Mental Wellness in Children Ages 0-5
The plethora of demands primary care routinely encounters, such as limited time, high patient volume and needs, structural barriers interfacing patient healthcare, and the risk for professional burnout, are well documented.1,2 The current global pandemic has presented anything but routine challenges for primary care to navigate. While these times are unprecedented, a literature review of previous pandemics suggests that 10% of healthcare providers may develop PTSD and many more may be impacted by symptoms of burn-out.3 National data collected over the past year suggest that the mental health toll of the current pandemic is greater than anticipated, with one quarter of essential workers having been diagnosed with a new mental health disorder since the start of the COVID-19 pandemic.4
New York State, as the early center of the COVID-19 pandemic in the United States, required primary care to mobilize rapidly in response to a catastrophic event with limited guidance or precedent for how best to support families in crisis. Family physicians, given their unique role within primary care, were tasked with managing patient care and supporting family resiliency in the context of rapidly changing medical protocols, fundamental shifts in the structure of service delivery, reduced resources, and increasing behavioral health needs. More than ever, family physicians functioned as pivotal anchors for their communities in the midst of profound uncertainty. The nature of the pandemic placed family physicians in the dual roles of having to help families on many levels while simultaneously navigating the catastrophic stressors themselves.
Project TEACH offers support to New York State PCPs through behavioral health phone consultations, in-person psychiatric consultations, trainings on a variety of media platforms, and linkages and referrals to community resources. In recognition of the evergrowing challenges that PCPs faced, and continue to face as a result of the pandemic, Project TEACH developed
and piloted wellness groups designed to support self-care, provide clinical advice, and partner with providers to help strengthen health systems. In July and October 2020, PCP wellness groups were piloted to assess feasibility and interest for a drop-in group designed to introduce key concepts of resiliency, promote resilience among providers, and identify methods for enhancing family resilience among patients. The process of offering this group to PCPs, first in the greater Syracuse area and then to the entire state of NY, illuminated tensions that arise when developing groups to support overworked and busy physicians, particularly for family physicians.
The wellness initiative emerged from informal observations that PCPs were increasingly using phone case consultations with Project TEACH psychiatrists to voice their own uncertainty, sense of loss, and emotional response to the pandemic. The conversations occurring within the context of patient-based phone consultations were felt to be emblematic of the unique dialectic PCPs, and particularly family physicians, experience secondary to the pandemic. Family physicians are pivotal sources of community strength, yet personally and professionally may feel vulnerable to systemic stress. They help hold patientsâ heightened anxiety, while simultaneously navigating the uncertainty of living through the same catastrophic event themselves. In recognition of the need for more formal opportunities to support wellness and resilience, a group model was developed to help mirror the dual task that PCPs have been charged with during the pandemic â caring for their patients while caring for themselves.
The first 4-session group held in July, 2020 (Series 1) was structured around providing short mindfulness and compassion-based practices with debriefing at the start and end of the group to help bolster wellbeing. Participants were empowered in each session to self-identify what they would experience as most beneficial to discuss, whether it was a challenging behavioral health case, extended mindfulness exercises, or other special topics. Based on feedback from participants, the groupâs focus was altered in framing and structure for the second 4-session group held in October, 2020 (Series 2) to include a more structured resiliency-based framework for PCPs in their work with patients and families. Short mindfulness and compassion-based practices to support provider resilience continued to be offered in Series 2. Each of the two series of group sessions utilized a drop-in open enrollment model. Approximately 10-15 PCPâs registered for each session in Series 1, which was limited to Central New York in piloting the program. During Series 2, registration increased to 12-20 for each session and was expanded to PCPs throughout New York State. Online satisfaction surveys were provided to participants following each series for feedback regarding structure, educational value, and suggested topics of discussion for future sessions.
In selecting self-care practices, efforts were made to identify brief exercises that could be easily integrated into the rapid pace of primary care, such as grounding practices like â5-4-3-2-1â or the compassion practice âbreathing in for oneself and out for the patient.â5 The materials from these drop-in groups and information on potential future groups can be found on the Project TEACH website: https://projectteachny.org/resources/. Given the demand for these wellness groups and positive feedback from participants in both sessions, a third round of PCP wellness groups of four sessions was provided statewide in February through March, 2021.
Themes that emerged during the process of these wellness groups included: 1) Challenges associated with creating space for self-care within busy workplace settings; 2) The importance of finding ways to increase community and reduce a sense of isolation; and 3) The unique role that PCPs, particularly family physicians, play in identifying structural sources of distress and advocating for solutions.
In Series 1 there was a strong tension between PCPs wanting a space to discuss their own wellness and mental health needs and the pull to discuss difficult behavioral health cases they felt alone in managing. They readily identified their own high levels of stress and anxiety, yet the discussion frequently defaulted to finding concrete solutions for their patients. One PCP in the cohort insightfully observed, âI know I need this [mindfulness exercises offered during group] but I canât switch out of this headspace [of work].â The absence of readily available school supports and other mental health resources for children and families during pandemic times in this largely rural cohort of PCPs genuinely resulted in a feeling of being âleft holding it all.â
Self-care, in this case and for many, was primarily about surviving the workday and prioritizing patient needs. This stark reality of primary care in under-resourced communities, and the level of personal sacrifice asked of family physicians during the pandemic was striking. Being mindful of this reality, Series 1 balanced providing collective resources to address specific case-based questions and holding space for providers to also share together and support one another in practicing during pandemic times.
Series 2 utilized a more structured and educational model for promoting discussion. The focus shifted more directly to resilience as the theme and pulled for ways providers and patients alike were thriving, in spite of numerous systemic stressors. Resilience concepts were explored in each group, such as family resilience, with a focus on âthe potential for transformation and positive growth.â6 Ensuing discussions identified how patients and providers alike were holding the emotional demands of virtual schooling, shifting schedules at school and at home, and the need for new rituals.7 The group explored the role of PCPs in supporting childrenâs and familiesâ sense of active agency and meaning making in the face of daily challenges.
In Series 2, the group composition was more diverse geographically, and demonstrated a strong desire for focus on personal wellness. The strength-based and meaning-ascribing functions offered by a resilience framework appeared to enhance the second cohortsâ increased comfort with sharing personal experiences, including the fear and intense tragedy of losing a patient to suicide.
The desire for peer connections was apparent in both Series 1 and 2. One provider new to a small rural community made a connection in the group and planned to connect over an upcoming holiday. Isolation was named as a primary challenge for all during this time, and meeting virtually in this way was one way to find connection and camaraderie.
Lastly, structural issues faced by patients and providers were discussed frequently. The global stressors of COVID-19 and racism were brought into the forefront. PCP participants in both Series 1 and 2 noted challenges of helping teenagers navigate watching potentially traumatizing social media, such as the killings of people of color at the hands of police. One PCP of color discussed his experience as a provider navigating predominately white communities and the discussions he has preparing Black and Latino teenagers for addressing this themselves. Another discussed challenges in her community regarding rising unemployment. As pillars of their communities, PCPs have an important role in understanding structural/systemic issues affecting their communities and impacting the health of children and families. These issues were magnified during the pandemic, and tasked PCPs with finding ways to hold hope for themselves and their patients.
The Project TEACH wellness groups highlighted the critical challenges many PCPs face in attending to personal wellness within the context of overburdened healthcare systems. Emergent themes highlight the critical need for structural changes to better support the resilience during the pandemic and beyond. The process of piloting and revising a support group to meet the needs of colleagues during pandemic times illuminated important experiences of PCPs across New York State, including the frequently competing needs for self- care and the logistics and weight of caring for patients with increasing behavioral health needs.
The challenge of creating time for self-care as a healthcare provider mirrors the conflict between values that have been described as integral to the culture of medicine and those that support a culture of wellness. The culture of medicine values a focus on putting patientneeds first and devalues asking for help or showing vulnerabilities.8 It also speaks to larger systemic forces within many busy practices that donât allow space or time to switch into a more reflective mode or take time for oneâs own wellbeing. In such environments, an hour of personal wellness may in fact be counterproductive when the focus is on efficiency. The themes of time challenges, and fostering health systems and environments that allow space for reflection and self-care, are not new for primary care physicians– these issues have become exacerbated in the context of added pandemic stress.
A resilience framework may offer PCPs one way to reconcile the seemingly dichotomous experiences of strength and vulnerability or caring for self and other. A focus of holding onto compassion and hope in the midst of crisis can help reframe challenging patient experiences for both patient and healthcare providers. Compassion practice can be sustainable in that it involves connecting with patient suffering while also cultivating hope; such focus on patient and family strengths and agency even in the midst of crisis can help reframe the patient and healthcare provider experience, set more realistic expectations, and improve long-term wellbeing. Simultaneously, themes from the groups highlight a critical dearth of patient resources, which was only exacerbated during pandemic times.
The process of adapting the Project TEACH wellness groups also highlighted structural adaptations needed in healthcare systems. Previous studies echo this need, with one recent study finding that the increasing expectations from patients and other healthcare specialties, compounded by limited resources and/or the ability of PCPs to independently place limits on such demands, is a huge driver of burn-out.3 Of course, finding solutions to these systemic problems is not simple. Whether it is shifting towards a multidisciplinary collaborative care model, or improving agency around time management with complex patients, solutions must focus on providing not just space to support individual wellness but collective avenues to support systemic change. The pandemic may be ending sometime in the future, but the challenges faced by PCPs, particularly family physicians, will surely remain without systemic structural change.
This article was originally published in Family Doctor, a Journal of the New York State Academy of Family Physicians, Summer 2021, Volume ten, Number one, and appears courtesy of the New York State Academy of Family Physicians.