Isolation and connection in “Cholera days” (and Corona) – and of solutions from our work in remote care
Dr. Arnon Rolnick, Nili Zohar, Adam Leighton
The headlines that deal with the spread of the COVID19 virus often emphasize the mortality rate and the severity of the infection. In this post, we want to deal with the isolation imposed on millions of citizens throughout the world – the difficulty involved and the interpersonal dynamics that develop in closure and isolation situations. We will try to offer both technology and know-how that we believe can greatly assist in reducing the difficulties associated with isolation.
First, we will review the Israeli isolation orders as updated as of the date of this posting, and second, we will try to speculate on the psychology of the isolation condition. For this purpose we rely on knowledge gained during previous epidemics, on material from the besieged city of Wuhan, we may also draw from the collective Israeli memory during the moments in which we withdrew from the fear of Iraqi WMD rockets and also rely on literature – although not on “Love in the Time of Cholera” but rather “The Plague” by Camus and Sarmago’s “The Blindness”.
Like these authors, we will concentrate on the question of human behavior in times of crisis, behaviours ranging from self-preservation to self-sacrifice. There is a considerable psychological research on concerning various isolation states.
But this time, perhaps also because of the need to offer a quick solution to an issue that may effect us faster than we thought, we focus on the technology solutions to reduce the isolation experience and create an encompassing human connection framework. Based on our recent book, we will attempt to offer knowledge from the field of remote therapy, learning from our experience using videoconferencing in psychological therapy for individuals, families and organizational work.
This weekend’s issue of The Economist (February 28, 2020) suggests that public health policy should shift from containment to social exclusion policy — Social Distancing. We suggest that physical distancing can be achieved without social distancing with the help of technological tools.
In this post, we will highlight not only technology but how proper utilization will allow for a social, intimate and even cohesive experience.
Israel ministry of health Quarantine and isolation orders
The isolation policy or Social Distancing is summarised by the harsh wording of the “Public Health Order”, some of which is presented below:
Public Health Order (New Corona Virus (Home Insulation)) Temporary Order, 2020. By virtue of my authority under section 20 (2) (a) of the Public Health Ordinance, I hereby order:
“A( A person who is in solitary confinement shall remain in solitary confinement in a residence or other place allowing the conditions of the solitary confinement – hereby the place of solitary confinement.
- B) The person was in doubt whether he was in close contact with a patient, he or she shall stay in solitary confinement, and contact the Ministry of Health for clarification.
- C) The isolation will be for a period of 14 days from the last stay of one of the destinations, and if there was more than one destination – from the last stay of their last stay, or 14 days from the last contact with a patient – hereby the isolation period
- D) A person in solitary confinement shall not leave the solitary confinement except with the approval of a district physician or the head of service and in accordance with the conditions of approval.
What happens to a population that is dealing with an epidemic, closure and ISOLATION?
Despite several outbreaks of viruses in the last fifty years (SARS, Ebola), never has there has been such massive infection and containment or isolation of millions. In Israel, as this post is being published, it is estimated that thousands of people are required to be in isolation.
Perhaps the closest thing we experienced in Israel was the isolation forced upon us in 1991 during the First Gulf War. We had to go into isolated, sealed rooms, and fear a covert enemy who would want to get into our homes and bodies. We must admit that in the early days there was a great deal of panic as we struggled to obtain plastic sheets and adhesive tape to seal rooms [to create shelters from threat of nerve gas rocket armament].
It may be worthwhile jumping the gun and mentioning that we learned about the importance of contact during periods of isolation. Whilst in the sealed shelters with my family and young children, during the Gulf Warm we found a method of distraction using computer-based correspondence with friends in the Netherlands and the US. We are talking about the Bitnet era, preceding the Internet, and there where certainly no video conferencing protocols back then – but we already saw how communication “in the time of cholera”, may ease those in isolation. Following our experience in this war, I developed, together with a British company, a program designed to help reduce the stress situation in the shelters. In 2000, I was invited to lecture at the NATO conference on psychological assistance for those confined to shelters.
In 2003 there was an outbreak of SARS (Severe Acute Respiratory Syndrome). One of the reports that can help here is that of the staff of a Taiwanese urban hospital placed in isolation at that time. Once SARS cases were identified among staff and patients, all staff, patients and visitors were suddenly and permanently limited to staying in the building for a two-week closure period. In their report on the chaos that followed, they describe how forced isolation “caused a sense of collective hysteria and led the team to desperate steps.”
Other lessons from that outbreak were:
First, the isolation is accompanied by an alarming message, which indicates that the authorities believe the situation is serious and may worsen.
Second, the imposition of isolation is seen by those who oblige them as an act primarily done for the benefit of others, thereby reducing the trust and confidence that authorities work in favor of the isolated.
Third, isolation has a negative impact on the sense of cohesion: the separation of family members compounds the difficulty. Additionally, the separation from other community members also reduces emotional coping ability.
Fourth, the rumor mill in these situations works extra hours. The need to get information is natural and the lack of clear messages raises levels of fear and forces people to look for information from less reliable sources.
The cumulative effect of these outcomes may be severe.
What we learned from literature:
Two memorable books: Albert Camus’s “The Speech” and Jose Sarmago’s “Blindness” depict communities exposed to isolation and quarantine due to a plague.
Camus tells of a plague that erupted in the city. He describes how initially everything still behaves as normal, residents spend more time sitting in street cafes. But gradually the situation gets worse and the quarantine lock-down creates a lack of basic commodities, fuel and food. People cannot work and financial shortages develop.
In order to protect the population that has not yet been infected, closure areas are set up to transport patients there.
Authorities begin enforcement of the closure by policing and fencing the city and are instructed to prevent residents from escaping, even killing those trying to escape the closure
As the epidemic intensifies and the whole place is put under isolation, the hope is lost and there is deep anxiety. Some of the desperate residents try to break the blockade and escape from the city, despair and isolation are abundant.
Years later, Sarmago’s book “Blindness” is published, which describes a place where a “milky blindness” epidemic, which in itself causes social isolation, suddenly shows up.
And so Batya Gore writes in Haaretz newspaper about the book:
“In this gruesome novel, Saramago describes human behavior during a pandemic for all the expected developments described in all kinds of ways over the last two thousand years in Western literature and art: from the government’s desperate attempts to isolate the plague carriers (they are led to one wing in the same hospital), through overcoming it – about three hundred blind are eventually incarcerated in the mental hospital in horrendous conditions, which leads them, quite quickly, to lose their humanity – to the loss of control and complete anarchy of the city” (quote from Batya Gur in Haaretz).
Evidence of the closure of Wuhan city
Ofer Dekel’s posts (in Facebook he is known as “Ofer China”) are an exciting record of the residents’ closure / curfew experience in Wuhan city. Ofer’s writing is exciting and, on the one hand, exerts the intensity of anxiety: “It’s hard for me to fall asleep. Every hour or two I get out of bed to check on the children. Place a big hand on their foreheads to make sure they don’t have a fever. A fever is scary now.”
However, the very existence of Ofer’s post and his ability to call and photograph the events in the besieged city seems to be of great help to him: He writes: “Outside is darkness. No noise reaches beyond the closed windows. I return to the computer, friends worrying on the other side. “Saw you on TV” they write to me, “You are a lovely family”. It is a relaxing feeling in the wee hours of the night that you see and think about us. ”
How will THE ISRAELI POPULATION RESPOND TO the isolation provisions
A survey was conducted by Dr. Rina Degani of the Geocartography Research Institute including 510 respondents aged 18 and over who are a representative sample of the adult population in Israel.
The survey showed that 49 percent of the public, about half of those surveyed, believe that Israelis returning to Israel will not heed the Ministry of Health’s isolation instructions. The survey also found that 55 percent of the respondents believe that the Israeli public will not report to the health authorities about neighbours violating the isolation and closure guidelines.
On the other hand, answering a direct survey question, 78 percent of the adult population in Israel stated that they will report their neighbours who have returned from the Far East if they breach the isolation provisions and endanger other people.
It can therefore be seen that there is great concern that Israelis will not comply with the closure policy and that this may lead to complicated interpersonal stress. How then can we alleviate isolation and how an experience of “being without and feeling with” be achieved?
In the last year, technologies have developed that allow for close contact at a distance. In the following paragraphs, we will present some of these options. Pointing out ways that allow families, groups and organizations to stay in touch almost constantly without using a computer and without having to sit in one place.
How to stay in touch within a remote state – our work in the field of remote care
I never thought this corona would be related to the areas I work in. A person deals with a particular field and does not know how the reality will come and deal with his daily work. I have been working for over twenty years on remote care questions.
Most of the psychological literature in the world dealing with remote therapy has focused on individual therapy. And indeed, important questions were discussed there about how “no body” treatment works
Together with my clinic team, we work on an Interpersonal Neurobiology approach, an approach that emphasizes the importance of the body in interpersonal encounters. That is why we found the lack of body in such a treatment a challenge that we must face. In the book we utilise this knowledge and offer therapists ways to include physical presence even though it is inherently absent in remote care. An article authored by myself and Dr. Yossi Ehrenreich is presently being published, titled “Can you feel my heart (via your camera and sensors)? The role of the body, its absence, and its measurement in online video psychotherapy.”
In this article, we offer ways to “restore the body” to maintain connection and relieve the loneliness of remote therapy using technological means and especially the use of biofeedback sensors. We point to options under development that allow cameras to sense patient’s psychophysiological responses (heart rate changes, blood flow and sweating). Such a camera can also allow the medical staff or the concerned parent to assess both the emotional state and physical condition of a person who is in isolation.
In the book “Theory and practice of online therapy”, we have expanded the issue of distance working with couples, groups of families and organizations. Which made us look for broader solutions that might also help during the closure and isolation that may be forced upon us during the Corona.
Although this post introduces new technologies, it is important to note that the tools and cameras readily available can also create a full-body experience that includes the physical components, when us correctly.
For example, most Skype users tend to sit “on the screen”, which means that only the participants’ heads can be seen. Sitting farther away from the screen will provide users with a richer experience of body language.
It is also of utmost importance that the participants in the conversation be able to experience an “eye-meeting”, a sense that one looks into the other’s eyes.
Remote meeting with families
In couples therapy, we would like the experience of “we are both together and each on his own “, in other words to allow each of the clients or family members to sit separately and yet see each other.
We located a series of cameras that allow the therapist to remotely control the camera and degree of zoom (distance or near) in such a way that the therapist can direct the spotlight on each family member and actually allow the use of a wide room where family members are present (and do not need to stick to a small screen). Below we will see how this ability will serve us in isolation.
Remote meeting with groups
Group cohesion and a sense of belonging are a key factors in building personal and social resilience. Resilience is what minimizes the lasting and detrimental effect of stress situations. IDF research has shown \that higher functioning units were characterized by group cohesion. Can such an experience be created when people are separated by isolation or physical exclusion?
In our book, Dr. Haim Weinberg writes about the principles of remote group work. In the book, we describe using the ZOOM software that enable bringing together many participants. Haim describes how a group based on people situated in their homes using a web camera – creates a group dynamic similar to the processes that occur in face to face groups.
We believe that we can relieve the feeling of isolation if knowledge from remote group work is used. For example, Haim Weinberg is presently helping colleagues in China who are experiencing a severe prolonged sense of siege.
Remote organizational work.
As I write this post, the news not only covers reports of the epidemic’s spread but also its economic results: China’s manufacturing capacity index is reporting an all-time low. The knock on effect on the global stock markets is dramatic. It is evident that the “social / physical distancing” as suggested by the Economist, will require (in sectors where this is possible) to work remotely. In the book in question, I initiated a whole section on remote organizational work. Among other things, there are two chapters by Rakefet Keret-Karavani and myself dealing with the field of remote work, and a practical section outlining principles for organizations that work remotely. We emphasize that moving from face-to-face meetings to remote work sessions is not trivial and requires awareness and adaptation.
In the isolation situations imposed upon us, employers and companies will need to learn to work remotely and we suggest that they rely on the knowledge gained in the field and detailed in our book.
Together with Adam Leighton who specializes in corporate work, we conduct workshops aimed at teaching companies and organizations to recognize the difficulties and opportunities facing companies that need remote work.
Knowledge from Long Distance RelationshipS
Although this field is not covered in detail in our book, both Haim Weinberg and I are familiar with the field …
These are situations that spouses are at a distance from one another and despite their physical distance, they maintain contact through video conferencing.
In the past, the couple had to sit in front of a computer and talk and maybe exchange words of occupation – today you can walk around the house without sitting at the computer, having dinner together when each of the couple sits at his desk
Amazon’s Alexa Echo Show devices, for example, allow spouses to feel close today. In any room of the house, such a device can be installed that allows one to “enter” a room in the spouse’s house and converse both in voice and vision.
The isolation situations we face can create very similar situations to Long Distance Relationship when spouses are required to live separately due to the fact that one partner is ill or infected, or even just staying in the presence of a contagious person.
Principles of Keeping a Family Connected When Children and Grandchildren Are Scattered around the World
Although we found that there are quite a few options for remote communication – most of them require a computer and a complex connection process to enable synchronized communication.
Many of us have children or relatives who are away from us. This is not unique to families whose children have left the country or have been temporarily or permanently relocated. The challenge is to stay in touch in these situations too.
Of course, children and grandchildren can be invited to a Skype call from time to time – but this requires coordination and family members sitting tightly at the computer.
So we looked for other ways.
Supposedly we could also review the possibilities for remote meeting here by phone. Our clear perception is that to allow a true or near-real-life experience cellular use does not allow this |: The small screen – the image that is unstable due to holding the phone in the hand, the inability to see the body and space – all prevent the use of a telephone as a basis for remote treatment.
We work quite a bit with older populations, for whom the computer is not trivial and these populations are very difficult to get out of the house and reach for treatment. We have therefore looked for ways to enable such populations to connect with the therapist (or as we will see in other family members) in a straightforward and immediate way.
Fortunately, Facebook has recently launched a new device called Portal TV that allows viewing at a very wide angle and allows a person to walk around the house and stay in touch with his family even if he is quarantined or isolated
Facebook’s device connects to TV via an HDMI cable and features a microphone and smart camera at 12.5 megapixel resolution, which automatically adjusts and focuses on who’s talking.
Such a device can be a temporary solution for people in isolation. The person can walk around his house and invite friends to chat with him while he eats, sits in his armchair or watches TV with his friend who is an ocean away.
Why do we think this technological solution will reduce the hardship of the people who are being placed in closure
You can ask why we think this technology solution will reduce the hardship of the people who are put in closure:
First, our premise is that human attachment is a prerequisite for creating resilience and coping with stress.
Secondly, in light of remote therapy research, we know that meeting a video conference properly conducted can prevent the experience of being isolated. For example, the studies show that the authenticity of the therapeutic encounter is the same as the experience of the face-to-face encounter. Also, the therapeutic alliance formed at these meetings is rated as equally high.
A possible scenario of life in isolation during social gatherings, between personalities and occupations
The isolated person wakes up in the morning when those close to him wave goodbye with a pleasant smile that emanates from the alexa show device placed by the isolate and his family.
He gets up to the kitchen to make him a drink and offers a smile to his distant friend to make him coffee. Eventually through the video conference they both have breakfast together. Then they both see news in common through tools and software that allow each of them to sit in front of their television screen and watch the same content together.
If the isolates are infected children and the parent has been separated, the parent can use the camera mentioned earlier and point it every time to another child and zoom in on his face and see the child’s feeling through the physiological measurements that the software will allow.
Even if the child in question is “suspicious of the virus” of the virus there is no reason not to learn. Options for distance learning have existed for quite a few years now, but this time we want the teacher / educator to understand a bit about the psychology of distance learning and know not only to deliver a presentation but to create a unified and supportive classroom experience.
At this point, our “isolator” is leaving for work. He connects to his organization and through the remote work rules he has learned he spends a significant portion of the day in video conferencing with his co-workers.
During the day when our isolates returned from work, they do gymnastics lessons with their personal trainer who also has the Portal TV installed.
Towards the evening a meeting of the occupants of the building is needed. Ofer Dekel (China) shares on his Facebook the complexity of the relationship with the members of the building in which he lives in Wenhan City. On the one hand, there is a great fear of infection. In the model proposed here, all building and neighboring people will connect to a multi-participant meeting in zoom or other software and a group of partners will create trouble and hope. If the isolates wish, a psychologist can be put in to conduct such a loaded session.
Connecting remotely will also allow leaders and authorities to have honest conversations with residents to hear their feelings and to give the isolates the hope of taking control of the situation.
In this post, we pointed out the difficulty of isolation forced on millions of people around the world. This characterizes not only China where the main isolationists are, but also other European countries. This isolation and the closure imposed on entire areas. Affects quite a bit in both economics and remote work in organizations.
We briefly described the processes within personalities and understood personalities that emerge during forced isolation during an epidemic, and we pointed out the need for human connection.
If we could, I would turn to Facebook, the device maker that allows remote meeting directly to the TV (a significant portion of which chips are manufactured in Israel) and offer it a cheap sale of such a device to any quarantined area.
Even more important, I am in favor of making a short training in using video conferencing for anyone who may require remote sessions.
By giving precedence to such a solution, it can also help the constant lack of mental health people around the Gaza Strip and the southern communities. My colleague Dr. Yair Einat suggested that we also use our “usual trouble” approach in the south. Indeed, security officials also consider such use after crossing the “Corona Bridge”
Today Southern schools are being conducted for distance learning in times of emergency, this learning is based on personal work without “human touch” can be based on existing infrastructures and require group learning sessions with the help of video cameras and some of the knowledge mentioned here to relieve the feeling of loneliness in the South. We propose the same approach to national emergency situations that require isolation or as the Economist-Social Distancing
We also call on employers who are already working remotely today – adopting widespread use of virtual group meetings to cope with the mental costs of physical remoteness.
It would not be right to end this post without requiring one of Kami’s easy-to-read sentences for the book to end:
“And indeed, as Rye listened to the joys of joy coming from the city, he remembered that joy was still in danger. For he knew what this jubilant crowd didn’t know, what was written in the books, that the bacterium never died and never disappeared, that it could be dormant for decades in furniture and bedding Patience in rooms, basements, suitcases, handkerchiefs and papers, and perhaps one day, to the calamity of humans and to teach them a lesson, will stir his rats and send them to die in a happy city. ”
Yes, talk about his various expressions as well as the Corona and as well as xenophobia and other “cholera” and such or other wars await us in the corner.
But in the spirit of this post that believes in the importance of human encounter from afar and close – I would like to propose to Kami and Sarmagu who were well-versed in expressing the humanity of some people who have been further isolated: this hope is about the ability of the human race not to succumb to illnesses that do not surrender to nature’s champions. The hope that says “find a solution” is to find an alternative way to save the human race.
So friends this is not a post about technology this is a song of praise for our courage to look for solutions it is a song of praise for the creativity and joy of the invention experience, and its mobilization for the benefit of the mental, interpersonal and social world.
Note: This post was written with my colleagues, Nilly Zohar and Adam Leighton.