The Experience of Distant Psychological Help Organization in Telemedicine During COVID-19 epidemic Olga S. Markinaa a Financial University under the Government of Russian Federation, 49 Leningradsky Pr., 125993, Moscow, Russia Abstract The COVID-19 epidemic changed the possibilities of traditional psychological help due to social isolation mode. The demand for psychological help increased in difficult and complicated time of health and life threats and movement limitations. Many psychological problems were developed during epidemic: fears, anxiety, depression, destructive coping strategies, aggressive behavior, feeling of loses. The project of distant psychological help organization in telemedicine during COVID-19 epidemic was realized with the participation of more than 3026 clients. New algorithms of psychological work were developed and realized, The data allowed to analyze client’s demands in dynamic in different stages of COVID-19 epidemic. Age and gender differences of preferences for distant psychological help are defined. Keywords 1 Distant psychological help, telemedicine, COVID-19 epidemic 1. Introduction The spread of COVID-19 epidemic leaded to sharp increase of quantity of people that were isolated to save their health. Up to fifth month of COVID-19 epidemic more than 2,6 billion of people were in isolation and limits of free movement [1]. In further the expansion of restricting measures to prevent the COVID-19 epidemic increased the amount of people that were forced to follow the rules of social isolation. The stress feelings are linked with the fear to infect yourself and your family with the deficit of effective treatment models and limits of coping behavior including orientated on social support. That situation creates space to degradation of psychological well-being, somatic health and social relations [2; 3; 4; 5; 6; 7; 8]. The method of struggle with developing infections such as movement limitations, quarantine restrictions are the factors of development of psychopathology symptoms [9; 10]. The recent investigations in countries affected by the COVID-19 epidemic showed bad dynamics. In Chine cities closed due to the COVID-19 epidemic were revealed the increasing of symptoms of post-traumatic stress, depression and anxiety disorders [11; 12]. The research in Italy showed that more than a quarter part of respondent’s esteem depression symptoms, intensive fears and distress. The distress factors are the fear to get infected by potentially fatal illness, the feeling of constant nonvisual threat as radiation [13; 14]. Earlier research about psychological reaction on infective illnesses showed that high speed and stealth uncontrolled disease transmission develop high anxiety level and fears [15]. The decreasing level of resilience in conditions of prolonged experience of anxiety and fear can effect on use of destructive coping strategies [16]. The results on US sample showed the increasing level of aggressive behavior orientated on myself: the increasing level of suicide feelings and actions to deliberate infection of yourself [17]. The results on Russian sample showed that quarter of respondents point the necessity for psychological help and support (22,3% of the sample). People with higher demand for psychological help showed higher level of psychopathology symptoms, higher suicide risks. The IMS 2021 - International Conference "Internet and Modern Society", June 24-26, 2021, St. Petersburg, Russia EMAIL: olga.s.mark@gmail.com ORCID: © 2021 Copyright for this paper by its authors. Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0). CEUR Workshop Proceedings (CEUR-WS.org) IMS-2021. International Conference “Internet and Modern Society” 383 increasing level of anxiety, depressions symptoms, somatization, psychoticism, paranoia symptoms were defined [18]. The investigation allowed to define that people need the prophylaxis and prevention of suicide behavior, decline of perfectionism in the situation with no chances to do everything ideally due to limitations, recovery of image of future, education of emotional self- regulation practices, development of repertoire of ways of complacency, mastering of effective and available active coping strategies in COVID-19 epidemic and orientation in digital alternative for usual leisure. Thus, the necessity for organization of effective distant psychological help in situation of movement limitations and social isolation mode became obvious. There are a lot of investigations that demonstrate the rather high efficiency of distant psychological help in different forms of somatic disorders (oncology, diabetic) and mental (depression) disorders [19; 20; 21; 22; 23]. Thereby the effective organized distant psychological help can be the equaling to traditional forms of psychological practice [24]. The distant form of medical help by telemedicine technologies was working well in Russia up to the moment of quarantine limitations in spring 2020. In 2018 the Federal Law about telemedicine was accepted and it leaded to increase of different services and platforms with mostly medical help. The telemedical service during spread of COVID-19 epidemic became an opportunity for patients to get quality medical help with no risk to health without leaving homes and shelters [25]. The experience of psychological help through telemedical services was not so big up to the moment of COVID-19 epidemic limitations. The experience of countries that earlier confronted the of COVID-19 epidemic demonstrates that the psychoprophylactic measures were very different. In Chine the online services with social networks and electronic mails were activated, online lessons of psychological support aimed on educational content how to overcome frustration and affective reactions were realized [26]. In Italy the initiative #psicologionline aimed to define forms of psychological intervention during COVID-19 epidemic was realized: online questionnaires to define risks and factors of potential psychological ill-being, psychological support of medical service and medical workers through smart devices, distribution of informational materials about psychological consequences of limitations and social isolation. The fast development of programs to manage online- consultations with video connection and message exchanges for patients that got used to personal consultations with psychologist and psychiatrists [27]. In Spain the idea of early psychological intervention included informational support by distribution of psycho hygiene, distant therapy through application and mobile phones [28]. At the same time telemedicine in remote regions was regarded only as a phone consultation [29]. In our country, hotlines for psychological help have been opened by various foundations and government agencies; private counseling platforms announced “open days,” setting aside «pro bono» hours for those who cannot afford paid counseling. An analysis of phone calls for psychological help to the round-the-clock emergency telephone of the Moscow psychological service for the population during the COVID-19 epidemic in the spring of 2020 showed that there is a sharp increase in calls for urgent acute stressful experiences, anxiety, panic attacks [30] However, there were practically no proven strategies and guides for psychological assistance in the telemedicine format. It wasn't until June 2020 that an adaptation of the Cognitive Behavior Approach (ICBT) protocols was published to help people with exceptionally high levels of anxiety and distress associated with COVID-19 [31]. In the fall of 2020, the results of the development of a protocol for telemedicine medical care, recommended by World Health Organization experts to solve the problems of telepsychiatry during the COVID-19 epidemic, appeared [32]. Thus, in the situation of the need for measures to prevent the spread of the SARS-CoV-2 virus, the use of telemedicine tools was considered by the community as the most accessible and practical way to alleviate the psychological state of the population. Strategies for providing such care by mental health professionals had to be practiced on the fly. 2. The Method The author of the article was one of the leaders of the organization of distant psychological assistance in the framework of a large telemedicine project. During the work on providing free online consultations with psychologists for residents of all regions of Russia, 3026 people ask for distant psychological help. The project of the psychological support hotline involved 25 psychologists from 384 PART 2: Internet Psychology various psychological schools. Each of the candidates passed the selection and preliminary training in a new format of work: technical features of the platform, basic information about the current situation with coronavirus infection, the specifics of the psychologist's work on the hotline in various formats. Psychologists were helped to navigate the needs of clients who applied to the line by personal work experience, as well as the passage of mandatory supervisory and intervention meetings. The former were carried out in individual and group formats, the latter only in group formats. In addition to the control and support function of such meetings, supervision also performed an educational task, implying the integration of the experience of psychologists working on the hotline, and the development of a common understanding of the schemes and formats of work in the conditions of telemedicine psychological support [33]. During the work of the line, 5 collective supervision meetings were held, dedicated to the work on the most relevant blocks of requests: 1) empathy opportunities in the telemedicine format; 2) the planning horizon of the future client; 3) assistance in dealing with anxiety and fears in the format of a hotline; 4) work with grief and loss in a telemedicine format; 5) work with family crises. The capabilities of the telemedicine platform made it possible to consult with the client within the framework of a chat message, audio call or video call. To improve the quality of work, the video communication format has always been declared preferable, however, the choice has always remained on the client's side. The choice of the form of work was determined by the preferences of the client, as well as the specifics of possible technical restrictions: violation of the signal quality, disruption of the video image during use, delay in video and sound, disruption of the audio signal. In distant psychological work when a lot of attention was paid to establish and maintain confidential contact, such technical difficulties can significantly reduce the effectiveness of the psychologist's work, including in conditions, when these difficulties are not caused by the psychologist's own mistakes [34]. The peculiarities of psychological counseling in these modalities entailed a necessary stage of adaptation of the manner of conducting clients by psychologists to the new format. Despite the fact that in the modern world consulting using Skype or Zoom platforms has already gained sufficient popularity among specialists, the need to introduce a setting framework was actual, taking into account such factors as: – spatial placement (a person can be anywhere and do anything while contacting a psychologist on the hotline); – maximum anonymity (with the exception of the video format of the appeal, the psychologist does not see his client: his emotions, non-verbal manifestations, environment); – unpredictable dynamics of contact and limited time (the client can interrupt the conversation at any time, simply by disconnecting the connection or being distracted by personal affairs); – disinhibition effect (decrease in the level of ethical and moral qualities of the interlocutor due to remoteness and anonymity). With an understanding of the specifics and limitations of the telemedicine consultation format, unified guidelines for work were developed, which included several stages: Stage 1. Establishing contact and identifying customer needs. Determination of the purpose of the call, the presence of a request for consultation with a psychologist, clarification of the current emotional state of the client. The main theoretical prerequisite for work at this stage is the understanding that the first condition for psychological changes in the state is contact with a psychologist [35]. Stage 2. The main part of the consultation. 2.1 Normalization / empathic confirmation - using the technique of recognizing the client's feelings and thoughts as natural and understandable in a given situation, if you look at the situation from his position [36]. With the help of responses, the psychologist confirms that the client's position and feelings are recognized by him. This reduces anxiety and increases the sense of security in the advisory alliance, and also gives the client freedom to explore their own feelings [37]. 2.2 Support - using feedback techniques, demonstrating understanding, caring and acceptance, helping to build trust in your own experiences, motivational support 2.3 Resource - assistance to those who applied in the mobilization of their intellectual, personal, spiritual, creative and physical resources to get out of the crisis. Expanding the range of socially and IMS-2021. International Conference “Internet and Modern Society” 385 personally acceptable means for clients to independently solve problems and overcome existing difficulties, strengthen self-confidence. 2.4 Building an "event horizon" in the short and medium term. Determination of a plan of small, but sequential actions, designation of the zone of immediate human actions, client routing within the framework of the decisions made and the desired result. Stage 3. Conclusion. Generalization, recommendations, informing clients about the activities of other services and organizations of psychological support; accompaniment of the consultation with the text of the exercises (if necessary) and memos. Thus, if at the first stage of work there was a rapport between the client and the psychologist, then the principle of organizing the further work of the psychologist made it possible to achieve different levels of elaboration of the request, but to provide feasible support to the client at any of the available levels of immersion in the problematic. The manifestation of empathy in the telemedicine format prevailed of particular importance. Empathy, as a phenomenological understanding of the experience of another person, acts as the primary link of acceptance and forms the basis for the formation of empathic contact between the psychologist and the client [38]. Skills in empathic listening techniques include the use of pauses, clarifications, paraphrases, echo statements, reflection of feelings, analysis of linguistic parameters of speech, paralinguistic and extralinguistic aspects (sounds, intonation, tempo, pitch, timbre), non- verbal communication ("body language" - facial expressions, pantomime, proxemics, tactile contacts). Showing empathy in telemedicine has proven to be a non-trivial task. Researchers have repeatedly pointed out that patterns of empathic acceptance, especially expressions of empathy, in the format of online communication are less obvious to a person [39; 40; 41]. While working on the hotline, psychologists faced the following difficulties: 1) Asynchronous communication. The pauses provided to the patient could be used not for intrapsychic work, as the psychologist-consultant implied, but for distracting the client to everyday issues, communicating with others, changing one's location. On the other hand, the patient's dissatisfaction with the speed of the consultant's reaction could be due to technical overlaps, the speed of the Internet connection, the need for time to write recommendations or attach the necessary document, instructions, memo. 2) Difficulty interpreting non-verbal cues. The format of telemedicine consultation makes it difficult to interpret both a person's body language and limits access to information about the state of his autonomic nervous system (redness, blanching, sweating, etc.). In this regard, the video format is certainly more informative, but it also limits the visual field only to a certain position of the client and the consultant's body [42]. 3) Maintaining visual contact. The difficulty of maintaining eye contact can be caused by distractions, a decrease in the importance of the communication environment with the use of gadgets, and the inability to keep a gaze on the screen of a technical device for a long time (for example, due to a feeling of pain in the eyes). When determining the duration of communication with a client on the psychological support hotline, we were guided by the boundaries adopted in full-time practice of 50-60 minutes. At the same time, in the course of the work, a dynamic modification of the time frame was also allowed. Inappropriate requests (not directly or indirectly related to COVID-19 issues) could be shorter - about 20-30 minutes; if necessary, for example, with acute symptoms, the duration of the dialogue could reach up to 1.5 hours. In their work, the hotline psychologists were guided by the central postulate - the need to provide primary psycho-emotional support. That is, the emotional state of the person who applied after communicating with the psychologist should be more stable than before contacting the line. 3. The Data The analyzing data consists of 3026 subjects – clients of distant psychological help service. All subjects were voluntary demanding for psychological help on their own initiative. The information about free distant psychological help was distributed through the internet resources. The age of the 386 PART 2: Internet Psychology clients varied from 19 to 69 years with the following distribution: groups of 19-24 years old constitutes 16% 25-29 years - 33%, 30-34 years -25% ,35-39 years – 16%, 40-44 years – 6%, 45-69 years–4%, The sex distribution was 76% of women and 24% of men. The geography of calls included regions from all Russia, regions residents were more active than Moscow residents. Due to confidential rule of psychological help no social information (professional status, family status and etc.) was collected. No special diagnostic questionnaires were used – only the dialogue between psychologist and client realized according to the telemedicine consultation format described above. 4. The Results The analysis of dynamic and content of requests for distant psychological help during the COVID- 19 epidemic on the bases of 3026 clients demands allowed to define several tendencies. First, there is a clear dynamic of the total number of people who applied to the line, depending on the time perspective and the growing or declining nature of the epidemic. Since the introduction of quarantine measures and the launch of the online psychological support line, the increase in requests has been systematic. The percent distribution of calls for psychological help in months of work of distant psychological help was the following: end of March and April – 25% of all calls, May – 41% , June – 34%. The peak of requests fell in May 2020 and lasted until the end of June, when the number of requests was also systematically decreasing with a gradual improvement in the epidemiological situation in the country. The resulting dynamics can be associated both with the popularization of the very format of distant forms of interaction in conditions of self-isolation, and with the search by the population for new forms of coping with increased anxiety and other unfavorable psychological symptoms (sleep disturbances, phobia, obsession, depression). Secondly, we can talk about the gender specificity of requests for distant psychological help - 76% of requests came from women and 24% from men. The women showed high readiness to addressing for psychological help in distant format as the same it happens in traditional forms of psychological support. That correlates with different results of other investigations: women are more active in search for psychological help both in offline and online forms. Thirdly, the analysis of age specifics showed that the greatest demand for online consultations of the hotline of the psychological service was demonstrated by the age group from 25 to 34 years old – 58% of the sample. The question of extension of popularity distant psychological help between clients from other age groups is actual. The age group of special interest is 35+ that often are ready to ask for psychological help but are not confident in efficiency of distant forms and don’t feel comfortable in internet format. For the group of younger than 25 years old the reason for lower popularity of distant psychological help is the fact that they often don’t perceive psychological help as necessary at the moment. Fourthly, we can talk about the time dynamics of the hotline requests themselves. At the beginning of epidemic and period of self-isolation for April 2020 data, the most popular requests were: anxiety about their health and the health of their loved ones (the need to attend work, outrage at non- observance of the mask regime on the part of other citizens) – 27% of requests, fear of the uncertainty of the future in conditions of blurred boundaries of social restrictions (where to get food, how to pay for electricity , if there is no work, etc.) – 21%, a feeling of loss of control over life in the current living conditions – 18%, depression symptoms – 11%. Anxiety and fears have been in demand throughout the entire operation of our psychological support hotline. About 80% of requests included fears of contracting a new coronavirus infection. The hotline's therapeutic area faced a stream of worried patients: in a situation of uncertainty and the threat generated in the media, people were inclined to interpret their physical condition (cough, fever, shortness of breath, diarrhea, conjunctivitis) in favor of carrying SARS-CoV-2 symptoms, and contacting a telemedicine doctor was considered as one of the possible coping strategies for overcoming the state of increased anxiety. People talked to psychologists about the restrictive measures used: increased attention to hygiene procedures (washing hands, wearing masks and gloves), avoidance and self-distancing behavior (refusal to travel on public transport, visit public places, restriction of going out). At the same time, there were many complaints and concerns about non-compliance with the recommended preventive measures among their social environment. In their consultations, the hotline psychologists also IMS-2021. International Conference “Internet and Modern Society” 387 observed a wide range of reactive reactions to fear of infection - from concerns about their health to the use of violent measures to impose isolation. Among the physiological manifestations, panic attacks, sleep disturbances, apathy or hyperexcitation were often mentioned. While empirical research on fear and anxiety about COVID-19, or “coronaphobia,” as Asmundson and Taylor put it in March 2020, is still in its early stages of development, practice has clearly demonstrated this new phenomenon. The latest research traces the relationship between the fear of infection with a new coronavirus infection with psychological stress, depressive manifestations, generalized anxiety and fear of death, draws attention to the correlation with some factors of vulnerability - neuroticism, anxiety about health and behavior aimed at seeking support [43]. Dealing with fear of infection and viral anxiety in the telemedicine format of providing psychological assistance had several advantages. Firstly, it did not imply direct contact between the psychologist and the client and, therefore, completely eliminated the risk of transmission of the disease. Secondly, the remote format removed the tension of social stigmatization, expressed in the spread of bias, stereotypes and discrimination against carriers of the virus and patients, which, according to WHO, was one of the most urgent consequences of the 2020 pandemic. The second most popular queries were those related to discomfort from the inability to leave the house, anxiety due to the lack of a unified treatment plan for coronavirus infection, panic attacks that first manifested themselves or worsened against the background of the influence of stress. After a long stay of the population in self-isolation (end of April-May 2020), the focus of inquiries has shifted somewhat. Problems in marital relations, relations with children, relatives, neighbors, associated with the need to stay in a confined space for a long time (27% of the data) , as well as the emerging feeling of guilt from violating the prohibition on self-isolation in the prevailing family circumstances, came to the first place (22% of the data). Appeals appeared related to the experience of grief about a serious condition or the loss of a loved one (14% of the data). The prevalence of treatment of people with psychopathological symptoms (sleep disturbances, phobias, obsessions, depression) continued to increase. There was an increase in the situation of actual population requests for psychological assistance in connection with grief and loss from the loss or grave condition of loved ones. If at the beginning of the hotline's work, such requests were sporadic, then by the time the level of epidemiological indicators reached the maximum estimates in spring 2020, the number of people who faced the death of loved ones from COVID-19 began to grow steadily. In addition, the growing barriers to access to health care, the decline in the priority of mental health, the economic downturn, neglect and violence at the level of interpersonal relationships, catastrophic media coverage of what is happening, all of this led to the actualization of such manifestations as: a sense of loss of health, time, relationships, expectations, trust, money, etc. The emergence of such requests has turned the work of psychologists to differentiate between primary and secondary losses[44]. At the final stage of self-isolation, in June 2020, before the lifting of quarantine restrictions, the nature of the requests also changed. More and more “inappropriate” calls appeared. People addressed the accumulated problems and questions about getting out of self-isolation: how to restore the study schedule, how to change jobs, how to wean the child from the uncontrolled use of gadgets - which spoke about the natural processes of the population coming out of the self-restraint regime and expanding the horizon of planning their lives (84% of the data). Thus, the dynamics of population requests when citizens contact the hotline for psychological support in the first wave of self-isolation demonstrated well-known mechanisms of a person's reaction to stress factors - anxiety, concern about real and hypothetical problems, loss of life resource, and an increase in the level of psychopathological symptoms. She also discovered the necessary adaptive reactions - limiting the scope of contacts and areas of responsibility, shifting the focus of attention to personal problems, making short-term decisions, limited by the lack of clear prospects for the development of the epidemiological situation [45]. The experience of distant psychological help organization in telemedicine during COVID-19 epidemic showed the effectiveness of that form in limitations of social contacts. The distant of psychological service was demanded by population with high internet involvement, mostly women with different requests connected with different problems caused by COVID-19 epidemic. 388 PART 2: Internet Psychology 5. Conclusions The experience of distant psychological help service showed good efficiency and it was in demand by Russian population. Clients from different regions of Russia used the free service to reduce their anxiety, overcome fears, stress and loses feelings. The work with affective state was highly demanded. The role of psychological support and possibilities for emotional reaction in save space was important for most subjects. The dynamic of requests for psychological help depending on the stage of COVID-19 epidemic was revealed. The practical significance of the empirical experience is the proved efficiency of distant psychological help. The limitations of online psychological help shown in the investigation are the enough narrow age range of most clients, the restriction of quantity of meeting with one client due to online format, the importance of technical possibilities for constant interaction during the session. The perspectives of the distant psychological help service are the creation of constant working online psychological support with differentiation for various types of psychological demands of the potential clients. 6. References [1] T.A. 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