COVID-19 emergency: an unprecedented pandemic
“I didn’t eat for days. I was very scared. I was counting the sirens of ambulances even when I was at home, and I kept picturing the image of a wounded hospital as if it actually had a wound that cut it in half and that was bleeding.” (nurse in critical care unit, Phase 2)
“It’s all surreal. Some patients were stroking the screen of the iPad while talking to their loved ones, and then there were those dying of air hunger…” (nurse in critical care unit, Phase 1)
“When I first heard about China, everything seemed far away. People at the airport were finding it funny to see Chinese people walking around in masks. Then, from one day to the other, it became a nightmare… The still image is that of a blender that works at different speeds, depending on whether you’re in or out of hospital wards completely transformed by the emergency, in a dirty or clean area.” (doctor in critical care unit, Phase 2)
On 31st December 2020, WHO headquarters in China were notified of cases of pneumonia of unknown origin in the city of Wuhan, in the Chinese province of Hubei. This started to outline the scenario of a health emergency that would affect the community very quickly, with increasingly global borders and with an incredible upheaval in the sense of safety and control.
The pandemic in Italy: beyond vicarious traumatisation
Understanding the mental health consequences of an unprecedented pandemic was, from the start, an important concern for those who were structuring support interventions for healthcare personnel (De Mei et al., 2020; EMDR Italy). As psychologists who worked (and continue to work) in health care during the COVID-19 epidemic, we experienced the urgency of providing the most effective and evidence-based responses possible, aware that the health emergency we were experiencing (and that the world is still experiencing) represented (and represents) a challenge to psychological resilience for all.
Many documents and reports have given indications (ad interim) for the management of work-related stress during this emergency (CSTS, 2020; WHO, 2020a; ISS COVID-19, 22/2020), highlighting very well how the psychosocial risk factors, closely linked to work organisation and employees’ safety and health, have been greatly amplified by this emergency, starting from those related to personnel’s safety, like prevention and protection measures. Besides physical stress, healthcare workers have also been exposed to a high level of psychological stress: fear of being infected and of spreading the infection, high mortality, suffering for patients’ and colleagues’ death, changes in work practices and procedures, the need to provide emotional support to patients in isolation and, in many cases, to accompany the dying ones. And then social isolation, due to distancing measures (including within their families) and quarantine or, in some cases, discrimination and stigma (WHO, 2020b).
Radical changes in routine, lockdown measures, daily bulletins of infected and deceased people, testimonies of healthcare staff or of people who survived the illness and the death of their loved ones in total isolation from their families, as well as the separation of healthcare workers from their children, are just some of the many significant aspects that affected many people’s lives in the first half of 2020.
What we have experienced in this pandemic is that healthcare professionals were, in spite of themselves, directly exposed to the trauma of contracting the infection and also living, through indirect exposure, the trauma of the COVID-19 patients that they were treating in hospitals. If we take as a reference the classification proposed by Taylor and Frazer (1981) – which divides the victims of Critical Accidents (Mitchell, 1983) into 6 levels – rescuers are classified as 3rd level victims (or 3rd type victims). This category has been extended to include not only those who operate in situations of natural and/or artificial disasters, but also those who operate in emergencies (Iacolino and Cervellione, 2019) such as doctors, nurses, social and welfare workers, psychologists, law enforcement agencies and all those who operate in complex scenarios. Moreover, what we have learned from experience during the COVID-19 pandemic is that these healthcare workers are 3rd type victims but could be also victims at all the other levels. And some of them were.
They could be 1st type victims (those who directly suffer the traumatic/emergency event) because they died from COVID-19 as a result of contagion; 2nd type victims (relatives or loved ones of the deceased and survivors) because of the possibility of losing a family member from COVID-19; 5th type victims (those who, due to their pre-critical characteristics, may react to the event by developing a short or long term psychopathological disorder) due to the presence of fragility or previous traumas with respect to which the traumatic impact of the pandemic leads to the development of post-traumatic or other symptoms. In addition, all the healthcare professionals that worked in the COVID-19 emergency were victims of 4th type (the community involved in the disaster) as they belonged to the population affected by the pandemic. They were all also victims of 6th type (those who could have been victims of 1st type) because of the continuous risk of contracting the virus that could, in fact, lead to death from COVID-19. This happened to many healthcare workers. In our country and in the world.
“When I was moved to a COVID ward, it was endlessly sad. I hardly remember anything about that period. Once I locked myself in a closet because I couldn’t stand CPAP anymore. I also had to put it on a colleague … Every morning I counted who was there and who was no longer there because they died during the night. The first thing I wanted to know was whether all the nurses were present or missing because they had also fallen ill…” (nurse coordinator in critical care unit, Phase 2)
“The image that keeps coming to the mind is that of the rows of bodies in the morgue. I have wondered about the dignity of dying and about accompanying the dying in this pandemic. Those days I thought it was the end of the world. An immense pain. I never cry, but now I keep crying.” (department nurse coordinator, Phase 3)
“That night I saw ten people die, one after the other. I shared everything with a colleague and from that moment on I was no longer afraid of being infected. Only to infect my children. So I called my ex-husband and told him to take our children with him. The worst moment was when I left them, because I felt guilty.” (doctor in critical care unit, Phase 2)
We wondered, in the light of these reflections, if this pandemic has not in fact subverted our references in emergency, forcing us to consider more co-existing possibilities and interpretations, such as that of vicarious or secondary traumatisation together with that of primary traumatisation. Vicarious trauma and direct trauma. As well as that of being victims on multiple levels.
For this reason, in order to provide adequate psychological support, we had to use different and complementary approaches, quickly evaluating their effectiveness so we could be ready for new redefinitions and adjustments, also resorting to our creativity. In fact, the complexity of what we were dealing with as the pandemic was spreading led us to re-write our knowledge on psychology in emergency so we could be of real support to first responders (including ourselves), patients, and their families (even if remotely).
The experience in emergency that we are going to describe is the result of the reflections that we have shared – of the intelligent, human and creative professionalism that we have rediscovered while being at the service of others (and of ourselves, as a group of psychologists); of an openness to our country and the world favoured and supported by the (many) people of EMDR Italy Association, who have accompanied us and worked with us remotely while we were inside those hospitals this pandemic “wounded”. It is also the result of all the pain we have gone through and the experiences of death we have experienced. It is the result of life and hope that we have shared and that have helped us to always look ahead.
In Italy, and especially in Lombardy where there has been the highest number of positive cases and deaths, the very rapid evolution of the pandemic has forced hospitals to adapt continuously.
All this has also happened in our hospital units (ASST in Lecco), which have been completely reorganised, from one day to the next, to deal with the SARS-CoV-2 emergency.
The Crisis Unit, which operated at different levels, was trained by 14 EMDR psychologist psychotherapists and 6 psychotherapists with other kinds of training backgrounds, for a total of 20 psychologists. Specifically, the psychological support interventions with EMDR group treatment for critical care unit staff will be described as follows.
Psychological support interventions with EMDR group treatment for critical care unit staff
“It was an unexpected event, a crescendo. My feet were swollen in the evenings. Then my colleague got sick and I was afraid: I was calling him and I could hear him panting. Today I know that I can protect myself, that I am more protected in the hospital than outside, that I can take care of myself and reclaim my time…” (doctor in critical care unit, Phase 2)
“It all started with the colours and the blossoming of a wonderful spring. In the background, the image of war, but we were not at war. We were “at care”: caring for each other, our colleagues, our families and our children, isolating from them to protect them. We were also taking care of ourselves in order to be able to support others. Protecting ourselves and protecting them.” (psychologist in critical care unit, Phase 1)
The healthcare workers we met during our support interventions were in a complex situation, characterised by the immediate and repeated change in their activities and procedures, teams, and work spaces/places, in a totally new and unpredictable scenario (ISS COVID-19 Report, 22/2020).
It is precisely in this context that the Crisis Unit activated brief EMDR group interventions for critical care unit staff, adapting to the organisational realities and needs – only partially expressed – of each ward, within a real “emergency vortex”. The continuous and untiring work of outreaching was necessary to reach all the staff and support them in their task of facing the emergency, “protecting those who protect.” As matter of fact, this evolving dimension of the pandemic has initially hindered the request for help, for various reasons. And yet, surprisingly and unexpectedly, we experienced the fact that it was sufficient to work with a single group (which for security reasons could not exceed the number of 3 participants) to generate an intrinsic and supportive force that pushed from within the staff of an entire ward to allow themselves to be helped and supported. In this regard, many reported the feeling that their colleagues were like their “second family” in the context of this emergency.
Three meetings were proposed to the staff, following a protocol – which we will call brief EMDR group treatment – created by the re-elaborated version of the guidelines for the stabilisation-decompression of Critical Incident Stress Management (CISM, Mitchell and Everly, 2001; Quinn, 2009) and by the specific EMDR protocols for Acute and Recent Traumatic Events (Shapiro and Laub, 2008; 2009).
The objectives of the intervention were a) to normalise emotional reactions, b) to break the sense of isolation, c) to screen for symptoms in the acute peritraumatic phase and to prevent the onset of disorders related to the acute stress reaction and post-traumatic disorder and d) to elicit individual and group resilience and post-traumatic growth.
The following tools were used in order to evaluate the effectiveness and the outcome of the interventions a) in the pre- (first EMDR group session) and post-intervention phase (third EMDR group session), the specific Impact of Event Scale IES-R (Pietrantonio et al., 2003) and b) at the end of the intervention, the PTGI Posttraumatic Growth Inventory (Gabrieli and Pietrantoni, 2006).
As this was an emergency with specific phases, the protocols used in Phase 1 (March – May 2020) have been re-adapted for the Phase 2 (end of May – mid-June) and Phase 3 (mid-June onwards). In these last two phases, the brief EMDR group protocol was used in the first group meeting, while the EMDR group protocol with the four quadrants was used in the following two meetings. In all phases, the third EMDR group meeting analysed, in depth, the topic of post-traumatic growth, with the composition of sentences that were then posted on the walls of the various wards of our hospitals.
In all phases – especially in Phase 1 – the exercises related to the stabilisation phase were adapted to this specific emergency, where “breathing” represented a trigger for the majority of the staff, making the breathing exercises in the stabilisation phase difficult. For this reason, we preferred to use the Grounding exercise where the breath is associated with a well-defined body image of stability.
The psychological early interventions carried out in our “wounded” hospitals during this emergency demonstrated what it meant to work in health care during the COVID-19 pandemic. In this perspective, the Crisis Unit experimented, in humanitarian cooperation with EMDR Italy Association (and with many colleagues in Italy and around the world), a clinical solidarity capable of generating effective actions and strategies in response to an unprecedented collective trauma. Together we were able, despite everything, to face and treat (as we could) this trauma, and we discovered to be more resilient and open to the future. Whatever it may be. As we have learned to do during this pandemic without ever deserting the impact with reality.
Without forgetting. With a perceptive and resilient look to the future.
Center for the Study of Traumatic Stress (2020), Sustaining the well-being of the healthcare personnel during Coronavirus and other infectious disease outbreaks
De Mei B. et al. (2020), COVID-19: gestione dello stress tra gli operatori sanitari, Centro Nazionale per la Prevenzione delle Malattie e la Promozione della Salute, CNAPPS, ISS, available at < https://www.epicentro.iss.it › coronavirus >
Iacolino C. e Cervellione B. (2019), Gli operatori dell’emergenza. Fattori di rischio e di protezione, Franco Angeli Milano
Mitchell J.T. (1983), “When disaster strikes: The Critical Incident Stress Debriefing Process”, Journal of emergency medical services, 36-39
Mitchell J.T. e Everly G. (2001), Critical Incident Stress Debriefing: An operations manual for CISD, defusing and other group crisis intervention services, Chevron Publishing
OMS documents (2020), available at < https://www.who.int > docs > coronaviruse :
a. Coronavirus disease (covid-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health
c. Addressing Mental Health and Psychosocial Aspects of covid-19 Outbreak, Interim Briefing Note, Version 1.5, February 2020, developed by the IASC’s Reference Group on Mental Health and Psychosocial Support in Emergency Settings, WHO (Italian translation: Affrontare la salute mentale e gli aspetti psicosociali dell’epidemia di COVID-19, available at < https://www.salute.gov.it/nuovocoronavirus >)
Pietrantonio F. et al. (2003), “The Impact of Event Scale: validation of an Italian version”, Journal of Psychosomatic Research, 55(4), 389-393
Prati G. e Pietrantoni L. (2006), “Crescita post-traumatica: un’opportunità dopo il trauma?”, Psicoterapia Cognitiva e Comportamentale, 12. 133-144
Quinn G. (2009), “Emergency response procedure”, in Luber M. (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Basics and special situations, 271-276, New York, Springer Publishing Co.
Rapporto ISS COVID-19 (2020), Indicazioni ad interim per la gestione dello stress lavoro-correlato negli operatori sanitari e socio-sanitari durante lo scenario emergenziale SARS-COV-2, n. 22/2020, Gruppo di lavoro ISS Salute mentale ed emergenza COVID-19
Shapiro E. e Laub B. (2008), “Early EMDR intervention (EEI): A summary, a theoretical model and the Recent Traumatic Episode Protocol (R-TEP)”, Journal of EMDR Practice and Research
Shapiro E. e Laub B. (2009), The New Recent Traumatic Episode Protocol (R-TEP). Eye movement desensitization and reprocessing (EMDR) scripted protocols: Basics and special situations, 251-270
Taylor A.J. e Frazer A.G. (1981), “Psychological sequelae of operator overdue following the DC 10 air crash in Antarctica”, Psychology, 27, 72