“Why Can Other People Live Normally While I Cannot?”: An Application of Telecounseling Due to COVID-19

In Nusa Tenggara Barat province, on May 04, 2020, there were 275 cases out of 11,587 total cases in Indonesia. COVID19 not only has an impact on physical health issues, but it also impacts on psychological issues. One of the psychological issues is how society experiences negative emotion (e.g., depression) during the spread of COVID-19. This study aimed to explore the telecounseling process on the individual who had experienced negative emotion especially in the case of depressive disorder in the COVID-19 Nusa Tenggara Barat province. This study used a single-case research design approach, and the collected data were analyzed qualitatively. The results showed that the participant reported everything she felt and thought about in stage I. Next, in stage II, the participant analyzed what she thought and wished. The statements of having suicidal thoughts, having negative emotions (e.g., feeling sad) and not being interested in any activities indicated that the participant experienced severe depression (BDI-II). Stage III took the form of a strategy of how the participant realized her goals. Through the telecounseling process, the participant understood the goals and strategies to achieve them amid COVID-19. Mengapa Orang Lain Bisa Hidup Normal Sedangkan Saya Tidak?”: Sebuah Penerapan Telecounseling yang Disebabkan oleh COVID-19


Introduction
In February 2020, there were reports in the media about a pandemic that was occurring worldwide. It was the Coronavirus Disease 2019 , which has been detected in Wuhan, Hubei province, Mainland China in December 2019 . In Indonesia, the first case of COVID-19 was in Depok, Jawa Barat province, Indonesia.
The World Health Organization (WHO) (2020a) reported that at the end of April, approximately 10,118 patients had tested positive for COVID-19 from 34 provinces in Indonesia, and more than 700 patients had died due to COVID-19. The numbers rose to 11,587 by May 04, 2020 (Gugus Tugas Percepatan Penangan COVID-19, 2020). Of the 11,587 patients with COVID-19, 275 were from Nusa Tenggara Barat province (Pemerintah Provinsi Nusa Tenggara Barat, 2020). Cao et al. (2020) state that COVID-19 not only can cause the death of individuals, but it also has an impact on individual psychological pressure. The same study also reported that 7,143 participants who joined the study experienced anxiety disorders. Similarly,  also found that 17,865 participants tended to be oppressed by negative emotions (e.g., anxiety, depression, and anger). The results of research conducted by Ho et al. (2020) confirmed that COVID-19 causes individuals to experience paranoid thoughts and panic. Not infrequently, these negative emotional experiences cause individuals to have difficulty sleeping . Further, Ifdil et al. (2020) found some citizens are burdened with poor mental health, and they specifically suffer from depression. In 2018, Yip and Tse revealed that negative emotions arise because individuals cannot overcome obstacles in their lives. They also present with negative emotions with symptoms of depression and negative feelings (Yip & Tse, 2018). Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia/The Indonesian Mental Medicine Specialist Association (PDSKJI, 2020) noted that 66% of 1,305 respondents were depressed. The respondents reported they experienced major depressive symptoms. Beck and Alford (2009) wrote that depression is defined by five terms: unstable mood (e.g., sadness, loneliness, and apathy), negative self-concept (e.g., self-reproach and self-blame), lack of motivation to engage in activities (e.g., suicidal thoughts and avoiding interacting with others), some changes in eating, sleeping, sexual activity, and the appearance of anxiety Further, Zandifar and Badrfam (2020) explained that one of the efforts to suppress the number of patients infected with COVID-19 was quarantine. Some people stayed at home and were socially isolated to prevent infection by others. Unfortunately, quarantine i.e., Pembatasan Sosial Berskala Besar/Large-scale Social Restrictions (PSBB) (Djalante et al., 2020) causes an increase in community mental health issues (such as stress, anxiety, and depression). Some studies revealed that people with mental health problems including anxiety and depression may have trouble managing the symptoms, which impacts negatively on quality of life (Polikandrioti et al., 2015;Natale et al., 2019). Xiao (2020) added that in addition to being afraid of the outbreak of COVID-19, individuals feel a lack of interaction and communication with others. This lack of interaction with others, doing activities and enjoying the environment outside the home leave individuals oppressed by negative emotions. Also, anxiety is caused not only by the low incidence of faceto-face interactions but also by concerns about changes in economic conditions, i.e., economic anxiety (Fetzer et al., 2020;Fernandes, 2020). Because of the reduced activity outside the home, people rarely travel, so accommodation services are used less by the consumer. As a result, hotel and other accommodation services are laying off staff To deal with issues related to poor mental health, psychological support is needed in the form of psychological intervention, counseling, psychotherapy, etc. (Duan & Zhu, 2020). Individuals with poor mental health may implement coping strategies that increase negative emotions and have a further negative impact on already poor mental health, e.g., maladaptive coping styles (Sim et al., 2010). Sim et al. (2010) provided a review of maladaptive coping strategies related to crisis conditions when individuals cannot accept the conditions that were happening by avoiding situations in which individuals feel insecure. Also, maladaptive coping strategies can be seen from how the individuals blame themselves, which is also the case of patients with positive COVID-19 (Sim et al., 2010). To change individual coping strategies to be more adaptive, individuals need psychological first aid oriented to increase resilience (Ho et al., 2020). Furthermore, Kun, Han, Chen, and Yao (2009) explained that psychological support is aimed at focusing on things that contribute to poor mental health, thus, the psychological support content focused on the psychological issues faced by the community, either before or after the COVID-19 pandemic spread in Indonesia, and the Nusa Tenggara Barat province specifically. Xiang et al. (2020) detailed three things that should be considered to improve community mental health, namely: (1) Creating a mental health team with diverse scientific backgrounds (e.g., psychologists and psychiatrists); (2) A clear communication process by educating the public regarding prevention of the spread of the pandemic COVID-19; and (3) Implementing psychological counseling following government appeals related to breaking the chain of distribution of the COVID-19 pandemic (e.g., telecounseling).
Following the regulations of the government of the Republic of Indonesia on breaking the chain of the spread of the COVID-19 pandemic in Indonesia, the public is urged not to go home for the Eid-Fitri celebration this year, to practice social distancing, and adhere to the large-scale social restrictions. Also, there is a policy about working from home (Djalante et al., 2020), therefore the application of telecounseling in the current situation is very efficient and effective. Appeals from Himpunan Psikologi Indonesia/Indonesian Psychology Association (HIMPSI) of Nusa Tenggara Barat province stated that amid the collapse of the COVID-19 pandemic, it was highly recommended to implement telecounseling to tackle several instances of poor mental health.
Previously, there were several studies on the application of telecounseling during the COVID-19 pandemic, some of which indicated that telecounseling was able to overcome the negative emotions of the people (Ghazanfarpour et al., 2020;Uscher-Pines et al., 2020;Zhou et al., 2020). By continuing to interrupt the spread of infection, telecounseling also makes it easier for individuals to receive counseling (Uscher-Pines et al., 2020). Zhou et al. (2020) also added that the application of telecounseling not only acts to keep individuals away from the crowd but is also beneficial to reach individuals who are outside the city, so even though it is separated by distance, it can be affordable to conduct a telecounseling process. Therefore, our goal is to understand the telecounseling process that took place during the spread of the COVID-19 pandemic.

Methods
Participant. This study was a single-case research design (N = 1). The participant was a 27-year-old female from Nusa Tenggara Barat province. She is an alumna of the master's degree program and wanted to pursue a doctoral program. She reported that she had psychological problems stemming from the impact of COVID-19. During the telecounseling process, the participant was cooperative in agreeing to complete the given assignment sheet. Also, she was not reluctant to be invited to think about her feelings and thoughts, so that she could evaluate her thoughts and feelings.
Procedures. Based on HIMPSI's appeal regarding policies taken to tackle COVID-19 cases in Indonesia, we took the initiative to be part of a volunteer team of psychologists. Furthermore, we shared information about free counseling through social media platforms. The information was spread across several WhatsApp groups. Then, the participant contacted us for consultation. Before the counseling process took place, we provided an informed consent to carry out the process of telecounseling, mentioning personal data, and her perceived ill-effects as a result of the spread of the COVID-19 pandemic in Nusa Tenggara Barat province. Also, we followed ethics in research based on the American Psychological Association (APA, 2010(APA, , 2017. Thereby, we obtained the consent of the participant to publish the collected data during the telecounseling process, with the condition of anonymity. Telecounseling approach. In this study, the process of telecounseling was by chat and voice call through the WhatsApp application. For counseling, we referred to the skilled helper model developed by Egan (2013). Egan's skilled helper model consisted of three stages: (I) exploring what the participant feels; (II) establishing what the participant's desire is; and (III) constructing some strategies to pursue the participant's goals. After stage I, we asked the participant to complete BDI-II. Also, at stage III of telecounseling, we gave the participant a task to complete the worksheet with a dysfunctional thought change approach in cognitive therapy (Burns, 1980). In this way, in this study, we applied Egan's skilled helper model (Egan, 2013) and cognitive therapy (Burns, 1980). Cognitive therapy emphasizes how individuals analyze their thinking (Burns, 1980;Persons & Burns, 1985, 1986, so changes in cognition will reduce individual depression levels (Peterson, Luborsky, & Seligman, 1983). The worksheet provided in the cognitive therapy process aimed to make the participant recognize the distortion of cognition that is in herself. Also, the worksheet consisted of a situation column (the participant was asked to write briefly about the actual events that caused unpleasant emotions, every 15 minutes); her emotions (the participant was asked to determine the emotions of sadness, anxiety, anger, etc., and rate the level of her emotions from 1-100%); automatic thoughts (the participant was asked to write down automatic thoughts that accompany these emotions or distorted thoughts); rational responses (the participant was asked to write down rational responses to automatic thoughts) and record the final result (the participant was asked to determine and estimate the level of her emotions in sequence 0-100%) (Persons & Burns, 1986).

Measurement.
We used the Beck Depression Inventory-II (BDI-II) (Beck et al., 1996) to assess the participant's depression. According to what the participant said, we asked her to complete BDI-II in order to reconcile what she said with the result of BDI-II on completion. Previously, this measure was used in Darmayanti et al.  (Beck et al., 1996).

Research design and data analysis.
This study was a single-case research design (Cozby & Bates, 2015;Gravetter & Forzano, 2016;Hott et al., 2014;Frey, 1978). We used single-case research to represent the strategies in applying counseling (Lenz, 2015) by social media platforms, for which, in this study, we used WhatsApp. Also, we implemented a single-case qualitative research design (Hilliard, 1993), for which analyzing the data was by performed by applying qualitative analysis, i.e., interpretative phenomenological analysis (Smith & Shinebourne, 2015).

Results and Discussion
The telecounseling process took place from April 16, 2020, to May 15, 2020. Telecounseling in this study was carried out through chatting and voice calling through the WhatsApp application. Also, we applied the skilled helper model (Egan, 2013) and cognitive therapy by Burns (1980) that are contained in three stages (see Table 1).
According to the World Health Organization (WHO, 2020b), depression is a common mental disorder in more than 264 million people of all ages and is more common in women than men (WHO, 2020b). A depressive episode can be classified as mild, moderate or extreme depending on the number and severity of the symptoms. People who suffer from this illness experience a depressed mood, loss of interest and enjoyment, and decreased motivation leading to at least two weeks of decreased activity. Many people suffering from depression may suffer from symptoms of anxiety, impaired sleep and appetite, and experience feeling of shame or low self-worth, poor concentration, and some symptoms that cannot be described by clinical diagnosis (WHO, 2020b).
Depression is caused by several factors. Research by Malinowski et al. (2016) found that depression is influenced by anxiety, shame, and poor acceptance of the past, which have a higher influence on depression than socially prescribed perfectionism. Furthermore, Hagerty and Bathish (2018) successfully implemented an intervention program that focused on self-management (SRIM-D) to tackle depression disorders. Depressive symptoms decreased after intervention using SRIM-D for half a year.
The counseling approaches applied to deal with depressive disorders as a result of COVID-19 are the skilled helper model developed by Egan (2013) and cognitive therapy by Burns (1980). The telecounseling process by applying a skilled helper model passes through three stages. Meanwhile, the application of cognitive therapy takes place during the third stage of the skilled helper model. Egan (2013) implemented stage I to find out what the participant felt and complained of. From what was said by the participant, we found that she experienced negative emotions (e.g., angry, sad, and afraid). Previously, the participant had experienced chronic illness. The impact of COVID-19 caused the participant to be increasingly prone to negative emotions (i.e., the participant cannot be as productive as before the presence of COVID-19). She also had difficulty sleeping, was not interested in engaging in any activities, and had a reduced appetite. Furthermore, she had thought about committing suicide. In terms of cognitive distortion, the participant said that she felt people thought that she was unworthy.
Based on the theoretical aspects of depression (Beck & Alford, 2009), the primary triad of depression in the participant can be seen from how her cognition influenced her feelings and motivation. Beck and Alford (2009) explained how a negative self-view causes suicidal ideation, often being alone, and lacking motivation. Beck (1976) described the cognitive theory he developed, one aspect of which consisted of dysfunctional attitudes. Pössel and Smith (2019) describe people who are depressed because of pressure, then this dysfunctional attitude will cause individuals to experience cognitive distortion and hence, unrealistic and extreme thoughts.
The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV-TR) (APA, 2000) stated that major depressive disorders last for two weeks, and the ailments felt by the participant lasted for 14 days. Therefore, according to this source, the participant experienced Major Depressive Disorder (MDD). The DSM-IV-TR also became a foothold of Beck et al. (1996) in revising the depression inventory that they had previously developed (the BDI-IA) to the BDI-II. Items in the BDI-II represent major depressive episodes (APA, 2000). Then, if matching with BDI-II, the two-week calculation includes the day on which we gave BDI-II to the participant.
The results of the BDI-II indicated severe depression in the participant. In this severe depression, besides the individual experiencing depressive symptoms for two weeks, she also felt five symptoms of depression (APA 2000). Some symptoms of depression include feelings of low mood, reduced interest in daily activities, body weight loss or gain, sleep disturbance, a loss of energy almost every day, feelings of worthlessness almost every day, poor focus in concentration, and thoughts of suicide (APA, 2000); thus, the participant was diagnosed by MDD. Almost every day, the participant felt uninterested in external stimuli. Such conditions must be overcome with counseling and psychotherapy approaches, treatment, and support groups. From the findings, we asked the participant to complete the BDI-II to ensure compatibility between what was delivered and the scale

Stage 2: Challenging-What do I want instead?
This section discussed previous findings (i.e., severe depression; with rating score = 31-40; BDI-II results) so that the participant is aware that she is experiencing problems.
1. The participant started to study the situation which she was feeling. 2. It began to be understood whether irrational thoughts on the part of the participant were her true needs. 3. The participant showed sad emotions (i.e., by crying) when recalling her condition, which had never been happy since she was diagnosed with chronic illness and the news of the arrival of COVID-19.

Stage 3: How might I achieve what I want?
The participant was given the technical worksheet column 3 and the dysfunctional diary (i.e., cognitive therapy approach). The task was given so that the participant would begin to realize that her problems were experienced because of an irrational way of thinking, so it impacted on her experience with daily activities. Then, the results of the worksheet are discussed.  (Egan, 2013). Regarding this, although the participant still showed negative emotions when she was reminded by her condition that she had never been happy since suffering from a chronic illness and the presence of COVID-19 cases in Nusa Tenggara Barat which were quite high in numbers. The participant began to understand herself and what was happening to her. The participant was also given space to analyze whether the things that she wanted were needed (e.g., she wanted to work and complete her doctorate).
Stage III was marked by how the participant conceptualized strategies aimed at getting whatever she wanted (Egan, 2013). In addition to applying "how might I achieve what I want?" from Egan's counseling approach (2013) and to deal with severe depressive disorders in the participant, this stage also involved cognitive therapy, which is applied by giving worksheets to the participant and changing dysfunctional thoughts by writing down some cognitive distortions (Burns, 1980). After she had written down cognitive distortions on the worksheet, the participant analyzed the causes of distorted thinking, and thus, when the participant was able to criticize the distorted thinking, she was also able to develop a more realistic evaluation system (Burns, 1980).
In this case, the participant began to make some plans for after the COVID-19 pandemic ends in Nusa Tenggara Barat. Also, she tried to regulate the negative emotions she was feeling so that her resilience would increase. The participant realized that negative emotions aggravated the condition that she felt, so she seemed more optimistic, looking at the future with positive emotions. The participant finally planned to apply for jobs that matched her interests. Also, during stage II, she had stated that continuing her doctoral studies was able to make her happy, so in mid-2020 she planned to pursue her doctoral degree at one of the universities in Indonesia (thanks to stage III's skilled helper model and cognitive therapy). Moreover, previously, the participant had been reluctant to interact with other people, which was caused by a feeling of inferiority. Now, she engages with her relatives in social activities by distributing food for abandoned children.
The participant is currently completing worksheets to deal with dysfunctional thoughts. She also reported that when interacting with her relatives, she often felt inferior. Nevertheless, she always tries to fight these inferior thoughts. When comparing the conditions of the participant at the first telecounseling process, there was a change in dysfunctional thoughts. However, the participant still needed assistance through counseling and psychotherapy.
In the context of dealing with the negative emotions of individuals during this coronavirus outbreak, telecounseling (i.e., therapy by phone, chat, or hotline intervention) is an effective approach as it has several advantages. According to Riemer-Riess (2000), the benefits of telecounseling may address much broader needs, including emotional support, empathic listening, psychosocial counseling, self-help and others' help tools, and referral to other providers of mutual assistance, as well as a medical intervention related to health issues.
On the other hand, the disadvantages of telecounseling also exist; Laszlo et al. (1999) revealed that telecounseling is less effective than face-to-face treatment because of the inability to interpret non-verbal signals. During the telecounseling process, there were several obstacles. One difference from face-to-face counseling, where there is an interaction between counselor and client, was that telecounseling is not able to attain. Moreover, we only utilized chatting and calling features on the WhatsApp application, and besides, we had unstable network quality.
Telecounseling also has advantages of access and availability, which are particularly important during crises, when access is often limited, such as the recent condition during this coronavirus outbreak in the majority of countries including Indonesia. It also allows complete anonymity, thereby helping to reduce the fear of needing help and being in treatment (Gelkopf et al., 2013;Glover et al., 1990;Pietrzak et al., 2009). Also, although face-to-face counseling can foster trust in clients to say whatever is felt and thought, our participant enjoyed describing all her ailments without any awkwardness. Telecounseling can be usefully applied in a country such as Indonesia made up of islands separated by the sea. Although constrained by the quality of the internet network, telecounseling can still be effective by writing messages through social media platforms (e.g., Email, WhatsApp, Messenger, Line, WeChat). For areas with better internet access, telecounseling can be through several virtual platforms that display videos (e.g., Skype, Zoom, CloudX).
This study is limited to the process of telecounseling with a participant who experienced negative emotions as a result of COVID-19. Although our participant was not afraid of being infected by COVID-19, she experienced depression caused by the impact of COVID-19 in Indonesia. We prioritized this research for participants in the province of Nusa Tenggara Barat. In the future, research participants could be recruited from areas outside this area, demonstrating the effectiveness of telecounseling in reaching clients from any region. For the application of the counseling approach, further research could apply internet-delivered cognitive behavioral therapy (ICBT) as conducted by Eriksson et al. (2017). Also, this research applies a single-case research design (N = 1) with qualitative methods. Further research could involve several participants accompanied by quantitative data analysis methods as well as research conducted by Acarturk et al. (2016) who studied depression that accompanied by intervention in the form of eye movement desensitization and reprocessing (EMDR) to reduce individual depression.

Conclusion
The telecounseling process took place in three stages, echoing to Egan's skilled helper model (Egan, 2013) and cognitive therapy (Burns, 1980). The first stage was an exploration of everything that the participant was feeling and thinking about. The second stage consisted of establishing the participant's interests and goals. The participant knew what she was doing to achieve her goals after receiving a worksheet to reduce dysfunctional thought at the third stage