COVID-19 on an acute psychiatric unit: an interdisciplinary, trauma-informed response

Purpose – There is a high prevalence of trauma among mental health clients, with risk of re-traumatisation when admitted to a Department of Psychiatry (DoP) (Kimberg and Wheeler, 2019). The COVID-19 pandemic poses challenges to therapy service operations in DoPs, with infection control measures impacting opportunities for therapeutic and social engagement. A trauma-informed care (TIC) lens was used when adapting services in Tallaght University Hospital DoP in response to COVID-19. Design/methodology/approach – An interdisciplinary approach was taken to adapt therapy services during early stages of the pandemic. Changes were informed by TIC principles to minimise re-traumatisation while maintaining high-quality services. Changes included expansion of the therapeutic activity programme, changes to groups, addition of COVID-19-specific groups and increased awareness of communication support needs. Findings – The early response to the pandemic, combined with the focus on TIC, resulted in continued, effective therapy services and positive client feedback. With clients’ involvement in their care enhanced, Individual Care Planning goals were achieved through group interventions. Originality/value – The COVID-19 pandemic brought unprecedented changes to mental health services. This paper highlights a response to unique challenges brought by COVID-19 on a DoP.


Introduction
Public health measures implemented by Irish Government in response to COVID-19 impacted mental health service delivery. The DoP in Tallaght University Hospital adopted measures to protect clients and staff.
Measures implemented to minimise risk of virus outbreak included isolation of new admissions, ceased visiting and leave off the unit, physical distancing, bed closures and staff wearing Personal Protective Equipment (PPE). These changes severely impacted clients' opportunities for therapeutic and social engagement. For many clients, the world they were being discharged to was different from pre-admission. Additionally, as time progressed, some admissions appeared directly related to the impact of COVID-19.
Evidence indicates programmes that focus on therapeutic occupational engagement support client's well-being (Hutcheson et al., 2010). The therapeutic activity programme (TAP) in the DoP draws on specialities of music therapy, speech and language therapy and occupational therapy to meet client needs and fulfils obligations for recreational and therapeutic activity stated in Regulations 9 and 16 of the Mental Health Commission's Judgement Support Framework (Mental Health Commission, 2020).
Delivery of therapeutic services was adapted to operate within public health guidance. Principles of TIC were used to inform service adaptation. The interdisciplinary team (IDT)previously incorporated TIC in response to trauma histories and traumatising effects of admission. TIC is additionally relevant during this time as the pandemic is globally traumatising (Macpherson, 2020) and necessary public health measures were potentially additionally traumatising.
This article will outline changes to therapy services and how principles of TIC were integrated.

Literature review
Trauma-informed care Trauma is a response to overwhelming stress from single or prolonged exposure to events, where individuals experience real or perceived threat of harm to themselves or others (Kezelman and Stavropoulos, 2012).
Therapeutic services in the department of psychiatry The Substance Abuse and Mental Health Services Administration (SAMHSA) (2014) highlights increased prevalence of trauma for individuals in mental health services. This, alongside the re-traumatising nature of admission (Kimberg and Wheeler, 2019), requires careful consideration and TIC to support well-being. As many clients on the DoP have experienced significant trauma, TIC is considered essential practice by the IDT. Mounting evidence that DoPs can be re-traumatising led the team to apply "universal trauma precautions", which align well with guiding principles of music therapy, speech and language therapy and occupational therapy (Walsh and Boyle, 2009;Muskett, 2013;Elliott et al., 2005). Irish mental health policy also asserts that services in Ireland should utilise TIC (Department of Health, 2020).
Representative bodies of professions maintain that occupational therapy, music therapy and speech and language therapy are well positioned to apply values relevant to TIC. Core elements include safety, trustworthiness/transparency, peer-support and mutual self-help, collaboration and mutuality, empowerment, choice and voice, sensitivity to cultural, historical and gender issues (Champagne, 2020).
Occupational therapy works from a holistic, nonpathological view of clients and emphasises respect and collaboration, therefore fitting well in TIC. Occupational therapists also focus on the therapeutic relationship, which is a key element in TIC and can be impacted by TIC principles (Fette et al., 2019). Speech and language therapy supports other professions in transparent communication and empowers clients' voices by supporting communication. Bruscia suggests that music therapy, ideally situated within TIC (Porges and Rosetti, 2018), uses musical experiences and relationships developed through them to facilitate positive change (Wigram et al, 2002) including increased emotional and psychological well-being.

COVID-19: the need for trauma-informed care
Changes required during the pandemic had a triggering impact for many, particularly individuals with pre-existing trauma. Public health measures, uncertainty, lack of control and stress, alongside increased likelihood of violence and mistreatment at home, often resulted in trauma responses (Macpherson, 2020).
The pandemic also resulted in differences in implementation of TIC. When working with individuals who experience trauma, there is emphasis on therapeutic use of self to establish rapport and build alliance (Champagne, 2020). Therapists' non-verbal communications such as facial expression and use of proximity are significant in developing therapeutic processes and relational security. Mask-wearing and social distancing curtailed these therapeutic tools.
TIC was integrated by the IDT to maximise therapeutic use of self and navigate trauma, caused by the pandemic and the DoP's subsequent response.

Methodology
Pre-pandemic department of psychiatry service Before COVID-19, open therapeutic groups and individual therapy sessions were available Monday to Friday in the DoP to up to 56 patients. Group sessions included up to 12 members and were open to participants from all wards. Individual therapy with occupational therapy, speech and language therapy and music therapy was available by referral.
Occupational therapy ran multiple groups including selfcare, cookery and art. External facilitators coordinated by occupational therapists included music therapy, yoga and dog therapy. Pre-pandemic music therapy groups included instrumental improvisation, song singing/exploration, lyric composition and circle drumming. Speech and language therapy was available by referral only, focussing mainly on dysphagia assessment.
Department of psychiatry service during the pandemic From March 2020, changes were made to delivery of therapeutic services in the DoP, including changes in the TAP and individual services.
Admissions were significantly curtailed, with approximately 50% occupancy during the early pandemic period. This resulted in increased facilitation of Individual Care Planning (ICP) goals through group work, and less need for individual input.
Changes made can be seen in Table 1.

Pandemic-specific groups
Keeping Well at Home with COVID-19 was a dischargeplanning tool supporting well-being during restrictions. The group focussed on routine, relationships and daily activity during lockdown, while providing information on government guidelines. Content drew on Compassion-focussed therapy and aimed to acknowledge feelings of active traumatisation (Gilbert, 2009).Group discussion and brainstorming was utilised to plan for self-isolation on discharge while accessing social supports, alongside tips on managing mental health during lockdown. During the pandemic, misinformation was common and individuals in the DoP had limited access to reliable information about COVID-19. Alongside this, some clients were unsure as to reasoning for restrictions as information provided did not meet their communication needs. This highlighted the need for speech and language therapy input to a COVID-19 Information Session to support individuals accessing reliable information as per their communication support needs. This was co-designed and delivered by occupational therapists, using their expertise in group facilitation.
Music therapy consisted of song-singing and music-listening groups only. Extra ad-hoc ward-based sing-alongs were introduced providing opportunities to experience music Initial adaptations continued until June 2020, at which time, increasing admissions and reduced national restrictions warranted a service review. The service adapted to meet changing demands, preserving effective elements, including infection control precautions and increased choice in groups.

Discussion
Outcomes of adapted services As a result of integration of TIC into the service, a number of outcomes were achieved: continuation of therapy service and TAP; increased awareness of communication support needs leading to increased speech and language therapy presence; more ICP goals achieved through group intervention; positive feedback from clients; effective, sustainable aspects of the adapted service preserved; increased emphasis on body-based trauma-processing; and enhanced focus on clients' involvement in their care.
To ensure service effectiveness, feedback was elicited using a number of measures, including group attendance and verbal feedback. This encompassed principles of transparency and collaboration, ensuring a trauma-informed environment was established and therapeutic relationships incorporated trust. An evaluation of music therapy found sessions supported decreased feelings of isolation and improved coping.
Occupational therapy evaluation was carried out through the yearly audit, alongside evaluation of the TAP as a whole, which demonstrated a 240% increase in the number of groups. The amount of time spent in group therapies increased by 10% from June 2019 to June 2020, despite significantly reduced numbers on the ward, demonstrating increased time spent engaged in meaningful occupation. Many clients attended most groups, reporting this supported them achieving ICP goals such improved routine, socialising and practicing coping techniques learned on the unit, which were key occupational therapy outcomes.
The TAP provided opportunities for social connection and peer-support when these were restricted. Face-to-face contact allowed continued therapeutic use of self, providing safe, social cues and reducing dysregulation. This fostered a sense of safety in groups, an important foundation of TIC (Champagne, 2020). With facial expressions and proximity restricted by mask-wearing, additional emphasis was placed on alternative methods of non-verbal and paralinguistic communication, including written communication.
Speech and language therapy services were further developed in two ways. Additional resources were allocated to address barriers to communication which exist in services which fail to take communication support needs into account, for example through staff training, review of communication accessibility of ICP processes and interventions. Extra resources were provided to assess, provide intervention and advise on communication support needs of individual clients.
The Mental Health Commission mandates ICPs in Approved Centres in Ireland to support clients communicating needs and planning to meet these in collaboration with their team. Given the smaller cohort in the DoP, these goals could effectively be met through group activity, requiring less individual work.
Limitations of the adapted service Service adaptation took place during early stages of the pandemic and, as such, was a reactive response to an emergency. Therefore there were limitations to its scope and effectiveness.
While the adapted service effectively met client needs, it required occupational therapists to work alone. The intensive input was unsustainable and at the point of service reduction in June, both occupational therapists were experiencing burnout.
As the number of admissions increased, it became increasingly challenging to meet ICP goals through group activity given increased variety in goals and number of clients, requiring reallocation of resources from group therapy to individual work. The TAP continued to operate in a slightly reduced capacity, with increased individual referrals to all disciplines. Meeting increasingly varying goals through activity was challenging given constraints of social distancing and IPC, requiring individual referrals.
The adapted service supported social interactions and connectedness, however, given restrictions on socialisation, clients continued to be isolated from support networks.
Implications for future practice Integration of TIC into therapeutic services in the DoP during the pandemic had positive outcomes despite limitations. This supports further integration across the DoP.
It is vital to acknowledge the role of interdisciplinary working in service delivery. Incorporating guidance from all disciplines supported consistency across therapeutic services. Close collaboration ensured cohesive integration of TIC, ensuring equity and consistency for clients. Regular IDT engagement and on-site working enabled effective implementation.
Music therapy's structured service evaluation provided insights into clients' perceptions. Further structured evaluation should be regularly undertaken to capture client's perceptions and enhance the collaborative nature of the service.

Conclusion
A need was identified at the beginning of the pandemic to adapt therapies services in the DoP. A trauma-informed, interdisciplinary suite of changes was made to services. Adaptations made to therapeutic services supported clients to safely engage with therapies during the pandemic. Adapting and offering enhanced services was challenging but necessary. Effective changes made included: changes to group structure and content; enhanced emphasis on body-oriented trauma-processing and embodied trauma; increased awareness of communication support needs; greater focus on supporting clients' involvement in their care; increased emphasis on social connections; additional speech and language therapy and music therapy resources; and continued development of practice into a traumainformed therapy service.
Limitations included difficulty with sustainability, burnout and continued restrictions. This brief description offers reflections on integration of principles of TIC into therapeutic services in a DoP during the COVID-19 pandemic. This was an effective response and continues to inform practice.