Psychological Science Into Practice During the COVID-19 Pandemic

Importance of Evidence-Based Practice (EBP) During the Pandemic

Adhering to EBP standards of evaluation while assessing the true impact of the pandemic and the effectiveness of interventions are difficult (Carley et al., 2020; King, 2020). For the current article, the American Psychological Association’s Presidential Task Force on Evidence-Based Practice (2006) definition of EBP is adopted as follows: “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273).

Traditionally, EBP means that evidence from various forms of research takes years to be produced in a manner that can safely guide practice. In a pandemic, the question is whether we are as rigorous in our approach and whether we wait or not until enough evidence is there to support the efforts (Carley et al., 2020). We still need the evidence to reduce biases, promote a shared approach to decision-making, safeguard against discrimination and power imbalance, and reduce haphazard responses (King, 2020). Carley and colleagues (2020) argue that even when the evidence is relatively weak, adopting a pragmatic approach based on the best available evidence, and identifying strengths and weaknesses through the EBP process, is not necessarily subpar. One is simply responding to the “time-critical and information light” nature of decision-making during a pandemic (Carley et al., 2020).

Emphasis should be placed on quality and fit-for-purpose information, not quantity or reaction speed (Carley et al., 2020). King states that “effectively responding to COVID-19 requires a commitment to producing, understanding, and acting on the best available evidence, fully recognizing its attendant uncertainties and accepting accountability for decisions” (King, 2020, The politics of evidence and uncertainty in the COVID-19 pandemic section). Ongoing evaluation of impact is also imperative. To that effect, the EFPA Board of Scientific Affairs proposed two special online symposia in health psychology and applied and clinical psychology, outlining the contribution of psychological science and the application of EBP during the pandemic (see https://efpa.magzmaker.com/covid_19/efpa_webinars).

Traditional research methods are not the only way forward. Practice-based research from settings such as clinics and service centers can be a great resource in producing rapid research responses addressing emerging pandemic factors and consequences (BPS COVID-19 Response Task Force, 2021; Norton et al., 2020). This form of “natural experiment” can inform EBP and help in further reducing uncertainty.

Showcasing Psychological EBP Through Vignettes

The pandemic presented with a unique opportunity to advance the usefulness and contribution of psychological science. In line with the APA Task Force’s (2006) statement that “the purpose of EBPP is to promote the effective psychological practice and enhance public health by applying empirically supported principles of … intervention” (p. 284), EBP is necessary to address the pandemic as a public health crisis.

The current article focuses on three vignettes connecting science and the “best available evidence” to practice. The science behind the actions bridges science and practice in a specific area and implementation in a specific country. In addition, they outline the need for future research. Most importantly, they relay the processes in which we can develop resilience as professionals and as individuals, families, communities, and societies by adapting in times of adversity like the pandemic (Rosenberg, 2020; Vinkers et al., 2020).

The first vignette pertains to the application of e-mental health, its acceptance, and use in Belgium following the first lockdown in March 2020. It describes how services can be developed by using existing scientific evidence to support e-mental health. The second vignette discusses the care for older adults during the pandemic in Croatia. It reviews existing evidence on psychological risks relating to the elderly as they apply during a time of crisis, focusing on social support and developmental control. The third vignette presents the case for social, community inclusion of refugees in Norway and the importance of considering broader research evidence on inclusion pertaining to the pandemic.

Context and Content of the Action

Until right after the first lockdown, which commenced March 13, 2020, online consultations had only known a limited uptake in Belgian clinical practice. The sudden need for online consultations and related services initiated a collaboration between the Flemish Association of Clinical Psychologists, the Expertise Unit Psychology, Technology and Society at Thomas More University of Applied Sciences, and EFPA’s Project Group on eHealth to help Belgian psychologists deal with issues at hand. Initial guidelines were set up, followed by an (inter)national survey to detect frequent and recurrent questions, which provided input for an online overview of frequently asked questions and answers. Joint efforts with other mental healthcare and welfare professionals, particularly concerning software available for online consultations, resulted in complementary overviews of relevant software tools. Finally, webinars with more experienced Dutch colleagues were set up, followed by academic publications to guide and document this rapid shift.

Science Behind the Action

The main focus was on facilitating online consultations, as these were an important means to overcome lockdown limitations for care provision in Belgium and across the world. The evidence-based for online consultations appeared relatively limited but generally favorable. For example, systematic reviews could, be found reporting online consultations as promising in depression (Berryhill, Culmer, et al., 2019) and anxiety disorder (Berryhill, Halli-Tierney, et al., 2019). There was also some indication that one-on-one contacts and online support groups were feasible and might result in similar outcomes as face-to-face sessions (Banbury et al., 2018). Furthermore, professional bodies already had set out some guidelines and good practices for the American Psychological Association (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013) and the American Psychiatric Association in collaboration with the American Telemedicine Association (Shore et al., 2018). These were supplemented in a later phase with general guidelines concerning e-mental health by EFPA’s Project Group on e-Health (Van Daele et al., 2020).

These existing evidence-base and guidelines were used to provide basic reassurance to psychologists that relying on such methods would be feasible and an effective means of providing care. The specific actions that were further undertaken to stimulate actual and effective could be linked back to a theoretical framework that guides the uptake of technology in clinical practice: the Unified Theory of Acceptance and Use of Technology (De Witte & Van Daele, 2017; Venkatesh et al., 2003). This model integrates the prominent user acceptance model, highlighting key determinants of user behavioral intention and usage. All ad hoc initiatives could be brought back to key determinants that make up this model. Directing colleagues toward specific information and techniques to be used in online consultations (reducing effort expectancy and increasing performance expectancy), bringing together large groups of psychologists in webinars, hearing from experienced, successful colleagues which they could model themselves after (increasing positive social influence) and offering an overview relevant and trustworthy tools (increasing facilitating conditions) all link into this theoretical framework.

Importance of the Work

In 2020, stakeholders joined forces in a coordinated attempt to help psychologists provide their services through technological means to ensure continuity of care. As most psychologists had to rely on online consultations in the weeks following the pandemic, the goal was twofold: (1) provide practical support for the start-up of online consultations, and (2) to share best practices on existing research and guidelines to promote effective online contacts. In the longer term, the pandemic might prove to be an opportunity to expand conventional care structurally. Not only with online consultations but more generally with e-mental health, that is, “the use of information and communication technology (ICT) – in particular the many technologies related to the Internet – when these technologies are used to support and improve mental health conditions and mental health care” (Riper et al., 2010, p. 1). It may help overcome an important barrier that e-mental health has consistently experienced in the past two decades, failing to move from research in controlled settings to structural use within the healthcare system.

The pandemic’s circumstances could be considered an unforeseen event that changes everything, a so-called “Black Swan” moment (Wind et al., 2020). However, to shape these conditions into a unique turning point for e-mental health, further investments are required. Psychologists have rapidly and massively adopted online consultations but did indicate a clear need for continuous education (De Witte et al., 2021). That need can be met by both academia and professional associations by introducing or expanding e-mental health in their curricula. Health services will furthermore have to install policies that facilitate the use of technology (Gaebel et al., 2020), and developers will have to (continue to) provide current, high-quality applications (Van Daele et al., 2020). All recent efforts, at the very least, illustrate that psychologists’ capacity and the willingness to help realize this change is there. Ideally, this will result in meeting current needs and helping to better shape future mental healthcare in meeting demands.

The Evidence Base for Older Adults

The Standing Committee for Geropsychology is the EFPA workgroup concerned with aging, with a scope to promote collaboration among neuropsychologists in Europe. As psychologists, the Standing Committee members know that lack of social contact, loneliness, anxiety, stress, and social isolation are among key problems of later life, linked to poor mental health, increased disability, and earlier death (Coleman & O’Hanlon, 2017; Haslam et al., 2018). Combining the said mental health risks and the risks of social isolation due to the COVID-19 pandemic may increase older adults’ health problems and impair the quality of their life and well-being. The Standing Committee members felt that recommendations regarding the older adults’ health risks related to COVID-19 preventive measures should be announced to the public and professionals. The EFPA published the first position statement in March 2020 (https://efpa.magzmaker.com/covid_19/older_adults), focused on enhancing social support via regular communication with older adults, reducing their feelings of loneliness, helplessness, and social isolation. This focus in recommendations was based on several theoretical models in psychology.

One of the most prominent models of adaptation is the Model of Selection, Optimization, and Compensation (Baltes & Baltes, 1990), related to health, well-being, and quality of life. According to this model, older adults adapt to constraints and losses by optimizing favorable outcomes for themselves, by selecting higher priority goals for individuals that suit their capacities and situation. The current pandemic situation related to prolonged social isolation may reduce older adults’ mental, physical, and social capacities. When capacities are reduced or lost, optimization with compensation is used to enable adaptation – by compensatory behaviors, self-efficacy, engagement with and support from significant others, aids, and so forth (Von Humboldt & Leal, 2014). Older adults’ responses to stressful situations, such as the COVID-19 pandemic, may differ from younger persons. In the Transactional Model of Stress and Coping (Lazarus & Folkman, 1987), Lazarus found that older adults tended to use more emotional control and less problem-solving in coping with stressful situations. As further explained by the Socioemotional Selectivity Theory (Carstensen, 1995), this reflects a shift in motivation toward greater acceptance of present situation (rather than future), avoidance of negative emotions, and preference for emotionally satisfying social relationships, which is more efficient in the situation when older adults are faced with problems too difficult to resolve.

Applying in Context

As an empirically based example, a case of rather specific local experience will be shared, providing an opportunity to confirm existing knowledge and recommendations. Simultaneously with the pandemic, on March 22, 2020, the second natural disaster – a destructive earthquake, shook Zagreb, the one million inhabitants capital of Croatia. A strong earthquake elicits a lack of control feeling, stress, and even posttraumatic stress disorder in those who experienced it. Four weeks after the earthquake, in the preliminary research on the associations between older adults’ perceived stress and their subjective health, fear and loneliness in two simultaneous natural disasters (Despot-Lučanin & Žukina, 2020), it was found that participants, on average, rated their health as good, and their fear, loneliness and perceived stress as moderate. However, when negative emotions like fear and loneliness are combined with lower self-rated health, they predict significantly more intensely perceived stress in participants (43% of variance explained). Their most important sources of support and coping were socializing or talking to family, friends, and neighbors, followed by physical exercising and hobbies. These findings may be attributed to better emotion and coping regulation in older adults, in order to attenuate or avoid stress, but also to their greater vulnerability when faced with situations causing sustained emotional arousal, like virus pandemic, or earthquake, or impaired health, or all together, by the Strength and Vulnerability Integration Model (Charles, 2010).

As the pandemic persisted, older persons were generally addressed as a risk group that needs specific shielding. Many older adults are still isolated in their homes and even more so in institutions. The Standing Committee felt another campaign was needed to increase intergenerational solidarity and communication with older people because of the unprecedented social exclusion of older adults, increasing their health risks that are not directly associated with the pandemic. In the second announcement, published by the EFPA in July 2020 (https://efpa.magzmaker.com/covid_19/older_adults), the Standing Committee focused on raising awareness of such exclusionary tendencies, leading to age-ism at the societal level and the loss of autonomy and social isolation at the individual’s level. It was also emphasized that older adults should not be seen as a passive and homogeneous group. Most older adults had been actively supporting others during the crisis and might dispose of specific resources due to their life experience. However, it is important to identify the particularly vulnerable older individuals, susceptible to negative emotions and distress, as confirmed by the described preliminary research findings in Croatia, and provide appropriate interventions in the form of social support, communication, and assistance, to reduce distress resulting from life- and health-threatening circumstances. Such recommendations have relied on substantial literature on stereotypes related to older age, and on psychological interventions adequate for older adults, and practiced by many psychologists (Butler, 1969; Coleman & O’Hanlon, 2017; Fernández-Ballesteros & Pinquart, 2011; Hyer, 2014; Stephens & Breheny, 2019).

Practical interventions often applied by psychologists and other professionals in the prevention or attenuation of negative psychological conditions in older adults (e.g., depression, anxiety, stress, etc.) include different counseling and behavioral interventions such as social skills training, promoting pro-social behaviors, activating social networks, relaxation techniques training, cognitive restructuring training, pleasant events, and coping training.

In the past year, several Standing Committee members have been included as researchers in longitudinal studies on older adults’ health and coping and resilience in the pandemic situation. Longitudinal findings could confirm the sustained consequences for older adults, their sources of adaptation, and especially their potential for resilience following this prolonged period of pandemic (Klasa et al., 2021).

Newly published research data are mainly cross-sectional, often lacking control groups or baseline data. With time, it is expected that more longitudinal research findings would be published, as well as more systematic reviews of the new data. This would facilitate the integration of numerous research findings and indicate future research and efficient EBP with older adults in times of crisis or after the crisis. New empirical research findings will direct the future Standing Committee actions.

What Are the Benefits of the Farming Project for the Refugees?

Refugees’ health and well-being are often connected to social contexts and employment conditions. Being part of the urban farming project has strengthened bonds and a sense of belonging between the refugees and their community. The results have nourished community strength, built resilience, and reduced effects from social isolation in times of pandemic. Relying on each other’s working skills can also build trust within a group, a cornerstone for community resilience. The emotional experience of togetherness is rooted in the physical experience of farming together as a team.

Research shows that people need to feel that one’s contribution is genuinely useful and helpful and influences an issue. People also need to have some level of control over themselves and the environment and be recognized for one’s efforts (Zani & Barrett, 2012). Through the farming project, the refugees learn the value of participating in useful work while learning a new language by working with people from other countries. Some participants even manage to make a future income by creating their own business, and others manage to share this experience with others. Thus, building on people’s implicit knowledge can be of particular value for the experience of inclusion. Utilizing this implicit knowledge in the farming group helps build community resilience in times of crisis, such as a pandemic (Stark, 2018).

The Idea Behind the Project

“People who cooperate in a small group, doing a meaningful activity together, are also learning a skill to facilitate the process of integration in society” (Sennett, 2012, p. XX). This inclusive approach considers the different contextual and cultural identities of social problems, aiming to transform the social fabric of communities (Orford, 2008). It is a step away from traditional public service attitudes toward refugees where they are labeled as a risk group challenging the host society to view them as a resource. For example, some refugees have experienced pandemics before and can share their knowledge about group and community resilience. Having achieved social integration before the pandemic can assist in accommodating the groups’ attempts to help, thus enhancing the sense of unity and trust. Furthermore, participatory methods such as the above, or listening to the refugees as a means of established communication during the pandemic, or including them in research, can act as capacity building (BPS COVID-19 Community Action and Resilience Working Group, 2020).

For social cohesion and inclusivity to work during a pandemic, community work needs to precede it. The dominant problem of all modern societies is connected to a lack of cooperation skills (Sennett, 2012). These skills can be learned both in classrooms and in workplaces by organizing activities into groups. The Norwegian approach of “learning by doing” has been translated into employing farming projects to introduce refugees to the new language by engaging in a helpful activity.

The farming groups have managed to maintain social bonds during the isolation caused by the lockdown of normal social life. There is evidence that secondary stressors continue to cause mental distress in the months after the disaster (Lock et al. [2012] cited in BPS COVID-19 Community Action and Resilience Working Group, 2020). To maintain social support and positive results, it is vital to keep the group alive and active as people slowly recover from the pandemic. Authorities should put resources into communities, such as local facilities, physical and online meeting places, to safeguard these groups and impact such interventions even after the pandemic (BPS COVID-19 Community Action and Resilience Working Group, 2020).

Results and Lessons Learned

This project has been essential for the integration process of refugees in the community before the pandemic. It has also helped them adjust to the demands of a new context, climate, lifestyle, and culture in an actively engaged manner. Especially, it has helped them build on pre-existing knowledge and practical skills beyond the farm, such as producing goods under less sunny and colder conditions, technologically advanced and indoor settings, applying environmentally friendly methods, even accounting skills, and learning a new language. Moreover, it helped them integrate by establishing their small businesses (e.g., produce stands in farmers’ markets), interacting with locals in daily activities, thus establishing themselves in the local setting. At the same time, having learned Norwegian and integrated into society meant the reduced chances of marginalization of this group during the pandemic. Such people-centered, inclusive approaches implemented at the grassroots level present a way for practice-based research to establish new EBPs specifically in and for community settings before, during, and after pandemics.

Understanding the Root Causes of Our Present Crisis

This project has illustrated the value of building resilience in vulnerable groups when a pandemic hits the community. Building community resilience to meet future challenges, even the next pandemic, will help build sustainable social networks. Our social capital and local cultures are useful in times of crisis. Psychological science applied at the community level can help increase connections between vulnerable groups and volunteers to develop people’s sense of being a resource. Accessible and inclusive communities are more resilient than others. A resilient community can act toward the regeneration of its resources (Wilson et al., 2020).

Regeneration of a community includes re-establishing a different connection with our natural environment, recognizing the importance of the natural environment for our well-being, and humankind’s impact on nature as part of the cause for the current disaster (Francescato, 2020). Urban farming can help develop people’s awareness about the importance and opportunities to adopt a more sustainable approach to our local environment.

Implications for Future Research and Practice

Technological and scientific advancements present us with a great opportunity. They provide a chance to gather enough information to help plan for future pandemics as best possible. Especially, the vignettes are good examples of promoting EBP in policy-making for future reference. More examples will be available as time goes by.

One way of securing EBP as standard practice during a pandemic is ongoing trials, research, and assessing implementation throughout all these efforts. Professionals base their current work on inferences and statistical evidence, but continuous program implementation progress monitoring is essential (APA Task Force, 2006). Constructive feedback from service recipients is another crucial aspect of EBP and of practice-based evidence that can feedback in new intervention design and research. In the pandemic, practice-based research can inform and direct research as daily practice adapts to new challenges (e.g., prolonged lockdown, long-term school shutdowns, long-distance work and learning, conspiracy theory effects on measure adherence, vaccinations, and the recent financial crisis). Thus, researchers and professionals should actively involve the targeted populations in their evaluations. Furthermore, in the spirit of transparency and open science, quality control of the research should be ensured. This affects the impact that results may have in future applications, health and social reform, and even funding of future efforts from governments and other key stakeholders.

Concurrently, research has been produced relatively quickly and without the necessary chance to have appropriate baselines or control groups or implement experimental and longitudinal designs that would allow for drawing etiological conclusions (Panayiotou et al., 2021). Caution must be paid in interpreting results as it remains important to hold research to the same, previously-held rigorous standards. Journals publishing systematic reviews and meta-analyses, such as the European Psychologist initiative, provide a solution since they provide a closer evaluation of the efficacy and effectiveness of current practices. Especially, rapid systematic reviews would be best suited considering the frequency and number of research output and the developments in dealing with the pandemic (Tricco et al., 2017). Several examples exist already and can help guide the way (Nussbaumer-Streit et al., 2020; Stuijfzand et al., 2020; Williams et al., 2021).

Another area of growth is the use of technology for advancing research and practice during the pandemic. E-mental health is viewed as a potentially cost-effective, time-efficient, and easily accessible option for hard-to-reach populations, provided they have access to necessary tools. Considering the pandemic’s forced social isolation and the impact on mental health, e-mental health has revolutionized how people continue receiving much-needed services safely. It has also affected how professionals plan to continue offering services in a post-pandemic world (Pierce et al., 2021; Sampaio et al., 2021). Finding effective alternatives is essential and holds true when developing services for at-risk populations such as the elderly and refugees.

Promoting EBP requires a long-term commitment to continuing professional knowledge, advancement of skills, and ongoing self-assessment (Kratochwill & Shernoff, 2004). EFPA and its Member Associations emphasize Continuing Professional Development (CPD) as part of a life-long learning process. In the pandemic context, CPD opportunities should connect EBP directly with aspects such as longer-term effects on mental health and effective interventions, care systems, adaptation and resilience, and other areas relating to psychologists’ work. It should also address psychologists’ adjustments to new work requirements within professional and ethical boundaries (BPS COVID-19 Response Task Force, 2021). Also, CPD provided for researchers, trainers, and practitioners alike should target EBP and promote adoption of such an agenda, as well as cross-collaboration (Kratochwill & Shernoff, 2004). Such activities can bridge differences, create a shared understanding and vision, and promote professional collaborations that can help the people and societies psychologists wish to serve, particularly during and after the pandemic.

Limitations

Two notable limitations are stemming from looking at EBP during the pandemic: limited data and limited funding.

Data relating to pandemics are limited as the last pandemic was over a century ago, while other relatively relevant information comes from epidemics such as Ebola, HIV, and others. The risks and effects of a worldwide viral pandemic are not exactly equal to those of an epidemic or a public health crisis that may affect only parts of a population. Therefore, good quality data and findings from this pandemic as a universal phenomenon can be the foundation for better planning in the future should another pandemic arise. Ongoing research could address this in the form of systematic reviews and meta-analyses.

Funding opportunities tend to be limited. Particularly now, we see most of the funding going to medical research because of the virus’ effects on physical health and the health systems. However, mental health cannot be neglected. It is high time for funding to be directed to mental health, research and evaluation of current practices, and activities that will foster collaboration among professional groups (e.g., conferences, symposia).