It seems incomprehensible now, but at the start of 2020 coronavirus (COVID-19) was a relative unknown. For the average person in Australia it felt far away, just the latest in a stream of viruses that caught the attention of the 24-hour news cycle then quickly disappeared from public awareness. Sadly, the consequences of COVID-19 have been devastating, far-reaching and required unprecedented levels of adaptation. This article explores the personal experiences of three provisionally registered psychologists (Kelly Brown, Vince Cram and Freya Wright), and their clinical supervisors (Dr Matthew Modini, Nicole Rafidi, and Dr Lil Vrklevski who shares her experiences below).
As we reflect on our experience, we wish to acknowledge our privileged position and the immense difficulties so many people in Australia and abroad are experiencing. We do not wish to detract from the importance of these stories, rather reflect on a different learning and personal experience.
Placements are an important component of training requiring students to demonstrate competent and ethical application of psychological knowledge across numerous professional domains (APAC, 2019). External placements, outside of university psychology clinics, are particularly critical for the development of students’ clinical skills. They provide a valuable opportunity to put years of theoretical study into practice with new and diverse client groups, and are often students’ first experience of working as provisional psychologists in a real-world context (Helmes & Pachana, 2006).
The Concord Centre for Mental Health (CCMH) provides inpatient care for Sydney consumers currently in the acute phase of mental illness. Students placed at CCMH typically gain practical skills providing psychological therapy to consumers with psychosis and other complex mental health needs as part of a multidisciplinary team.
Before COVID-19
From the clinical supervisor
Lil Vrklevski
This year began with every sign that it was going to be another busy, demanding yet predictable year. I was looking forward to having weekends free after having completed my own PhD studies. We had planned an educational placement for our students in the Sydney Local Health District mental health service. At CCMH we had three provisional psychologists on placement with us – Freya, Kelly and Vince – each from a different university. They had settled in well, having completed orientation without any hiccups and they had been assigned their respective wards, individual cases and commenced delivery of a cognitive behavioural therapy (CBT) group for psychosis. Even though I was keeping an eye on the news about a new coronavirus in Wuhan, I naively expected it to be an unremarkable year.
From the provisional psychologists
Kelly Brown
I was both excited and nervous, it felt like a steep learning curve to be leaving the familiarity of the university clinic and jumping into an acute mental health setting. I knew that this semester was going to be particularly challenging with concurrent internal and external placements, coursework and thesis requirements, and my part-time job. However, I had not anticipated that in the first week of placement I would also sustain an ankle injury, which would severely restrict my mobility. I was determined to complete my placement at CCMH and did not want to let a temporary setback like this prevent me from continuing.
“I remember feeling so grateful that we were supported by our placement supervisors to keep attending CCMH. However, at the same time, the news was flooded with devastating images of hospitals in Italy and Spain, overworked emergency rooms and people dying”
Vince Cram
Life was busy, so busy. It was the end of my journey to become a psychologist, with a thesis, two placements, two casual youth-work positions, and the final units of my Master of Clinical Psychology to manage. However, I was excited. This year saw far less time in lectures and the opportunity to find my feet on the wards of an intensive psychiatric care unit. I had it all planned out. Get the grades, utilise my externals as opportunities to develop my skills and explore potential careers, and upon graduation decide where I wanted to be. It all seemed so straightforward.
Freya Wright
February 2020 marked the beginning of my final year of study. I was excited and nervous at the prospect of finally practising the psychological skills I had been studying for what seemed like an age. While I had the experience of working with real clients at my university clinic, the idea of seeing patients in a hospital setting with complex mental health needs brought new challenges I was preparing myself to face. Those few weeks before COVID-19 hit were filled with a nervous energy as I sought to prove myself as worthy of a place at the multidisciplinary team meetings.
“Not only did the students cope, they were magnificent and continue to make me incredibly proud to be part of their training. I was reminded that flexibility, agility and adaptability are core aspects of the competencies required for clinical practice”
The pandemic begins
From the provisional psychologists
Kelly Brown
I was just starting to settle in and feel comfortable on the psychogeriatric ward as I built rapport with staff and clients and began to receive my first referrals. In my sessions, COVID-19 was a growing source of anxiety for clients who were aware of the age-related risks and fearful of experiencing severe complications.
It was these clients that I thought of when I suddenly came down with COVID-like symptoms myself. During four days of self-isolation, I anxiously awaited my test results, thinking of all the people I had contact with in recent days. I desperately hoped that I had not inadvertently introduced the virus to the ward while pre-symptomatic. I catastrophised, and wondered how I would live with myself if a client contracted the virus and died. When I tested negative, I felt immensely relieved. However, the realisation that I could have infected both essential staff and elderly clients was sobering.
As I recovered I questioned the ethics of returning to work with such a vulnerable population. I was not an essential staff member, and did not want to place others at any risk in pursuit of my educational goals. Around me, many colleagues were having their placements suspended or cancelled, and the university clinic was shifting to telehealth. I felt I had little choice but to request to suspend my placement. In retrospect, I should have reached out to my supervisors, rather than grappling with these issues alone.
Vince Cram
It is difficult to write about this period as one entry, each week (if not day) introduced change, stress and decisions. I had just established a routine at CCMH with my two new colleagues (Kelly and Freya), we ran CBT for psychosis groups together, and were charting the unknown waters of our first clients with complex psychotic disorders.
However, each week the rules changed. Our group numbers started to be limited, we were restricted from the geriatric wards and our previously bustling office full of occupational therapy, social work and speech pathology students was limited to three people at a time.
I remember feeling so grateful that we were supported by our placement supervisors to keep attending CCMH (many of my university cohort had already had their placements cancelled). However, at the same time, the news was flooded with devastating images of hospitals in Italy and Spain, overworked emergency rooms and people dying.
It was not long before I was the only psychology student remaining. If I am honest, most days I contemplated withdrawing, questioning whether I was truly an ‘essential worker’, particularly after my first COVID-19 scare and anxious wait for results. But I justified my presence. I was adhering to strict social distancing, my loved ones were not classified in the at-risk population, and I felt I was supporting my clients through a (hopefully) once in a lifetime event.
Freya Wright
It was not long into my first few sessions working with clients before news of COVID-19 was starting to surface. My initial reactions included minimisation and disbelief. Gradually the magnitude of the pandemic started to hit and my role as a provisional psychologist interacting with different wards and healthcare workers each day started to concern me.
In retrospect, this was exacerbated by the level of uncertainty we were facing and the constant onslaught of media reports. During this time my supervisor was always open to questions and was supportive of our learning by keeping our placements open.
Over time, news about my peers being pulled out of their placements, suspending learning or starting telehealth was surfacing daily. Discussions with friends and family working in health and the international news of the effects in countries such as Italy had me questioning my role as ‘essential’.
Ultimately, I made the decision to suspend my placement. At that time, I saw the decision as a personal responsibility to try and do my small part in the community. I reconciled myself to deal with any ramifications the suspension of my placement would have on my learning at a later stage.
From the clinical supervisor
Lil Vrklevski
By early March, I was beginning to sense that life was dramatically going to change for us all. My colleagues were voicing their anxiety and the tension in the air was palpable. NSW Health swung into gear preparing for the worst possible outcome. Our students were anxious. First Freya and then Kelly approached me, concerned about continuing their placements. Internally I wrestled with protecting the students while abiding by the directive of our Chief Executive not to terminate student placements. I reluctantly acquiesced to their requests to suspend their placements, feeling that I had let them down.
However, there was not much time for reflection or processing as I deployed staff to health hotels, responded to requests for information, experienced a crash course in Zoom, attempted to contain and support my psychologists while adapting to all the changes at breakneck speed.
During this frenzied period, I received an email from the Royal Prince Alfred Virtual Hospital (rpavirtual) General Manager, requesting psychological assistance for highly anxious and distressed COVID-19 positive patients who were being virtually monitored whilst quarantined at home or in health managed hotels. Established on 3 February 2020, rpavirtual is a pioneering new model for community-based multidisciplinary care. During the pandemic, it evolved from its initial two full-time equivalent clinical staff into 40 nurses, five doctors, a team of nine psychologists, and social workers. I remember asking, “When do you want to start?” Her response, Saturday. I had two days to recall the students, create a seven-day roster of students backed-up by clinical supervisors and be ready to start at rpavirtual.
The introduction of rpavirtual
From the provisional psychologists
Kelly Brown
As the first psychology student rostered on at rpavirtual I was not sure what to expect. Although I was extremely grateful to be continuing my placement and to have the opportunity to support people directly affected by COVID-19, I also missed being on the psychogeriatric ward and worried that telehealth might limit my learning.
I tried to approach my first shift with an open mind. Having never performed crisis-response or telephone counselling work, I was out of my comfort zone. It was challenging and fast-paced, and I had to constantly think on my feet.
On the other end of the phone people were struggling with claustrophobia, panic, anxiety, worry, frustration, sleep dysregulation and low mood, often in the context of active COVID-symptoms, financial stress, recent bereavement, or exacerbation of a pre-existing mental health condition. I was surprised at the diversity of client presentations, many of which I was encountering for the first time.
I felt supported by my supervisor, who was only a phone call away, and enjoyed working as part of a team that included experienced psychologists and nursing, medical, and allied health staff. Every shift was different and unpredictable, and I was learning more than I ever could have anticipated.
Vince Cram
On my first day, I walked into a buzzing hive of nurses, their usual urgency and pace was present but rather than seeing them hurry to the typical ward, they were equipped with two large screens and a headset. On their displays were the quarantined patients in isolation in varying degrees of illness. Some bored and frustrated, others scared and crying, several angry and oppositional, and a few just focused on fighting back the overwhelming panic.
Once I was established at a station, a nurse approached. “Are you the psychologist?” I began my usual spiel on my provisional status but was interrupted. “Patient, male, mid 60’s, currently in isolation, distressed that his partner is in ICU and he can’t visit, haven’t assessed suicidality yet, can you call ASAP?” It was clear nursing staff were here to do a job, and I was expected to do mine, being provisional was not important anymore.
I used to think I was busy, that day was something else entirely. You never knew what each call would bring. Having to assess, formulate, and adapt my interventions for what was available in basic hotel rooms. These people were in a situation they had never faced, did not have access to their usual coping strategies and many had never spoken with a psychologist before.
Freya Wright
The opportunity to work in a telehealth environment at rpavirtual was a real blessing in that time of uncertainty. This placement was offered to me with no expectation, however, the decision to work there was clear for me. I would be able to obtain more direct client hours and learning experiences but also, importantly, be part of a response that would be working with those hit by the pandemic I had been fearing. It felt at that time and continues to feel like a real privilege, hearing their stories, their resilience, honesty and moments of fear has been eye opening.
Since starting this placement at rpavirtual I have been supported by a number of supervisors offsite, who were all prepared to pick-up their phone and provide guidance should I feel out of my depth. And admittedly, I have felt out of my depth, but as a psychology student the moments without doubt are still few and far between.
I have also been supported onsite by the knowledgeable and dedicated nursing team that make up the heart of the rpavirtual response. Their understanding of the importance of psychology and mental health for those in quarantine has encouraged me.
From the clinical supervisor
Lil Vrklevski
I worried whether I had made the right decision regarding the students. I knew it would be demanding and challenging at rpavirtual. They would be using telehealth, providing crisis interventions, following up on highly distressed and complex people without the benefit of a proper orientation or even procedures, which were being developed and changed daily.
In all honesty, my anxiety levels were sky high for the first two weeks of rpavirtual, but my fears were unfounded. Not only did the students cope, they were magnificent and continue to make me incredibly proud to be part of their training. I was reminded that flexibility, agility and adaptability are core aspects of the competencies required for clinical practice.
Lessons learned
From the provisional psychologists
Kelly Brown
Both personally and professionally, I feel very fortunate to have had the opportunity to continue my placement at rpavirtual. It has not only allowed me to sit (thankfully with my injured ankle up!) and focus on helping those with difficulties far greater than my own, but also provided an important sense of purpose, perspective and routine during uncertain and unsettling times. I have grown from the experience and feel it has taught me a lot about adaptability, clinical versatility and resilience.
Vince Cram
Rpavirtual taught me perspective. At the time of writing there are a lot of unknowns in my life due to COVID-19; my employment has been affected, my thesis topic has changed multiple times, and it is unclear whether I will be able to locate a second external placement, meaning a potential degree extension. However, none of that really matters.
I am lucky enough not to be on the other end of that rpavirtual call. I am not the one isolated in an unfamiliar hotel room for weeks or months, with little to stop the ruminating thought that my worsening cough is the final sign I will be joining the casualties of this worldwide pandemic, except maybe the occasional call from a nurse to check my sats (oxygen saturation levels) or a psychologist to offer support.
Freya Wright
Whilst I started 2020 expecting to work on a mental health ward developing CBT skills for psychosis, in reality I have actually learnt what a privileged position it is to stand with someone (virtually speaking) as they deal with one of the major world crises in recent times. As a student I have learnt a lot about those therapeutic skills I had previously been so concerned about developing. On a more personal level I have now learnt so much about adapting in times of change and uncertainty and the importance of hope. As I reflect on this experience it has become apparent that this time has been formative in my training and it will shape my understanding of what it means to be a clinical psychologist.
From the clinical supervisor
Lil Vrklevski
In the nine weeks since its establishment, the rpavirtual psychology team has provided assessments, counselling, interventions, support and referrals to more than 120 people from a variety of culturally and linguistically diverse backgrounds, and more than 720 occasions of service lasting between 20 to 90 minutes. The team has received referrals to support people with a range of pre-existing mental health conditions including complex trauma, substance use, domestic violence, anxiety, depression, PTSD, and bipolar affective disorder among others.
Freya, Kelly, and Vince have now completed their placements and we are preparing for the next group of students.