Psychological Trauma: Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 12, No. S1, S105–S107
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000802

Promoting Resilience in the Acute Phase of the COVID-19 Pandemic:

Psychological Interventions for Intensive Care Unit (ICU) Clinicians and
Family Members

Barbara Lissoni Silvia Del Negro

Niguarda Hospital, Milan, Italy
Santi Paolo e Carlo Hospital, Milan Italy

Paolo Brioschi, Giampaolo Casella, Isabella Fontana, Giulia Lamiani

and Claudia Bruni University of Milan
Niguarda Hospital, Milan, Italy

This contribution draws from the experience of intensive care unit psychologists at 2 frontline hospitals
in Milan, Italy, during the acute phase of the COVID-19 pandemic. In this contribution, we describe the
main psychological needs observed in clinicians and in the families of COVID-19 patients and illustrate
some psychological interventions implemented to respond to these needs. Containing emotions and
promoting resilience were the aims of our interventions. In the future, psychological interventions should
focus on the elaboration of traumatic experiences and losses.

Keywords: COVID-19 pandemic, resilience, psychological support, health care professionals, family
members

The coronavirus 2019 (COVID-19) pandemic has led the Italian

grief (American Psychiatric Association, 2013). However, the
health care system to face an unprecedented health emergency,
literature emphasizes how, in emergencies, many people are able
currently accounting for more than 25,000 deaths (Ministry of
to make use of internal resources—resilience—which allow them
Health, 2020). Hospital intensive care units (ICU) became satu-
to maintain mental health (Bonanno, 2004). The complexity and
rated in a few weeks, to the point at which other departments had
pervasiveness of the effects of the COVID-19 pandemic has the
to be reorganized to receive COVID-19 patients and new physi-
potential to undermine individuals’ natural abilities to respond in a
cians and nurses added to the care team. Entire hospitals were
resilient fashion (Fiorillo & Gorwood, 2020). It is therefore
rehauled. This is the photo of a far-from-static scene, within which
crucial that the objective of psychological interventions in the
even the hospital psychology clinic had to change its form of
acute phase is to sustain resources and reinforce the factors that
intervention to recognize and address the needs of the ICU team
may provide a protective action from posttraumatic stress and
and the family members of COVID-19 patients.
complicated grief (Horesh & Brown, 2020).
It is known that in emergency situations and under high levels
This contribution is the result of experience gained so far by
of stress, people can develop a posttraumatic disorder, a major de-
ICU psychologists in the Niguarda Hospital and the ASST Santi
pressive disorder, or a generalized anxiety disorder and, in the
Paolo e Carlo in Milan. Its aim is to describe the main psycholog-
case of the death of a family member, a pathological or
ical needs observed in clinicians and in the family members of
complicated
COVID-19 patients during the acute emergency phase and to
describe some psychological interventions implemented to re-
spond to these needs and support resilience. The needs analysis
Editor’s Note. This commentary received rapid review due to the time- was carried out in the ICUs during the first weeks of emergency
sensitive nature of the content. It was reviewed by the Journal Editor.—KKT through field observation and some individual interviews. It was
possible to structure the interventions on the basis of the needs
that emerged.
This article was published Online First June 18, 2020.
Barbara Lissoni, Unit of Clinical Psychology, Niguarda Hospital,
Milan, Italy; Silvia Del Negro, Unit of Clinical Psychology, Santi Paolo e Interventions for Staff
Carlo Hospital, Milan Italy; Paolo Brioschi, Giampaolo Casella, Isabella
Fon- tana, and Claudia Bruni, Intensive Care Unit 1, Emergency Primary psychological needs emerged in the team during the
Department, Niguarda Hospital; Giulia Lamiani, Department of acute phase (Maslow, 1954), such as the need for safety, belong-
Health Sciences, University of Milan. ing, to be listened to, and emotional decontamination. Staff inter-
Correspondence concerning this article should be addressed to Giulia ventions were developed around the objectives presented in Table
Lamiani, Department of Health Sciences, University of Milan, Via Di 1. These include the following items.
Rudinì 8, 20142 Milan, Italy. E-mail: giulia.lamiani@unimi.it
S105
S106 LISSONI ET AL.
Table 1
Aims of the Staff Interventions
Aims
Promote safety
Restore calmness
Normalize acute reactions
Promote self-efficacy
Promote a sense of belonging
Maintain mental openness
(a) The need for physical safety to be able to work with a sense
of individual and collective self-efficacy. In the reorganized dis-
organization, clinicians looked to the leaders as a reference and
self-promoted protection from further traumatic and disorientating
exposure. The leaders held short briefings on a continuous basis to
satisfy this need. These briefings involved physicians, nurses, and
health care assistants to transmit precise information on the orga-
nizational aspects linked to the present and to stay on course
together without defections.
(b) The need for belonging, that is, to feel a part of a cohesive
team with shared working objectives. Work objectives can
change, but it is important that they are clear, short term, and are
pursued consistently. In both hospitals, the support of the
psychologists to the ICU leader made it possible to value
teamwork and promote team cohesion through e-mails from the
leader to the team. Be- longing was also reinforced through group
defusing activities, described in the following paragraph, which
enabled the sharing of experiences between colleagues.
(c) The need to be listened to. The effective strategy was the
psychologist’s support to the team at certain fixed times in the day
during the frenetic daily activity. Defusing is the process intended
to facilitate the expression of staff’s thoughts and emotions with-
out feeling obliged to do so (Young et al., 1998), such as through
a short informal conversation for small groups or for individual
clinicians. Defusing was often carried out in the kitchen or break
areas because they were perceived as emotionally clean areas.
During defusing, we contained and normalized intense reactions
as a result of traumatic events, reduced negative judgments on
one- self, and enhanced the resources of the individual
professional and of the group.
(d) The need for decontamination and physical and emotional
decompression. An emotional decompression room was set up in
both hospitals in which clinicians can freely access an area, other
than the department, to offload tensions and cleanse themselves
from physical and psychological pollution. Informative material
and mattresses for autogenic training were prepared in the room,
and the presence of a psychologist was ensured at certain times.
Interventions for Family Members
The family members of a patient suffering from COVID-19 are
often in quarantine at home, without the possibility of any contact,
or have other family members who have been admitted to other
departments in other hospitals. The families are often scattered
and have suffered multiple losses. Family members cannot visit
their loved ones in the hospital. Therefore, information is mostly
ob- tained over the phone. The needs that emerged for family
members were the need for information, the need for
reassurance, the need
EARLY PSYCHOLOGICAL CARE IN THE COVID-19 PANDEMIC
the inability to see the corpse, and to hold funeral rites, which
to be listened and supported, the need to preserve a relationship
with their loved ones, and the need to be supported in the grieving
process. Interventions for family members were developed around
the aims shown in Table 2. These include the following items.
(a) The need to receive information. Information that is
provided correctly helps the family to give meaning to a situation
that is out of control. For this reason, telephone conversations
from physi- cians began with the first hospital admissions to keep
family members informed at least once a day and at an agreed
time (Mistraletti, Gristina, & Mascarin, 2020). Information over
the phone needs to be simple, true, and empathic. The phone call
from the physician provides the family member with reassurance
to be able to withstand this situation.
(b) The need for reassurance on the fact that their loved one is
not abandoned and he or she is being taken care of not only from
a clinical point of view but also relationally. In the phone calls, we
found it essential to communicate that clinicians were taking the
best care of the patient and that their loved one was not suffering
(Mistraletti et al., 2020). It is important to dedicate time to tele-
phone conversations or video calls, not only to respond to doubts
but also to provide the possibility of giving a face to clinicians and
to creating a relationship. In case of family members living far
away, we sent a photo of clinicians who were taking care of their
sick family member as a strategy to humanize and personalize the
care provided.
(c) The need to be listened to and emotionally supported. To
meet this need, phone calls from physicians were accompanied by
phone calls from the psychologist to family members. During the
daily communication, the physician introduced to the family mem-
ber the opportunity to be contacted by a psychologist forming part
of the multidisciplinary team. Phone calls are made twice a week
or as needed, with the aim of offering support and containment to
the emotions of family members and, at the same time, to emo-
tionally protect staff. The phone calls give voice to the thoughts of
family members, giving shape to their experiences and transform-
ing the unspeakable into words.
(d) The need to preserve a relationship with their loved one.
Given the impossibility of visiting COVID-19 patients, family
members are sent images of the department. If the condition of the
patient allows it, video calls are organized. Only in specific cases,
where there is a risk of the development of psychological disor-
ders, we set up visits accompanied by the psychologist. These are
held behind glass, with the use of protective clothing and commu-
nication through a transistor radio.
(e) The need to be supported in the initial process of grief. In
this situation, risk factors for complicated grief (Burke &
Neimeyer, 2012) are sudden death and at a distance the abduction
of the patient who disappears without having any more direct
contacts,
Table 2
Aims of the Interventions for Family Members
Aims
Contain and legitimize emotions
Enhance preexisting resources
Integrating the event into a biographical narration
Preserve the relationship with the patient
Facilitate the elaboration of grief
S107
serve to activate the grieving process. The psychological team briefly
trained clinicians on communicating the death through the sharing
of the main protocols on the bad news (Buckman, 1992). It was
also decided that psychologists should phone family mem- bers a
few days after the notification of death to contain emotions and
assess any spiritual needs. Coordination with the pastoral service
has enabled some families to participate in the benediction of the
deceased over the phone or to say good-bye to the patient who
was placed in a closed coffin.
Conclusions
This contribution described the needs and some psychological
interventions developed in the acute phase of the COVID-19
pandemic in the knowledge that needs will change and, conse-
quently, so do the intervention strategies and objectives. We have
been experiencing a feeling of fluidity for almost 2 months now.
“Fluids cannot maintain their shape for long; they change contin-
uously and unpredictably. The condition of need implies the on-
going necessity to reidentify what generates attraction and pain.
We are living in uncertainty” (Bauman, 2000, p. 37). For this
reason, in the acute phase, it has not been possible to offer
clinicians and family members structured interventions to reflect
on and process experiences, at times traumatic. Nonetheless, it
was possible to support them by containing emotions and
reinforcing resources through the strategies described. It is highly
probable that also COVID-19 patients, discharged after a period
of deep sedation and long hospitalization, will present signs of
stress and adjustment disorders. An adage says: “It is only
possible to deter- mine the ship’s position after the storm has
passed.” In the next future time, it will therefore be vital to create
spaces for psycho- logical support to integrate the lived
experience in our own bio- graphical narrative and to work on
traumatic experiences and losses emerging in this period.
As never before in recent history, the global spreading of the
COVID-19 pandemic forces us to deal with the possibility of
simultaneously being the healers, the patients, and the family
members. The pandemic’s transversality reveals our humanity and
fragility and draws us close to our patients in the sharing of a
difficult historical moment. For this reason, we mental health
professionals must cultivate a careful self-awareness and congru-
ence (Barnett, Baker, Elman, & Schoener, 2007) to be able to be
of help to our patients, recognizing how this pandemic has im-
pacted individually on each one of them.
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Received April 30, 2020
Revision received May 21, 2020
Accepted May 21, 2020 ■