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Disadvantages Of Narrative Therapy



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Fear of losing family members who belong to a risk group can increase. In case of death, the pandemic disrupts the normal bereavement processes of families. Grief and mourning of lost family members, especially in cases where contact with the infected member is restricted or refused, could lead to adjustment problems, post-traumatic stress disorder, depression and even suicide of both, adults and young people [ 11 ]. Taken together, this can result in enormous stress and psychological distress for all family members.

The pandemic has major economic implications and puts financial pressure on many families. It has been shown in previous economic recessions that economic pressure, even if not accompanied by social distancing, can pose a severe threat to mental health. Firstly, economic recessions and connected factors such as unemployment, income decline, and unmanageable debts are significantly associated with a decrease of mental well-being, increased rates of several mental disorders, substance-related disorders, and suicidal behaviors [ 12 , 13 ]—risks that of course also concern parents [ 14 ].

The recent recession therefore has added to the fact that low socioeconomic status is a well-known risk factor for poor mental health in children [ 15 ]. Mental illness and substance abuse of parents significantly influence parent—child relations [ 16 , 17 , 18 ] and increase the risk for mental health problems in children [ 19 ]. Additionally, in economic recessions a significant increase in domestic violence can be seen [ 20 ]. Income loss and economic hardship can lead to feelings of economic stress and consequent marital conflict [ 21 , 22 ].

Quarantine can lead to decreased freedom and privacy, and consequently higher stress. It may also increase existing controlling behaviors by perpetrators as they struggle to regain a sense of control. Exposure to perpetrators is increased, and the possibilities of victims to temporarily escape abusive partners are reduced [ 23 ]. In the current COVID crisis, there have been reports from all over the world about a significant increase in domestic violence [ 24 ].

Exposure to domestic violence again significantly affects mental health of children [ 26 , 27 ] and has the potential to create long-term consequences [ 28 ]. Moreover, a notable increase in physical, emotional and sexualized violence against children during recession has been reported. In the literature, an increase of all forms of child maltreatment has been proven during a recession in a wide variety of cultures [ 30 ]. Based on these data, for the COVID pandemic, a worldwide increase in the risks for children and adolescents is a plausible assumption. The current reduced societal supervision and lack of access to child protection services is an additional burden. Taken together, despite a lack of literature specifically addressing the impact of recession on children, existing data point towards threats to mental health of children and adolescents.

This is confirmed by one study that directly assessed adolescent mental health during the financial crisis in Greece. The researchers found an increase in mental health problems during the recession [ 31 ]. Notably, this study also demonstrates that mental health was impaired disproportionately in the most vulnerable socio-economic groups—adolescents whose families faced more severe economic pressure. Besides economic pressure, COVID pandemic-related quarantine in several countries could significantly affect mental health. Additional quarantine-related mental health problems include depression, low mood, irritability, insomnia, anger and emotional exhaustion [ 32 ].

Horesh et al. The scarcely available data point towards a detrimental effect of disease-containment measures such as quarantine and isolation on the mental health of children. Another quarantine-associated threat is an increased risk of online sexual exploitation. Since the beginning of the pandemic, children and adolescents have spent more time online, which may increase the risk of contact with online predators. As more adults have been isolated at home, there may also be an extended demand for pornography [ 35 ]. Europol has already reported an increase in child pornography since the beginning of the pandemic [ 36 ]. The question remains, whether infection with COVID can directly lead to onset or aggravation of mental disorders.

Seropositivity to influenza A, B and Coronaviruses has been associated with a history of mood disorders [ 37 ]. In addition, onset of psychotic disorders has been reported to be associated with different Coronavirus strains [ 38 ]. In summary, phases one and two of the current COVID pandemic represent a dangerous accumulation of risk factors for mental health problems in children and adolescents of enormous proportions: re-organization of family life, massive stress, fear of death of relatives, especially with relation to grandparents and great-grandparents, economic crisis with simultaneous loss of almost all support systems and opportunities for evasion in everyday life, limited access to health services as well as a lack of social stabilization and control from peer groups, teachers at school, and sport activities.

Together with multiple threats to mental health, the current pandemic could also provide opportunities. When families successfully complete the initial transition phase, the absence of private and business appointments, guests and business trips can bring rest and relaxation into family life. Several external stressors disappear. Mastering the challenges of the COVID crisis together may strengthen the sense of community and cohesion among family members. More time with caregivers can go along with increased social support, which strengthens resilience [ 39 ].

In addition, children troubled by school due to bullying or other stressors, can experience the situation of home-schooling as relieving, as a main stressor in their everyday life ceases to exist. Moreover, mastering current challenges could contribute to personal growth and development. Personal growth is an experience of psychological development as compared with a previous level of functioning or previous attitudes towards life. Thus, successful management of stress and trauma can lead to personal growth, which in turn reinforces the sense of competence and becomes a protective factor for coping with future stressors [ 40 ].

However, environmental factors such as socio-demographics, individual social networks and social support affect the outcome of a crisis [ 41 , 42 ]. Nevertheless, personal characteristics determine stress-related growth as well. These factors include intrinsic religiousness and positive affectivity. Intrinsic religiousness is suggested to help to find meaning in crisis, the relevance of positive affectivity shows the importance of positive mood and attitude for stress-related growth [ 42 ]. One major challenge after the pandemic will be to deal with its sequelae.

One main consequence will be the economic recession and its implications for mental health of children and their families, as discussed above. Economic problems may be recognized mainly after the acute phase of the pandemic, although their starting point was in an earlier phase. Some parents might have lost their jobs or businesses, while others might have to deal with an accumulated workload or face major re-organization at work. For children and adolescents, the pressure from school to catch-up for time lost during the acute phase of the pandemic may increase. However, there is evidence that rate and direction of change in macroeconomic conditions rather than actual conditions affect harsh parenting [ 43 ]. This suggests that the expectation of a negative economic development is a stronger determinant of negative parental behavior than actual recession, which could point towards the conclusion that harsh parenting and violence will have its climax during the acute phase of the pandemic.

Due to interruption of regular medical services, resources in the health care system may not be enough to overcome previous lack of treatment and supervision. Moreover, not only the accumulation of inadequately treated cases, but furthermore the enhanced need for mental health services might be a problem. The increase of mental health problems in children and their families due to recession and quarantine is discussed above and can be expected to further increase in phase three due to emerging recession. Literature suggests that mental health symptoms will outlast the acute phase of the pandemic.

In health-care workers, the risk for alcohol abuse or dependency symptoms was still increased 3 years after quarantine [ 44 ]. A quarter of quarantined subjects avoided crowded enclosed places and one-fifth avoided public spaces [ 45 ]. Additionally, the increased risk of child maltreatment and household dysfunction may not diminish immediately after the pandemic as several triggers such as economic pressure and mental health problems of parents will last for some time. Moreover, sequelae of pandemic-associated increase of maltreatment of children and adolescents may last for a lifetime. Adverse childhood experiences are known to affect the life of survivors across their life span. Long-term effects include increased risk for numerous mental and physical disorders [ 46 ], reduced life quality [ 47 ], developmental and cognitive impairments [ 48 , 49 ], social problems [ 50 ] and a reduction of up to 20 years in life expectancy [ 51 ].

The consequences of the pandemic can hit every child. However, there are several indicators that children who are already disadvantaged are at highest risk. First, financial losses will cause increased economic pressure to low-income families due to lack of savings. Second, there may be increased disparities between families with high and low socio-economic status, for example due to differences in parental support for home schooling and leisure activities during the pandemic. Specific modalities such as telemedicine and telepsychiatry may be less accessible for children of low-income families who may not have the resources to use telepsychiatry or to use it in a safe and confidential environment.

Another highly vulnerable group is that of children and adolescents with chronic disorders, for whom important support and therapies may have been reduced or cancelled. For children with intellectual disability, it can be hard to understand the situation and the necessity for the restrictions, with consequent increase in anxiety and agitation. Besides, children with disabilities are at higher risk for child maltreatment [ 52 ]. During the pandemic, due to lack of social control and impaired ability to communicate, this risk can increase. Children and adolescents having experienced adverse events before the pandemic occurred are especially vulnerable for consequences of the COVID crisis.

The experience of adverse childhood experiences ACEs is associated with higher risk for mental health problems. Maltreatment has been found to be associated with consequent heightened neural response to signals of threat [ 53 ]. Moreover, while emotional reactivity is increased, emotion regulation is decreased [ 54 ]. This suggests that children and adolescents who have experienced adversity before the pandemic are at higher risk to develop anxiety and adopt dysfunctional strategies to manage the COVIDassociated challenges.

Another important high-risk group is that of children and adolescents with already existing mental health problems. Most mental disorders require regular psychotherapy and psychiatric treatment. Therefore, lack of access to health services can be particularly detrimental. Severity and outcome of mental disorders could worsen because of delay in prompt diagnosis and treatment. This would be especially problematic for conditions such as early onset schizophrenia, in which early treatment is an important prognostic factor. However, there are more pandemic-associated risks for this group. Taking care of children with mental health problems, in particular externalizing disorders, can be challenging [ 55 ]—thus adding to the already increased distress of parents during the pandemic.

With increasing levels of psychopathology, capacity for emotion regulation and adaptive coping is reduced, while maladaptive coping increases [ 56 ], a pattern also observed in children and adolescents with a history of child maltreatment [ 57 ]. Likewise, children with previously existing psychopathology are at greater risk to show severe worry about political news [ 58 ]. Together, this suggests that current COVID crisis-associated stress is particularly harmful for children and adolescents with mental disorders or a history of child maltreatment.

On the other hand, stress exposure can enhance already existing psychopathology [ 59 ], which can lead to more severe courses of mental disorders—meeting reduced treatment resources. An impact of recession on self-harm has been shown in different studies, especially after the world economic crisis [ 60 ]. As self-harm is predominantly found among adolescents [ 61 ], an upsurge of self-injurious and suicidal behavior in youth can be hypothesized as a consequence of the COVID pandemic. This issue should receive urgent attention. Thus, it is likely that the COVID pandemic will lead to an exacerbation of existing mental health disorders as well as contribute to the onset of new stress-related disorders in many, especially children and adolescents with pre-existing vulnerabilities—aggravating pre-existing disadvantages.

Unaccompanied and accompanied refugee minors are a high-risk group for all the aforementioned vulnerabilities—low socioeconomic status, experience of ACEs and mental health problems [ 62 ]. Additionally, as some early cases of COVID have been reported in refugee institutions, shelters and camps, the consequent panic and fear of infection can increase the risk of stigmatization of refugees. As many countries are hosting a large number of refugees, and there is a lack of medical and psychiatric specialist care for them, COVIDassociated mental health risk may disproportionately hit these children and adolescents already disadvantaged and marginalized [ 63 , 64 ]. During preparation phase, it is necessary to provide clear and correct information to parents and patients.

A good understanding of COVID is important to prevent panic and help comply with the measures for containment and mitigation mandated by the government. Information can include tips for parents on how to talk to children and adolescents about COVID, the associated risks and the changes in daily life. Moreover, information on how to manage daily life at home during quarantine and social distancing as well as home schooling can be helpful. Support regarding how to address anxiety and stress in children is important For information on these issues see e. Information should be made available to parents regarding how to ensure regular psychotherapeutic and psychiatric treatment and crisis intervention during social distancing and other restrictions of phase one and two.

Parents and patients in need of ongoing medication should be advised by their doctor to stock a certain amount in case of a rupture in stock. This is not regarded as hoarding but taking adequate measures to treat chronically ill patients. Furthermore, doctors could issue extra prescriptions in order to ensure that patients have sufficient medication during phase two of the pandemic. A good option to maintain treatment during the pandemic is telepsychiatry. During the preparation phase, technical prerequisites should be met and already existing tools can be adapted. Concerns about data protection and high technical protection standards should be addressed and user-friendly systems that can be used by all age groups regardless of abilities shall be established.

It has been shown in several studies, reviews and meta-analyses, that online-delivered psychotherapeutic care for children and adolescents is feasible and effective [ 67 , 68 , 69 , 70 ], so that it can be understood as primary source of standard care in times of restricted physical contact. However, not all children and adolescents may have the technical equipment for telepsychiatry. More importantly, not all may have the opportunity for a safe, confidential space at home. In most countries, national societies of CAP have taken an active role to face the pandemic.

They have been putting forward initiatives to support the continuity of care, to guide parents, teachers, children and health professionals on how to handle the mental issues and to advocate national authorities on the bio-psycho-social impact of the crisis on the life of children and adolescents. First, CAP needs to provide services for children and adolescents with mental health disorders. A proportion of children with acute and life-threatening psychiatric disorders require CAP inpatient treatments throughout all phases of the pandemic.

Children with pre-existing mental needs, e. Due to closure of specialized and complex educational settings for children with developmental problems and multiple handicaps in many countries, problems will exacerbate. CAP institutions should keep contact with patients of special need by using online interventions or phone contact, to avoid disrupting current treatment programs and offer support to caregivers.

This would be especially problematic for conditions such as early onset schizophrenia, for which the duration of untreated psychosis has been linked with future level of functioning. Crisis interventions must be accessible all the time. This support will not only be needed by patients with existing mental health disorders, but also those developing anxiety, depression or adjustment problems and post-traumatic stress disorder as a consequence of losing near relatives during the pandemic.

Moreover, there are several additional pandemic-related risks for traumatization. As discussed earlier, domestic violence and child abuse might increase due to extended periods of isolation within an abusive or unsafe home, and less intense supervision from child protection services and lacking support from peers or schools. To offer specific help is a central task of CAP. Therefore, several appointments should be arranged for patients with new onset of child psychiatric disorders and adequate care provided. Since there is a shortage of CAP professionals throughout Europe, protection of this scare resource is crucial.

Therefore, screening of patients via helplines could be useful as a triage measure to identify the most severe cases. Patients who need to be seen in person due to an acute and severe mental health problem should pass a COVID screening before getting into contact with CAP professionals to assure appropriate safety measures including protective gear. The latter also needs to be existent in handling severely agitated or aggressive patients in emergency psychiatric care.

As COVID can spread via saliva, protective measures in addition to masks, gloves and protective clothing need to include face shields. Another important issue regarding CAP treatment during the acute phase of the pandemic are restrictions on parental visits for inpatients and their increased isolation from families and social contacts that can lead to an increased risk of depression, anxiety and suicidal behavior.

Some young child psychiatry trainees have been re-assigned to assist in other medical departments for urgent care during the pandemic [ 1 ]. This could leave them at risk of delaying or disrupting their training and qualifications. Alternatively, innovative didactic modalities such as online training and supervision, video presentations, web-based programs and courses can provide trainees in child psychiatry with formative activities. Allowing time spent in providing critical care if re-assigned to count towards their overall clinical requirements would be an important step to ensure timely completion of training. In the third phase of the pandemic return to normality , it will be important to quickly re-organize and re-establish lost treatment with patients and develop strategies for CAP to deal with the burden and strain of new patients not seen and not referred during the pandemic.

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