Isabel Fernandez – Lucia Formenti
Psychotraumatology Research Center – Milan
The purpose of this article is to share reflections of what we have experienced in dealing with the Covid 19 emergency. We know that every mass disaster is different from the others that we might have dealt with, but this emergency is very special, because of its characteristics.
The Coronavirus emergency forced people to change the basic ways they conduct and organize their lives. They were forced to lockdown, putting their lives “on hold” for a long period of time, that is very difficult to tollerate and overwhelming. We were being asked to trust completely what the government and politicians said and follow their indications and this was also unusual. This complex change happened almost overnight and it was too fast for people to process. Things have been changing quickly day by day and the information was often conflicting, creating a great sense of confusion.
Along with this, the virus activated a feeling of vulnerability, where people feel exposed to an invisible “threat or enemy” that is difficult to fight. They felt fear of getting infected, anger, depression, sense of threat, blame or feeling of being rejected and faulty if they got ill. Everybody was aware that their safety depended from others’ behaviours. If people were not following the rules, others would get angry and feel helpless. People who had their loved ones infected could not take care of them and could not accompany them as they passed away.
Last but not least, those who were engaged to help the population, the medical staff, was one of the categories most affected by the pandemic.
As clinicians we have to be aware that this emergency will have an important effect on the whole population, not only on people with major psychological risks factors. The lockdown can have long lasting effects, since it is an “avoidance” response. At this time, we are avoiding people, physical contacts, places, crowds, etc. During lockdown it is easy to develop catastrophic thoughts and interpretations of what is happening. There is no way to plan any kind of activity since the emergency seems endless and without perspectives. It is possible that going back to normal might not be easy for everyone.
An article published in Lancet a month ago found that quarantine produces negative psychological effects including symptoms of post-traumatic stress, confusion and anger. According to these researchers from King College London quarantine can have long-lasting psychological impacts –“The psychological impact of quarantine and how to reduce it: rapid review of the evidence”. Brooks, S.K. et al. King’s College London. The Lancet doi:10.1016/S0140-6736(20)30460-8. Some of these symptoms, particularly post-traumatic stress symptoms, have been shown to remain long. According to this research, those with a psychiatric disorder history and health care workers who have suffered major psychological impacts due to quarantine, may be at risk.
Another publication “Neurobiological Trajectories Involving Social Isolation in PTSD: A Systematic Review.”Vlachos II1, Papageorgiou C1, Margariti M1, stated that isolation can be an important risk factor in terms of physical and mental health, linked to the effects of neuroendocrine and immune reactions, neuroplasticity and telomere length. The article was recently published on Brain Science. 2020 Mar 18;10(3). pii: E173. doi: 10.3390/brainsci10030173.
This means that psychological interventions must be significant and take into account all these phenomena and mechanisms that will play an important role in people’s health in the upcoming months and years. Making a preventive intervention, strengthening resilience and follow up is fundamental.
According to the guidelines published by the International Society for Traumatic Stress Studies (ISTSS) in October 2018 “PTSD Prevention and treatment guidelines. Methodology and Recommendations “” (Guidelines for the prevention and treatment of PTSD. Methodology and recommendations “), psychological interventions such as EMDR are considered an “evidence-based intervention in adults as early intervention, in the acute phase” and it produces effects on the clinical reduction of symptoms and on the improvement of the functioning / quality of the life. Another article by Mavranezouli et al. “Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults” concludes: “A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them.”
The Italian EMDR Association in the last 20 years has done more than 700 interventions in emergency situations and mass disasters. All the experience and expertise we have gathered through these years had to be adapted to this new emergency related to Coronavirus.
Since the beginning, on February 21st, the Italian EMDR Association and all its members have been trying to make a difference in terms of psychological support and prevention for the wellbeing of all those who have been strongly affected by the pandemic: medical staff (doctors and nurses), people infected, families of those infected and the population in general.
As clinicians our priority is to use our psychological expertise to help and communicate the necessary information correctly to reduce anxiety and panic and to support all the people who have been in close contact with the disease (patients, relatives and health workers). The Italian EMDR Association received many requests from institutions, hospitals, local health units, Health Protection Agencies, Ministry of Health, Ministry of Education and municipalities. We have been active on the field with 200 different intervention projects, reaching thousands of people, providing psychological support to the population, to the people who have lost a loved one to the disease, to the health workers and the people who work long hours in this emergency every day and who are exposed to patients and to new stressing situations.
In these weeks, EMDR Italy have been sharing their experiences and material with other European Countries, so they could have a base that could be useful and concrete.
We are aware that our medical practitioners are exposed to great risk and concerns; dealing with many patients at the same time, with not enough resources for the paramount emergency; exposed to the infection and many have become sick with the virus or died; fear of infecting their families to the point of deciding to live and sleep elsewhere in order not to infect their children and relatives. They are one of the most important populations in need of psychological support during the emergency, but their need will be even greater in the future when they will be finally in the condition, to restore their working serenity and their daily routine. Most of the work will be done probably at the end of the emergency, since medical staff are focused on taking care of the sanitary aspects and are not accessing their own emotional response, except for some of them who are devastated.
We produced videos on stress reactions, on stress management, on EMDR and for the jail directors and personnel, for the National Health Service for medical teams and for the population, in general. These videos are 5 minutes long and are very practical, especially for doctors and nurses who do not have the time and possibility to call or have psychological support right now. We have had good feedback. They are watching them and following the suggestions that were tailored for the Coronavirus emergency, for instance, what to do at the end of the shift, etc.
In emergencies, things change quickly and giving a correct information is fundamental in order to prevent confusion – both in health workers and in common citizens. This is the reason why we created specific texts for different targets (children, elders, medical staff).
After 3 weeks of the Coronavirus emergency, EMDR Italy through its members is supporting:
- 20 Hospitals
- 11 Municipalities (big cities and towns)
- 13 National Health Service centers
- 4 Regional/State Health Services (covering around 15.000.000 inhabitants) of the Northern Italy
- 11 different associations and NGOs
- 4 Regional/State Psychological Associations
The National Psychological Association
- Network of jails administration of Northern Italy
- Costa Cruises (with guests and crews infected during the Cruise)
- Ministry of Education (programmes for teachers and students of all ages regarding the
- We organized a free seminar focused on EMDR protocols and tools applied to the Coronavirus emergency.
We are doing all this by phone, Skype, Zoom, etc. We were surprised that our work could be done remotely and be so effective, even with groups of doctors and nurses.
- Emergency Concerns: During an emergency, everyone responds with his own personality, characteristics and the abilities he/she has learnt in life. Many will develop anxiety or fear; others will become depressed, etc. It is important to know that these effects will not stop with the end of the emergency, but they might persist in the medium-long term or they might even grow and generalize to a number of situations that used to generate no disturbance before.
- Providing an Environment of Safety: During an emergency, and particularly in this case when we are fighting against an “invisible” enemy, the people might feel in constant danger and they might feel constant fear. This feeling of threat has the priority over the cognitive rational structures because this is a question of survival and hence it is innate and irrational. In this first phase, it will be important to provide the people with a sense of safety and remind them that there are things that we can do, so we are not so helpless. When providing support even in this situation, we noticed that it is possible to find resources, positive aspects or situations, where the client was able to feel safe. It has been fundamental in order to promote safety, to provide information and psychoeducation on what is happening and how and why we are reacting this way.
- Support Official Channels of Information: In situations of emergency, people feel the irrational need to be reassured and to have control over what is happening. Hence, many will feel the need to follow the online news constantly. Quite often, however, they will get fake news: since it is written to stir an emotional impact, it will become viral and difficult to manage. It has been necessary to repeat how important it is to follow the official channels, like the website of the Ministry of Health, or other official websites managed by health organizations, to reassure the population and not to disseminate panic as fake news often does.
- Legitimize Emotional Responses: Explain the coronavirus as if it were an “invisible enemy” difficult to control and to predict. This emergency has been challenging our mental schemas, those we are used to as human beings. This is the reason why strong anxiety and concern may arise. Trying to normalize and legitimate all these emotions can be helpful to calm down the client and to explain what is happening in them.
- Support Resilience: Just as our body is equipped with an immune system, our brain is able to adapt psychologically to adverse situations thanks to its resilience. It is important to extend the perspective of what is happening: we are not helpless even if we cannot change things. We can change our reactions and perspectives, the way we see what we are experiencing.
- Constructive Viewpoints: Provide a constructive view of what we are experiencing: It is possible to find resources in each situation, which can be used. This is an opportunity to devote time to a slower life, to our family and ourselves. In this moment, we can do things that have never been a priority for us. Now we can do them and use technology – streaming and platforms – we are all isolated, but we are all connected as a community at the same time.
- Support What We Can Do: For all these factors, it is not possible to predict results. Many people may feel difficulties due to this unpredictability. Providing simple and clear indications on what to do allows the people to feel this sense of unpredictability less. For instance, washing your hands, cleaning all home surfaces, paying attention if we sneeze or cough, etc., but also emotional and psychological strategies to feel grounded and safe.
- Focus on the Here and Now: The fact that we cannot make projects in this moment, no plans, may create new challenges and feelings, since we are not used to not make plans. However, it is important to state that we must focus on the here and now. This is a great opportunity to simplify our lives that are generally very complex and fast. We have the possibility to explore this simpler and easier life that the Coronavirus emergency is compelling us to conduct, changing our hierarchy of priorities.
The Contribution of EMDR Therapy: At sanitary level, specific scientific protocols have been pursued, following medical protocols, knowledge and expertise. From the psychological point of view, we must also address the needs and dynamics that are being triggered in the people, through research-based protocols considered effective according to the International guidelines as EMDR therapy.