, it is essential to understand that risk-taking is a multifaceted construct that is measurable and observable by oneself, others in the environment, and mental health practitioners. The in-tersection of agreement of these three observers (self, others, profes-sionals) involves a complex equation defining What is risky behavior? The construct of risk-taking during the COVID-19 pandemic shares many characteristics and long-term implications for mental health with addictive and behavioral health concerns (Zvolensky et al., 2020). From a mental health perspective, risky patterns of behavior (i.e., suicidality, depression, anxiety, posttraumatic stress, substance use disorders) are well defined by diagnostic categories and decision trees in the fields of psychology, counseling, and mental health.

Risk also involves (a) the assessment of a situation, (b) the use of cognitions in the decision-making process, (c) acting on a decision, (d) the influence of neurobiological mechanisms on feelings and emo-tions, and (e) the navigation of complex environments associated with risk-taking behaviors (H. F. Chan et al., 2020). Regardless of how simplistic or complex the decision to take a risk is, the psychologi-cal adjustment and adaptation involved in living during phases of a pandemic virus creates unrelenting stress, anxiety, and fear for many Americans. Thus, the impact of taking risks during a pandemic virus may not be immediately known. For example, leaving your home to go shopping, go to work, and/or attend school may create appre-hension and conflict between yourself, your family members, your environment, and society. Social, interpersonal, and intimate relation-ships are particularly strained during a pandemic virus. Risk-taking is inherently involved in maintaining these types of relationships and interactions. Thus, a risk–reward decision-making process occurs as

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the average American takes daily risks in many different life areas, such as virus hygiene and living intentionally with good medical, physical, mental, and behavioral health.

Risk-taking is indeed multidimensional in nature. There is strong empirical support for the effects that emotions play and the neuro-biological consequences of risk-taking behaviors (Kusev et al., 2017). Accordingly, risk-taking is not solely a behavioral response. Rather, it has a mind-body component that propels the individual to action or inaction. For example, several key hormonal correlates act as deter-minants of risky behavior. We see this in the minirevolution of neu-roscience related to veterans responding to combat operational stress and those diagnosed with posttraumatic stress disorders (Stebnicki, 2021a). For example, chronic sustained activation and elevation of cortisol, testosterone, and oxytocin levels have been associated with the modulation of healthy and unhealthy risk-taking behaviors. These hormones influence our cognitive-emotional patterns of behavior during the decision-making process. When the biophysiological mark-ers of posttraumatic stress disorder are measured in the amygdala, the link between associative learning (Schiller et al., 2008) and the expression of other emotions (i.e., anger, sadness) is manifested by a host of mental health conditions (Lin et al., 2017).

Overall, there are critical pathways to taking unhealthy risks during phases of a pandemic disaster. Mental health practitioners are trained in distinguishing healthy risk-taking (e.g., asking the boss for a raise, trying out for the soccer team) from unhealthy risk-taking (e.g., us-ing drugs and alcohol excessively, having unprotected sex, practicing poor virus hygiene). It is critical to recognize and understand the unique risk-taking behaviors of persons transitioning through phases of a pandemic disaster.

Resiliency

Resiliency is often described as the capacity to adjust to difficult life situations. It is closely aligned with the construct of coping, in which individuals attempt to protect themselves from a psychologically dis-tressing event. A new science emerged in counseling and psychology beginning in the early 1970s that uses a biopsychosocial approach to discover a person’s resiliency and coping characteristics after ex-posure to trauma. The literature is robust, and researchers suggest that persons who are more stress hardy and stress resistant have a greater capacity for empathy and possess better overall health and wellness. These individuals enjoy what Siebert (2005) referred to as the “resiliency advantage,” which comprises eight factors: making a conscious choice in life, harnessing the power of positive think-ing, taking responsibility, having an internal locus of control, being self-motivated, not being afraid to try out new and different things,

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taking control of one’s life, and practicing positive approaches in life. Positive psychology and complementary, integrative, and behavioral health care strategies have had a significant influence on resiliency programs in the disaster mental health response (Stebnicki, 2017).

The intention of accelerating resiliency programs during disaster mental health response improves medical, physical, and mental health conditions. Resiliency programs overall have the potential to empower individuals by affecting positive change within the family system and promoting the practice of self-care. The early contributions of clinical researchers in resiliency psychology identify why some individuals are more stress hardy than others. There are excellent resiliency models to choose from that provide guidance on integrating resiliency strategies into evidence-based practices for individuals struggling with stress, trauma, and disaster-related mental health symptoms.

Mental, Behavioral, Psychosocial, Medical/Physical Health as They Apply to the PRRC Theoretical Model

The PRRC theoretical model proposed here is useful for evaluating a variety of mental, behavioral, and psychosocial health risk and resiliency characteristics as they relate to the COVID-19 pandemic. Pfefferbaum and North (2020) suggested that most COVID-19 cases are treated in health care settings by medical professionals who have little or no training in the assessment, diagnosis, and treatment of psychiatric and psychosocial conditions. Thus, education and training regarding the screening of mental, behavioral, and psychosocial health issues would enhance patients’ overall medical, physical, and mental health.

Although reliable and valid self-assessments exist for clinically diagnosing anxiety, depression, posttraumatic stress, and substance use disorders, the unique characteristics and measurement of the psychological distress experienced during a public health crisis such as COVID-19 have not yet been identified in the literature (Feng et al., 2020). A preliminary scale, the COVID-19 Related Psychological Distress scale, is under development by Feng and associates (2020) to measure psychological distress due to the COVID-19 pandemic in healthy individuals. Feng et al.’s paper presents a scientific review and discussion of this instrument.

The intent of the PRRC theoretical model in this early stage of development is to provide a global theoretical measure of a person’s experience of risk and resiliency during the phases of the COVID-19 pandemic disaster. Risk and resiliency are measured within the core areas of mental, behavioral, and psychosocial health with implications for medical and physical functioning. The psychological distress caused by pandemic viruses and its implications for mental and behavioral health practice is a unique area of study in disaster mental health response. This distinctive area involves a constellation of psychologi-