The co-occurrence of the COVID-19 pandemic and our nation’s long overdue attention to issues of racial injustice has resulted in both significant challenges and newfound opportunities on many personal and professional levels. Within the VISN 5 MIRECC we are making collective efforts to improve delivery of recovery-oriented treatments, services, and resources to help Veterans thrive during the pandemic.  We have also started on what I hope will be an ongoing and concerted effort to more actively pursue anti-racist policies and create a just and equitable environment for our staff as well the Veterans we serve.  For this current issue, we are including several items relating to our response to the COVID-19 pandemic.  Our next issue will highlight efforts relating to our progress toward being more explicitly anti-racist in both how our organization is structured and the range of activities and outputs coming from across our Research, Education and Clinical Cores.  We are all in this together and I am confident we will both survive and grow both individually as a MH Center of Excellence committed to improving the recovery and community integration of Veterans living with serious mental illness.  

With the declaration of COVID-19 as a pandemic and the unexpected transition to teleworking, a feeling of unease and uncertainty arose. Questions about what the pandemic meant and how to handle the ever-growing seriousness of the situation put many, including the Veterans we serve as well as staff, into distress. To try and answer these questions and help ease the uncertainty among us all, VISN 5 MIRECC staff decided to pull together resources at both a local and national level.

A team of VISN 5 MIRECC peer support specialists, a research assistant, and an investigator set out to create a repository of resources to support staff and the Veterans they serve on topics such as social distancing, how to stay active and engaged, ways to cope, whole health coping strategies, community resources for those in need of food or assistance, and national hotlines to assist with inquiries or crises. By spreading the word about this project to the rest of the VISN 5 MIRECC, resources found in newsletters, personal research, and from other MIRECCs across the country were sent in abundance.

Staying true to the VISN 5 MIRECC mission of enhancing the recovery and functioning of Veterans with serious mental illness, many resources focused on how to continue with recovery and prevent relapse during quarantine. Specifically, many of the resources focused on assisting interventionists as they continued to provide services to Veterans virtually. These included training resources, guides on how to provide remote services and resources for interventionists’ self-care to ensure their well-being. Making these materials accessible to the interventionists allowed for a smoother transition to working virtually with Veterans.

In addition to gathering a repository of resources for MIRECC staff and Veterans who are participants in our MIRECC studies, we also wanted to provide support to VA clinicians across the country who are continuing to provide recovery-oriented clinical care to Veterans in these stressful times. To this end, MIRECC Investigator and Clinical Core Assistant Director, Dr. Anjana Muralidharan initiated a project to create a recovery handout to be shared at a national level with clinicians so they might pass it on to the Veterans they serve. The collaborative efforts of Dr. Muralidharan, Certified Peer Support Specialists Howard Turner and Tracy Robertson, Research Assistant Kinnera Atluri, and Communications Specialist Joanna Strong Kinnaman, led to the creation of a resource with the primary focus of setting the VISN 5 MIRECC’s vision of Putting Recovery into Practice into action. The resource, found here, utilized each of the ten SAMHSA guiding principles of recovery to help demonstrate ideas for coping during physical distancing. The different principles of recovery include hope, person-driven, many pathways, holistic, peer support, relational, culture, addressing trauma, strength and responsibilities and respect. The team discussed each principle in a collaborative manner in order to reflect all the perspectives of those who assisted and potentially reach a broader audience. Some of the ideas for coping spanned from establishing a routine and finding an information balance that works for each person, to considering physical distancing as an opportunity to give more attention to certain relationships – including pets!

This project began with the hope of finding ways to help individuals cope during these turbulent times and continues still with that hope. Everyone has different ways of handling difficult circumstances. Encouraging individuals focus on positive ways to deal with challenges, remains true to the principles of the VISN 5 MIRECC.

Reference:

In March 2020, the COVID-19 pandemic hit and caused a nationwide shift for VA mental health treatment to be provided via telehealth modalities. The existing VA Social Skills Training for Serious Mental Illness (VA SST) telehealth protocol, which requires an offsite trained SST provider leading the group via videoconference and an on-site VA provider taking the role of a “roleplay buddy” for face-to-face roleplays with the Veterans in the SST group, has shown promising fidelity, feasibility and group member satisfaction. However, it would not be ideal to implement during the COVID-19 pandemic as it requires Veterans attend groups in-person and risk virus transmission. This presented a dilemma for the provision of treatment to Veterans with serious mental illness diagnoses such as schizophrenia because it is unknown whether group therapy delivered via telehealth for individuals with serious mental illness is adequate or comparable to in-person services (Greenbaum, 2020). Despite these unknowns and by necessity, VA providers began to adapt SST for telehealth independently so that Veterans could virtually attend SST groups from their own homes via phone, Veterans Affairs National Telecommunications System (VANTS) conference calls, VA Video Connect (VVC) videoconference calls, or through a combination of both VVC and VANTS. 

The VA SST Training Program communicated with these providers to learn more about how the intervention is being adapted to identify possible clinical recommendations regarding its provision. Based on the information they provided, along with knowledge acquired from the SST literature and from VA telehealth resources, two PowerPoint presentations were developed and delivered in advanced practice SST meetings for previously trained SST providers. The presentation topics focused on providing SST groups via telehealth and providing SST individual sessions via telehealth. Initial recommendations shared in the presentations included information about group composition, telehealth methods of delivery, and practical considerations. A sample of preliminary recommendations included the following:

• SST groups of smaller size (e.g., 4-6) rather than the more typical 6-8 group member size might work better in a telehealth platform.
• Access to group member phone numbers and addresses where the Veterans are located while participating in telehealth is vital to have in case of an emergency.
• Having an SST co-facilitator for the group to follow-up with Veterans who are having technical issues during the group is helpful.

The presentations also covered topics related to modifying steps of the structured SST session sequence to accommodate a telehealth format and/or the current pandemic, modifying the discussion of the skills according to the method of telehealth delivery (e.g., an SST facilitator would discuss importance of eye contact if it is used in-person but acknowledge that eye contact is not something that can be well practiced via videoconference or via phone), and developing individualized practice assignments for outside group that are feasible and safe (e.g., involve calling someone on the phone vs. visiting someone in person). The teaching of specific social skills in the Bellack et al. (2004) manual that are relevant to the COVID-19 pandemic were also discussed. The following SST skills (among others) can be adapted for pandemic-related social situations:

• Reminding Someone Not to Spread Germs
• Making a Doctor’s Appointment on the Phone (e.g., for a telehealth appointment)
• Leaving Stressful Situations (e.g., if you find yourself in an area where you can’t maintain 6’ physical distance)
• Asking for Information (e.g., to learn how to order groceries for delivery; to ask about COVID-19 information or about how to access telehealth services)

Knowledge about SST via telehealth is in its infancy. For this reason, bringing providers together to generate and manage knowledge about this new delivery method of SST through a virtual Community of Practice (CoP) seems wise. The purpose of this CoP organized by the VA SST Training Program is to share information, improve skills, and advance the general knowledge about SST via telehealth. A distribution mailgroup for the CoP was created, and the inaugural SST via telehealth CoP meeting was held on June 22^nd, 2020, with 51 VA staff attending. The CoP meetings are scheduled monthly and a means of managing information gained from these meetings and conducting more formal program evaluation on the developing intervention is planned. Providers trained in SST are welcome to attend the meetings, and the SST website will be updated with information about SST via telehealth as this information evolves. PDFs of the two presentations on SST via telehealth are available on the SST website http://www.mirecc.va.gov/visn5/training/social_skills.asp and additional materials will be added as this knowledge base develops. Hopefully, this is one example in which clinical practice will shape and inform future research.

References:

Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for schizophrenia: A step-by-step guide (2nd ed.). The Guilford Press.

Greenbaum, Z. (2020, July/August). How well is telepsychology working? Monitor on Psychology, 51(5), 46.

The VISN 5 MIRECC has supported several important telehealth efforts since the initiation of telework due to the COVID-19 pandemic. In two recent examples, the MIRECC initiated novel tele-consent and tele-research procedures and has helped support a local clinical program in examining more closely the responses of Veterans to telehealth services.

The Development of a Patient Centered Mental Health Intervention for Recent Veterans (RR&D RX002159) research study staff have worked hard to make the study easily accessible to Veterans remotely. Consent forms are either mailed in hard-copy or encrypted and emailed to Veterans ahead of their consent appointment. For assessments, word documents containing the response options are emailed to Veterans to allow them to follow along with the assessor during telephone appointments. All the intervention sessions are conducted through Virtual Care Manager, an encrypted VA video chat program. Overall, the switch to remote appointments has been met with praise from Veteran participants. Those who began the study prior to work-from-home have reported appreciating greater flexibility in scheduling since they no longer must drive to a VA center. They have also appreciated the ability to continue to participate in the study without putting their health at risk. New Veteran participants who have only met with us remotely have mentioned that they likely would not have been able to participate, or would not have been interested in participating, had the study been conducted in-person.

Collaboration also seems to be a driving force in a recent VISN 5 MIRECC partnered effort related to telehealth. The MIRECC is partnering with the VA Maryland Healthcare System (VAMHCS) Psychosocial Rehabilitation and Recovery Center (PRRC) located at the Baltimore Medical Center. Dr. Neil Weissman, Coordinator of the PRRC, recently reached out to Dr. Richard Goldberg, Director of the VISN 5 MIRECC, with an interest in obtaining feedback from participating Veterans about their current experiences with the telehealth services provided by the PRRC. The MIRECC helped the PRRC develop procedures and an assessment instrument focused on Veteran opinions and experiences with the telehealth program.

In this effort, the MIRECC offered initial direction for the PRRC through consultation on the best way to obtain the information from Veterans. The MIRECC also helped construct the survey with scaled items as well as open-ended questions and provided ongoing feedback and guidance on the survey. The survey includes questions such as satisfaction with group and individual telehealth sessions, progress toward recovery goals, and how much the program has helped Veterans manage their mental health symptoms (anxiety, depression, etc.).

In the current procedures, Veterans are sent mail or email copies of the survey and a MIRECC staff member reaches out to each Veteran for a telephone interview. Tracy Robertson, a MIRECC Certified Peer Support Specialist and a group facilitator at the PRRC, was chosen as the individual that would give the phone survey. As Dr. Weissman put it, “we wanted to have someone that Veterans knew and [with whom] they could be comfortable that it [the information they provided] would be anonymous.” The Veterans are informed about the forthcoming telephone surveys during telehealth groups. The telephone interview takes about fifteen minutes. According to Ms. Robertson, “Everyone who completed the survey has been willing to do it and appreciated that the PRRC was doing it. Everyone thanked me at the end.” Ms. Robertson’s general impression is that it seemed that most of the Veterans have felt fee to talk to her about their experiences and liked having an individual connection with her on the phone. The PRRC hopes to have all the information soon, and when they do, they MIRECC has also offered to help analyze the data so that the program can look at the Veteran responses in aggregate.

Dr. Weissman described the PRCC as a recovery-oriented program that values collaboration with their Veteran participants. When asked about the reason the PRRC initiated the survey, he responded, “We really wanted to know if it [the program] was meeting their needs and to what degree it was meeting their needs…we hope they [the Veteran participants] would see the obvious  - that their opinion counts a lot.” He stated that the PRRC will use the feedback to adjust the program to meet their needs better. For example, he stated that “if Veterans report being unsatisfied or doing groups seems difficult on the phone, then we might try and do more video groups.” The survey procedures were also put into place to get a general sense of the impact of social distancing on individuals’ symptoms and their recovery goals. Finally, a big question that Dr. Weissman hopes will be answered through this effort is: what might be the takeaway post-COVID? More specifically, many Veterans that attend the PRRC seem to struggle with isolation as a norm (i.e., before the pandemic). Dr. Weissman is hoping that learning more about the experiences of the PRRC Veterans could inform if telehealth services should be provided to people who are isolating as a bridge for connection or does telehealth reinforce isolation? These are important questions to answer as the program works to support the Veterans during this unprecedented time. Using this survey to get direct feedback from Veterans, look at the data in aggregate and modify the program services as needed, is an excellent way to facilitate collaboration and to involve Veterans in their own care.

These telehealth efforts have supported continued participation for Veterans in research and clinical programming that otherwise would not have been possible during the COVID-19 pandemic. And the positive responses of Veterans to these services? Is an invaluable added bonus!