Translation: Hector Tsougarakis
And what'll you do now, my blue-eyed son?
And what'll you do now, my darling young one?
I'm a-goin' back out 'fore the rain starts a-fallin'
I'll walk to the depths of the deepest dark forest
Where the people are many and their hands are all empty
Where the pellets of poison are flooding their waters
Where the home in the valley meets the damp dirty prison
And the executioner's face is always well hidden
Where hunger is ugly, where souls are forgotten
Where black is the color, where none is the number
And I'll tell and speak it and think it and breathe it
And reflect from the mountain so all souls can see it
And I'll stand on the ocean until I start sinkin'
But I'll know my song well before I start singin'
And it's a hard, it's a hard, it's a hard, and it's a hard
It's a hard rain's a-gonna fall
Bob Dylan, 1963
Introduction: a pandemic chronicle
We are in the middle of a storm, at least as far as Italy is concerned. Here in Greece it’s possibly only the beginning… I came back from my country four weeks ago. Until then the corona virus was a threat that was not very close to us. We felt that China, where the virus had initially developed, was distant. The scenes from Huwan, a city of 10 million, transformed into a science fiction set seemed surreal to us, while information on the new corona virus was still very contradictory… In Florence, where I had traveled for a scientific meeting, people were behaving normally. Thousands were in the streets, tourists as always, the restaurants were packed with queues forming outside, and we as usually hugged and kissed with old colleagues. Gradually, though, messages started to come from family and friends in the regions of Lombardy and Veneto: they are going to shut down the schools, two towns are isolated with the army deploying around them.
What’s going on, we wondered. Was all this too much? The next day I moved to my town near Venice, and the mood was already very different: The carnival festivities were banned in the whole country (How can that be? Venice without its carnival???). Moreover, all schools, universities, churches, museums, theatres, cinemas, gyms etc. were completely shut down for the next two weeks at least. In the streets people were numb, cautious but still in the mood for aperitifs (“we are sitting outside, it is not dangerous…”), for shopping, for bookstores etc. Then, the fear for the elderly and the vulnerable groups began: The first loss to COVID-19 in the city’s hospital was discussed here and there. It is a small city and news travel fast. The hospital department was quarantined with patients and doctors still inside.
The day of my return to Greece was approaching. Meanwhile, like a wave that was rising, concern was growing, passing from one person to the next along with information about what was happening in the isolated regions, interviews, testimonies, televised debates. These gradually concentrated more on the spreading of the virus and the contradicting opinions and points of view (“the disease is not as serious as the common flu”, “it is only dangerous for the elderly and those with a history of serious or active disease”, “the children are safe”, “it causes deadly pneumonia”, “we still don’t know its severity”, “60% of the population is going to get sick”, “millions are going to die”).
My loved ones encouraged me to return to Greece as scheduled: “You risk being stranded here”, “we will be fine, don’t worry”). I left halfheartedly, with no hugs, because we had already been informed they were dangerous, full of worry and contradicting emotions, but with the hope that soon we would return to normality. That I would soon see my loved ones again and that they would all be fine. I did not know that my flight, that should have been full of Greeks, returning from the “Clean Monday” festivity, would be empty, and that it would be the last flight from Venice to Athens. I landed in Athens expecting my temperature to be taken, like when I had landed in Italy a week earlier. Nothing, no interest at all for us coming from the corona virus hot spot. I applied social distancing measures (almost quarantine) on my own free will for two weeks. You never know what I could have brought with me from Italy or from the plane. I had no symptoms at all, but all the talk about non-symptomatic hosts had frightened me, so I kept also my family members here at a distance. Feeling that you might be dangerous for others is a weird feeling…
Gradually, news from Italy became more upsetting. A week later the whole regions of Lombardy and Veneto, as well as those bordering them, were declared “red”, and all commercial activities, save for supermarkets and pharmacies, were shut down. The night before the movement restriction measures were enforced, there was a wave of mass escaping of people from the North to the South. Students, employees, pensioners, were all seeking a way out of the “contaminated regions” not realizing the terrible responsibility, the terrible danger of spreading the epidemic everywhere, and especially to places where hospital infrastructure was not as functional and developed as in the North. We know what happened next: A few days later, Italy as a whole was declared a “red region”, with strict restriction of movement from city to city without certified serious reason, with very limited right of leaving the house for supplies, with encouragement for work to be converted to smart work for all public and private companies. It is only but a week ago that something similar happened here in Greece as well: from what I know, Greece is the first European country to follow Italy’s measures, and as we write these words we hope that this will be effective in controlling the spread of the virus in our country (like Italy, Greece is also “my country”). As of right now, “lockdown” is the model that has been adopted by most countries in the world, including those that were initially cautious and wasted valuable time in defending their population from the spread of the virus.
On 11 of March WHO Director-General Tedros Adhanom Ghebreyesus announced that we are in the middle of a pandemic. COVID-19 had already spread to 114 countries worldwide with more than 118,000 patients and around 5,000 dead. Apart from China, where things had started improving, the most affected regions were Italy, South Korea, and Iran. And now we all bear witness to what a pandemic everywhere in Europe and in the world means. That announcement was only two weeks ago, and already the numbers have multiplied, with a suspected one million infected in Italy.
We shut ourselves in our houses, those of us who could work from home started using internet applications – a theme that will come up later – and cyberspace became the main communication and meeting platform, for millions of people, with others, service users, family, friends and colleagues.
Daily reports of patients and casualties from every country of the world started coming in. At the same time, a collective international scientific effort began to study medication that could be effective in treating pneumonia, induced by the virus to a percentage of the patients, the worse pneumonia that has ever been observed, as well as an effort to create a vaccine.
Nobody knows how long the restrictions will last for. A ray of light shines from China, as well as from Codogno the first Italian hot spot, where there are no new cases, but the quarantine is continued and the level of danger is not yet lowered.
What is happening these days, these months is unprecedented: only a few distant echoes of the pandemic of another deadly flu that ravaged Europe 100 years ago: the reputation of the “Spanish flu” (A/H1N1) had reached us through family stories (“Grandma had caught it but survived”). But it had left more dead in Europe than World War I, 50 million only in our continent (Tognotti, 2002; Sabbatani, 2003). Medicine, however, was not as developed back then. Penicillin had not yet been discovered, and the new virus was striking a population already worn-out from the war.
**“Quarantine” and its psychological Impact **
The word quarantine (quarantena in Italian, meaning a period of forty days) refers to the period of movement restrictions in cases where it is suspected that somebody may be the carrier of a contagious disease. It is a concept that differs from that of total isolation with the purpose of protecting people from a contagious disease, in the case of somebody who is already sick. The term was first used in Venice during the leprosy epidemic in the early 12th century A.D. (1127), where ships with cases of the disease were made to remain in the open sea for forty days before they approached port, and has since been used worldwide in other deadly epidemics, such as the plague in 1300 A.D. and later in 1600 A.D (Brooks et al., 2020).
In recent months, probably for the first time in contemporary history, whole territories, such as Huwan and Northern Italy are quarantined. Lately these measures have been enforced on the whole of Europe and many other countries. A worldwide quarantine. The world halted in record time. It seems impossible but it is true. In order to protect our physical integrity and the greater good, we have stopped, modified or restricted our daily activities. We have severed contact with even our closest relatives, we have restricted our movements insufferably, we have isolated ourselves in our homes. And in this period of uncertain duration we quietly ask ourselves: “How long will we endure? How long will society endure? How did they endure it for four months in China?”
There are some data concerning the psychological impact that quarantine conditions may have (Cetrullo, 2020). Brooks et al. (2020) reviewed the relevant literature and focused on 24 studies that were published between 2004 and 2019, concerning the Ebola, the SARS and the H1N1 virus epidemics. The results showed that anxiety disorders, feelings of stress and intense fear, anger, depression, sleep disorders, psychological disorders similar to post-traumatic stress disorder, emotional exhaustion, irritability, feeling of loneliness and helplessness appeared in 7% to 54% of adults, adolescents and children alike, depending on the specific symptom, and the study (Brooks et al., 2020). Some of these symptoms were observed up to three years after the restrictions had ended. Furthermore, the habits acquired during quarantine do not disappear immediately, and 21%-54% of participants, depending on the study, continued to exhibit avoidance behaviors and anxiety disorders after quarantine had ended (ibid.).
The psychological burden of quarantine was especially evident in medical personnel that was put in isolation after being infected. In addition to the aforementioned symptoms, they felt intense feelings of guilt, as they felt responsible for potentially infecting other patients (ibid.). And unfortunately a story on yesterday’s news was that of the nurse in Northern Italy that committed suicide after testing positive for the corona virus. Having seen the unbearable pain that COVID-19 causes to terminal patients, she could not stand the thought that she had infected other people with such a grave disease.
In the literature review, the quarantine periods had different durations and concerned different populations, showing how cultural differences may play a role in psychological resilience of the population, as do the characteristics of the disease and the social stigma it may carry.
This new epidemic, however, has a very distinctive characteristic compared to those of the previous century: It has spread everywhere and quarantine, in most cases, concerns the whole population and not just those who are infected or might be infected. A very recent study, carried out in China on a sample of 1210 participants from 194 cities, showed that 53.8% mentioned moderate to severe impact of restrictions on their mental state. Another 16.5% mentioned moderate to major depressive symptoms , 28.8% moderate to major anxiety disorder , and 8.1% moderate to severe stress symptoms (Wang et al., 2020). The majority of participants (84.7%) were quarantined at home and 75.2% were afraid that a family member would get sick (ibid). Women, students and persons with physical disabilities and poor physical health experienced increased mental burden and more intense stress, which is interesting because women and young people suffer from less severe symptoms, when infected, while persons with physical disability are indeed more exposed to the dangerous consequences of the virus. This finding highlights the importance of providing correct and valid information to the public about the scientific findings and conclusions. Increased stress, reported by women in the Chinese sample (most of which were married with children), may be connected to the role of primary caregiver in the family (a woman’s role beyond cultural differences!) who might worry more for her family members’ health.
Access to relevant information seems to play an important role on the level of psychological burden of the population in the present pandemic, as well as in past ones (Wang et al., 2020, Brooks et al., 2020). According to the authors and recent experience:
- Providing valid and regular information to the population that is in quarantine conditions is crucial. It is only that way that people under quarantine can cooperate and comprehend the situation as well as realize the collective meaning of isolation. Effective and fast communication is essential.
- Medical and other daily supplies must be easily accessible.
- The isolation period should be as short as possible with a predetermined duration. Presently these conditions seem very uncertain.
- Most of the adverse effects stem from imposing restrictions to freedom. Voluntary quarantine is connected with less discomfort and fewer long-lasting complications (Brooks et al., 2020, Rubin, 2020).
The World Health Organization’s (WHO, 2020) pamphlet about mental health in quarantine conditions came out on March 12. It addresses decisively the danger of socially stigmatizing people infected by the corona virus, and even dictates how we must refer to these cases by disconnecting the person from the disease. It discourages people from constantly following the news and encourages choosing a valid source of information on a specific time of the day, so as to not be constantly exposed to fear and anxiety. It promotes self-protection and protection of family and friends and others in the community that might be in need of help. It encourages discussion of positive examples of people getting cured, as well as the expression of gratitude and reinforcement towards the medical personnel that is fighting against the pandemic in the “front line”. Brief instructions for coping with the psychological burden of restrictive measures, as well as managing bereavement, were also recently issued by a team of colleagues from the First Psychiatric Department of the University of Athens (Mavromara et al., 2020, Mitsi et al., 2020).
Spontaneous initiatives that took part these days in Italy and in Greece, like, for instance, people acknowledging patients and medical personnel with songs, music, ovation and other creative forms of expressing support from balconies, offer a sense of collectivity, optimism and positivity that are extremely necessary in these difficult and unprecedented conditions.
Family relations in pandemic conditions
How are family relations modified and formed in quarantine conditions and in the fear of virus transmission? We know very little about the impact of this unprecedented situation on family life and the relations between family members. Most of what we know comes mainly from personal experience and the communication with family, friends and service users. A first observation is that every family activates resilience and adjustment abilities. The challenges are many and vary, depending on the structure of the family system, the stage of the family’s life cycle, the family’s financial situation, the health status of its members, its living conditions and the environment and community to which the family belongs. Ostensibly, it seems that conditions are quite dissimilar for a family living in the countryside, in a village or on an island as compared to those of a family living in a large city neighborhood. Contact with nature and the opportunity to safely go out in a garden or a field unrestricted, have positive results on both one’s mental state and immune system. The feeling, however, of difficult access to proper healthcare services for any medical issue, can increase feelings of anxiety and insecurity for those who live in islands or remote regions.
Families with small children in lockdown conditions experience the challenge of creatively occupying them during the day, without their scheduled activities, with no change of scenery, without contact with other relatives (especially grandparents), with no outdoors strolls with friends, and little or no contact with school (depending on age and educational level). In Greece and Italy alike, as well as in other countries I would imagine, teachers are making tremendous efforts to keep contact with the children, to teach online and to hand out and correct homework (usually with poor means and no clear guidelines). Stressful conditions may have more of an impact on parents and young children, especially the last experiencing the parental emotional state of stress without having the capability of fully understanding what is happening. Simple, clear, and honest communication concerning the issues of the pandemic and the necessary protective measures may reduce children’s anxiety and sense of unsafeness (see relevant UNICEF and WHO instructions in the references). In Greece, the Laboratory of School Psychology of the National & Kapodistrian University of Athens Psychology Department recently published an online document containing useful information for the psychological support of families, children and adolescents during the preventive home confinement (Χατζηχρήστου και συν., 2020). It is worth mentioning that quarantine conditions may provide an opportunity for parents and children to enjoy one another’s company, spending plenty of time together, in a novel experience of a very different daily life, with much fewer out of home “running”.
Families with adolescents and young adults may experience more intense stress. Most adolescents feel less threatened by the pandemic: “It doesn’t concern me; young people are safe” (an erroneous opinion that made the rounds in social media: in Italy cases of young people’s deaths are on the rise) “my parents are exaggerating”. As Jacopo Dalai - coordinator of the “Nivalis” center in Milan that offers psychosocial support utilizing creative methods to young people, families and the community - points out: danger perception in young people is very different than that of adults. Moreover, COVID-19 does not have the characteristics that would scare adolescents, i.e. physical disfigurement. The enforcement of isolation and curfew (restrictive measures are even tighter in Italy) contradicts young people’s needs for independence and socialization. Guilt-tripping that might be utilized by some parents (“you are going to bring the virus in the house and make us sick”) may induce a stubborn symmetrical reaction of the young person. One of the “Nivalis” center’s activities is the creation of a digital supportive network between peers, where a group of adolescents (coordinated by a staff member and following a brief training) offers online help to children with social or learning difficulties. As we all know, offering support to others gives meaning to young people’s lives, helps them develop altruism, and cope with anxiety and fear.
What happens, though, in families who live in conflict? How do high-conflict couples deal with the restrictions? Do cohabitation conditions worsen unbearably, or does the couple achieve truce, feeling the severe threat and insecurity about the future? How do families with a member who is already in a stressful situation and presents psychological difficulties or disorders deal with the tensions? Can the common great fear and anxiety, in some cases, reduce and soften personal emotion? Or will it make them even more unbearable? How much more difficult is it for single parent families? How do the homeless and the refugees deal with the inhuman conditions of the camps? How do the families of doctors and nurses who put themselves in danger in order to save the lives of corona virus infected patients, deal with stress and fear?
The questions come like waves…
For most people it is as Brooks et al. (2020) put it: the more one realizes that this is a condition necessary and useful for himself, his family and community, the more he accepts it in a spirit of cooperation and altruism, the more he offers help and usefulness to others in these unprecedented conditions, the less he experiences the traumatic consequences of quarantine.
Altruistic and supportive initiatives for the weakest have multiplied in Italy as well as in Greece: communities and municipalities have organized groups of young volunteers to safely supply the elderly who live alone (who are many!) with groceries and medications. Blocks of flats have become communities of solidarity: As Gabriella Peracchimentioned in a local newspaper, in Padova (one of the first hot spots) the residents of a block of flats found packs of masks and a note, outside their apartment doors, from a young Chinese family that had recently moved in. It seems simple, but this gesture, at a time where getting hold of surgical masks is almost impossible (a problem that is still unresolved), had a huge symbolic impact, beyond the practical one, mainly concerning attitudes of stigmatization and racism. More so, coming from a family that in the recent past had faced suspicion and accusations from many, due to being from China.
As Luigi D’ Elia (2020) put it, quarantine is like “involuntary hospitalization” for everybody. Organisms that have evolved, however, adapt to changes in the ecosystem, and we need to understand immediately what adaptation the corona virus is enforcing and what radical changes society (globalized by the virus!) must activate, in order to emerge refreshed from this situation by rectifying the “hubris” (of man’s control over nature, of domination of powerful financial interests, of military attacks) that reigns (Bateson, 1972).
E-mental health: Providing online mental health services
Most mental health professionals adapted to the need of providing online psychological support and psychotherapy, in record time. It is an activity that was still limited in the field of mental health, even though it had been growing fast in recent years (Borcsa and Pomini, 2017). The effectiveness of digital practices has mostly been researched in connection to treating anxiety disorders and post-traumatic stress, and mainly in applying Cognitive Behavioral Therapy (CBT) (Algeri et al., 2018). There are, however, data concerning other disorders and a variety of clinical populations (Mucic & Hilty, 2016).
The percentages of psychosocial and psychiatric service users’ adaptation to the new reality are impressive: according to colleagues Francesco Di Paoloand Eva Angelini more than 50% of service users arranged to connect online and accepted the new form of support without particular difficulty or protest. Many of them were relieved that they could have remote access to mental health services. Feeling safe, by avoiding leaving the house and being exposed in public spaces, where there is a high risk of being infected, gave people a new motivation for using technology (for those who were not already familiar with it). Furthermore, they feel that healthcare professionals make sure they continue providing psychological support in these new stressful conditions of movement restrictions and social distancing. These are the main advantages of using online applications in the present situation, which have outweighed all the other reasons for choosing them under normal circumstances of mental health services’ functioning. The mandatory enforcement of social distancing, which is only bypassed in emergencies that cannot be dealt with remotely, has suppressed all reservations about the appropriateness of digital media, even for the first contact with a service user (Bischoff et al., 2016; Borcsa and Pomini, 2018). Such reservations have been highlighted by several studies that examined the use of technology by mental health professionals (Lazuras and Dokou, 2016; Cipolletta and Μοcellin, 2018; Borcsa and Pomini, 2020).
E-mental health practices are classified into asynchronous and _synchronous _ (Manfrida et al., 2017). The first category includes use of e-mail and written text messages in various applications. They are easy to use, cost effective, offer quick communication, discretion and the opportunity to keep an archive. However, they restrict expressive means which may lead to a higher risk of miscommunication and to identity uncertainty. They are usually utilized for quick and brief communication, i.e. scheduling a meeting, changing the schedule, communicating in an emergency etc. (ibid.). Furthermore, a wide offer of digital discussion groups and online “communities” focusing on specific issues with supporting aims, which are easy to join and connect to, are available on the web (Campaioli et al., 2017).
Videoconference is by far the most popular widely used synchronous practice. It is the application that mimics the real session more closely, it is cost effective or even free of cost and it is usually easy to manage and flexible. It also offers the possibility of recording (provided that all participants knowingly consent).
Most mental health professionals that are familiar with this practice, usually select it as a continuation of their face-to-face sessions, and only seldom for the preparation of an in vivo meeting. This choice is usually preferred with adolescents and young adults who feel more comfortable with support through digital media. Online activities with groups of high risk young persons in the community, have shown to facilitate relationship building between peers and interaction between adults and young adults in the real world (Dalai, 2017). Furthermore, digital practices may reduce fear of stigmatization over mental health issues, thus facilitating seeking help through anonymity and distance, as well as revealing difficult experiences more easily.
It is a fact that the pandemic conjuncture has sped-up the evolution of online practices in the field of mental health. It is important that our appreciation for the possibilities of intervention and support they offer does not lead us to underestimate the limitations and difficulties that their use may bring. The most commonly mentioned difficulties are the following (Wrape and McGinn, 2018):
Difficulties of empathy and of understanding the other person’s emotional state and the emotional mood of the session.
Restrictions in communication connected to the lack of eye-contact.
Difficulties in crisis management, in facing very negative emotions and severe psychiatric disorders.
Ethical and legal issues, e.g. higher risk of breach of privacy.
The online session demands the creation of a digital therapeutic setting, in which the therapist has much less control as compared to what happens in his professional space. Thus, it is important that therapist and patient agree on simple but important rules. In normal circumstances the therapist connects from his office and the patient usually connects from his home. The present emergency situation however, forces therapists to connect from their private space as well, which makes the initial contract concerning the setting all the more important. Both participants “visit” in a way the other person’s private space and must ensure privacy during the session. This means that there will be no third party “intrusions” (which, for some, might be difficult in this “stay home” situation, with children that are difficult to detain, or indiscreet “ears” in the next room…). The patient must know in advance that the session will be of a specific duration: it is important that the therapist makes sure that, at the end of the session, the patient is not emotionally overcharged, and he might use the final 10-15 minutes for emotional decompression. In fact, the lack of eye-contact, and restricted perception of body language on his part, may prevent him from fully understanding the patient’s emotional state. Moreover, it is good practice on the therapist’s part to ask the patient how he felt during the online session and to ensure that there are no unanswered questions concerning the procedure (i.e. confidentiality issues). Also to provide the possibility of telephone contact in case of a sudden disconnection and inability to reconnect is a good practice.
Sessions with more than one person (couple or family) presents additional challenges. E-couple and family therapy - E-CFT – (Borcsa and Pomini, 2018) has recently grown and there are relevant good practice guidelines, mainly by the American Association of Marriage and Family Therapy (AAMFT) (Caldwell et al., 2017).
The family and couple digital setting may involve two therapists working from the same place or connected from different locations, and the patients, who, also, can either be in front of a single screen or connected through separate devices in the same or different locations. The rules have to be even clearer: taking turns to speak, for instance, as online conversation is extremely difficult if people are talking all at once. It is useful that the therapists propose and explain a signal (i.e. hand signal) indicating that one of the participants would like to speak, or as an indication to discontinue the conversation if there is too much tension. The duration of the session must be predetermined, with a longer period assigned by the therapists to the phase of concluding it and ensuring emotional decompression: when the session ends, the family members will remain together, without the intermediate distance of time and space that exists when the session takes place in a professional office. The therapists may ask the family or the couple to consistently follow the rule of not discussing the issues that came up in the online session for several hours afterwards. It is not of course always necessary to strictly follow this rule, but it is a way of avoiding further tensions, and ensuring that each of the participants will reflect on the material or the experiences of the session. If a small change has occurred during the session, distance and silence may preserve it better.
Apart from the use of online media it is important to also mention the use of the simple, easily accessible and easy to use telephone line. It is a medium for which there is an abundance of experience (S.O.S. helplines for a variety of issues and psychological difficulties), and provides immediate response and first aid in cases where support, relief and information transmission are necessary. Many telephone lines have been activated from the beginning of the pandemic, like the one set up by the First Psychiatric Department of the University of Athens in Aeginition Hospital. They are operated by psychologists and other mental health professionals, with the objective of the initial assessment of the request, of providing information and guidance in case of further need, of alleviating feelings of stress, fear, unsafeness, loneliness, as well anxiousness for those who have sick loved ones and grief support for those experiencing loss.
Ε -training & supervision
As is the case with providing online psychological support, many of us found ourselves in a position of continuing our educational work and clinical supervision through modern technology. This will be discussed in a next article.
**Providing psychological support to medical personnel **
From the outset of the pandemic the high level of intense stress and burnout of healthcare professionals was clear. People working in hospitals, medical centers and first aid facilities, come in immediate contact with carriers of the corona virus and patients with the complications of COVID-19, knowing fully well how easily this virus is transmitted and the high risk to which they are exposed. Furthermore, after the first few weeks, hospitalization conditions became increasingly difficult: in Italy, mass patient turnover severely tested the functioning of the large, modern hospital units of the North, where equipment shortage was immediately evident (i.e. I.C.U. beds, respirators, and also medical personnel protective supplies). Doctors, nurses and other health professionals started covering multiple consecutive shifts, and witnessing the unbearable pain and the last breaths of thousands of patients that died with no loved ones at hand and no emotional support. Some hospital departments in Northern Italy were put in total isolation with the personnel locked inside. Personnel started to count casualties amongst their own, and as of today more than 50 doctors have passed away. Despite the adrenaline and the exceptional sense of duty and self-sacrifice, these people are in a continuous situation of extreme stress and traumatic experience, which – as previously mentioned- may have both immediate and long lasting impact on their mental health and on their functionality at work (Μαρούγκα et al., 2020). Efforts to support these professionals have multiplied, and in many regions are mainly applied online. Some regions organized Balint groups with closed or open groups, while others refer to specific teams. The mobilization of all the supportive forces of a community seems to be progressively more important in order to reinforce the collective resilience.
**Reflections: The democracy of cure, the role of Europe, globalization, environment issues, collective avoidance mechanisms and more **
From the moment that the pandemic showed us its destructive force, and the problem became global, the international scientific community (a great part of it in any case) has been mobilized in a common effort to find an effective cure for COVID-19 and a vaccine against the corona virus. And this is an impressive outcome yet! Some have put forward the principle that it must not be the property of a single corporation or country: the situation calls for accessibility to the cure for all populations without distinction. It calls, in other words, for a democracy of the cure that goes beyond private and national financial interests. A democratic cure for a democratic virus that, as we find out, does not make any discrimination. Will they be able to support what they declare now? If, as we hope, that happens, it will be a marvelous result, a win for mankind in the age of globalization. In this sense it will be a positive consequence of globalization. In any other case, mankind will have lost an opportunity to take advantage of the general crisis that the pandemic has already created: the opportunity to promote a different model of development and relations between populations and cultures. As many people reflect lately, it is the first time that a pandemic strikes the whole world simultaneously. The corona virus took advantage of the modern way of life, effectively: the expansion of transportations, of communication and exchanges of the fast-paced modern societies. Many people think that nothing will ever be the same again, and we will have to change a lot of things in the way we live and in the way our societies function. Towards which direction though? In democratic countries (in Europe and other parts of the world) we have accepted movement restrictions and social distancing, which up to now we believed could only be enforced in authoritarian regimes. We have accepted the restriction of our freedom and the control over our movements in the name of protecting our physical integrity, our health as well as the health of our family and community. We quickly learned to live with restrictions that seem impossible when we open our eyes every morning. At some point, though we do not yet know when or how, this will pass and we will make our assessments. We wonder: will we be in a position to leave the restrictions behind, and not allow the conservative forces to take advantage of isolation and fear? Will we have a “vaccine” against that? We hope that the international economic crisis that has already appeared as a result of the pandemic, and that we will have to face in the coming months will not have the same results as the previous ones: namely, greater poverty for most and concentration of the wealth of the world into the hands of small groups of people. We hope that a different globalization model, based more on the solidarity between the peoples that we see developing these days, will prevail. We hope that governments will seriously examine the issue of environmental destruction and its consequence on public and personal health. Is the fact that the regions that suffer more from the corona virus are those with the worst cases of air pollution in China and in Europe incidental? Will Europe be able to once again find the course of democratic unification that our parents envisioned after the end of World War II? Will it be able to reinforce its democratic forces and be a hospitable place for those who escape wars and poverty? Will it give priority to reinforcing health and education systems?
At the moment, we are all testing our psychological resilience and the strength of our bonds… Can we adjust to the compulsive and avoiding way of life that is imposed on us by taking advantage of any opportunity of connection, support and solidarity that we are allowed, in the hope that we will not get trapped in collective compulsion habits and enclosure? As Sarantis Thanopoulos writes, referring to Pericles: “We do not fear sacrifices, but we make them in order to obtain a better management of the city with the goal of rectifying the disasters of the past and to avoid their repetition in the future”.
I thank my family members in Northern Italy, that appease my fear for their safety on a daily basis, my friends and colleagues Eva Angelini, Jacopo Dalai, Francesco Di Paolo, Gabriella Peracchi and Daniela Sciamma for regular communication and invaluable sharing of opinions and questions, Stratos Padavos and Dimitris Kokkalis for their encouraging comments and corrections on the Greek text.
Algeri, D., Gabri, S., & Mazzucchelli, L. (2018). Consulenza Psicologica Online: Esperienze pratiche, linee guida e ambiti di intervento. Milano: Giunti
Bateson, G. (1972 ). Steps to an ecology of mind . Chicago University Press.
Bevilacqua, P. (2020). Ambiente e pandemia il drammatico connubio della pianura padana . Quotidiano Il Manifesto , 20.03.2020
Bischoff, R.J., Springer, P.R., & Taylor, N. (2016). Global Mental Health in Action: Reducing Disparities One Community at a Time. Journal of Marital and Family Therapy, 43 (2): 276–290. doi: 10.1111/jmft.12202.
Borcsa, M., & Pomini, V. (2017). Editorial: Virtual relationships and systemic practices in the digital era. Contemporary Family Therapy, 39 (4): 239-248.
Borcsa, M., & Pomini, V. (2018). Couple and Family Therapy in the Digital Era. In: Lebow, J.L., Chambers, A.L., & Breunlin, D.C. (Eds). Encyclopedia of Couple and Family Therapy . New York: Springer.
Borcsa, M., & Pomini, V. (2020). La diffusione delle pratiche digitali nella psicoterapia sistemica: Lo stato dell’arte in Europa ed oltre. In: Manfrida G. et al. (Eds.). (submitted).
Caldwell, B.E., Bischoff, R.J., Derrig-Palumbo, K.A., & Liebert, J.D. (2017). Best practices in the online practice of couple and family therapy. Report of the online therapy workgroup . American Association for Marriage and Family Therapy (AAMFT). Retrieved 01.09.2017 from http://www.aamft.org/iMIS15/AAMFT/Content/Online_Education/Online_Therapy_Guidelines_2.aspx
Campaioli, G., Sale, E., Simonelli, A., & Pomini, V. (2017). The dual value of the web: Risks and benefits of the use of the internet in disorders with a self-destructive component. Contemporary Family Therapy, 39 (4): 301-313. DOI: 10.1007/s10591-017-9443-9
Cetrullo, L. (2020). Quarantena da Coronavirus e ripercussioni psicologiche negative. http://www.psychiatryonline.it/node/8501
Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L., … Zhang, Z. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet Psychiatry . doi:10.1016/s2215-0366(20)30078-x
Cipolletta, S. & Mocellin, D. (2018) Online counseling: An exploratory survey of Italian psychologists’ attitudes towards new ways of interaction. Psychotherapy Research, 28 :6, 909-924, DOI: 10.1080/10503307.2016.1259533
Dalai, J. (2017). Web Waves and Positive Resonance in the Community in Milan. Contemporary Family Therapy, 39 (4), 329–336. doi:10.1007/s10591-017-9433-y
D'Elia, L. (2020). COVID-19: La pandemia è come un Trattamento Sanitario Obbligatorio collettivo. http://www.psychiatryonline.it/node/8510
Hilty, D.M,, Yellowlees, P.M., Myers,K., Parish, M.B., & Rabinowitz, T. (2018). The Effectiveness of e-Mental Health: Evidence Base, How to Choose the Model Based on Ease/Cost/Strength, and Future Areas of Research. In: Mucic, D. & Hilty, D.M. (eds.). e-Mental Health . Springer.
IASC (2020). Briefing note on addressing mental health and psychosocial aspects of COVID-19 Outbreak-Version 1.0. Inter-Agency Standing Committee IASC Reference group for Mental Health and Psychosocial Support in Emergency Settings.
Lazuras, L., & Dokou, A. (2016). Mental health professionals’ acceptance of online counseling. Technology in Society, 44, 10–14. doi:10.1016/j.techsoc.2015.11.002
Liu, S., Yang, L., Zhang, C., Xiang, Y.-T., Liu, Z., Hu, S., & Zhang, B. (2020). Online mental health services in China during the COVID-19 outbreak. The Lancet Psychiatry. doi:10.1016/s2215-0366(20)30077-8
Manfrida, G., Albertini, V., & Eisenberg, E. (2017). Connected: Recommendations and techniques in order to employ internet tools for the enhancement of online therapeutic relationships. Experiences from Italy. Contemporary Family Therapy, 39 , 314–328. DOI 10.1007/s10591-017-9439-5
Μαρούγκα, M., Σκαλή, Δ., Κοντοάγγελος, Κ., & Οικονόμου, Μ. (2020). _Οδηγός για υγειονομικό προσωπικό για την ψυχική διαχείριση της επιδημίας _ COVID _-19. _ Α’ Ψυχιατρική Κλινική, Ιατρική Σχολή, ΕΚΠΑ, Αιγινήτειο Νοσοκομείο
Μαυρομαρά, Λ., Γεωργούλης, Α., & Γονιδάκης, Φ. (2020). Σύντομος οδηγός για άτομα που βρίσκονται σε απομόνωση λόγω του κορονοϊού ( COVID -19) . Α’ Ψυχιατρική Κλινική, Ιατρική Σχολή, ΕΚΠΑ, Αιγινήτειο Νοσοκομείο
Μήτση, Χ., Τζιντζηροπούλου, Φ., & Γονιδάκης, Φ. (2020). _Οδηγός διαχείρισης της ψυχικής οδύνης από τη νοσηλεία ή την απώλεια προσφιλούς ατόμου λόγω της πανδημίας _ COVID -19. Α’ Ψυχιατρική Κλινική, Ιατρική Σχολή, ΕΚΠΑ, Αιγινήτειο Νοσοκομείο
Mucic, D., Hilty, D.M., & Yellowlees, P.M. (2016). e-Mental Health Toward Cross-Cultural Populations Worldwide. In: Mucic, D. & Hilty, D.M. (eds .). e-Mental Health. Springer. DOI 10.1007/978-3-319-20852-7_5
Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., … UnÜtzer, Jü. (2018). The Lancet Commission on global mental health and sustainable development. The Lancet. doi:10.1016/s0140-6736(18)31612-x
Pennington, M., Patton, R., Ray, A., Katafiasz, H. (2017). A brief report on the ethical and legal guides for technology use in marriage and family therapy. Journal of Marital and Family Therapy. doi: 10.1111/jmft.12232
Sabbatani, S. (2003). Health service organization during the age of pestilence. Le Infezioni in Medicina, 4, 216-221.
Schinaia, C. (2020). COVID-19: Gli psichiatri per i medici in prima linea. http://www.psychiatryonline.it/node/8502
Thanopulos, S. (2020). COVID-19: L’epidemia, la “Città” e il vivere e filosofare. http://www.psychiatryonline.it/node/8511
Tognotti, E. (2002). La “Spagnola” in Italia. Storia dell’influenza che fece temere la fine del mondo (1918-1919). Milano: Franco Angeli.
UNICEF (2020). _Briefing note on addressing mental health and psychosocial aspects of the coronavirus disease (COVID-19) outbreak. _
UNICEF (2020). How to talk to your child about coronavirus disease 2019 (COVID-19).
WHO (2020). Mental Health and Psychosocial Considerations During COVID-19 Outbreak . www.who.int
Wrape, E. R., & McGinn, M. M. (2018). Clinical and Ethical Considerations for Delivering Couple and Family Therapy via Telehealth. Journal of Marital and Family Therapy. doi:10.1111/jmft.12319
Χατζηχρήστου, X., Υφαντή, Θ., Λαμπροπούλου, Κ., Λιανός, Π., Γεωργουλέας, Γ., Μίχου, Σ., Φραγκιαδάκη, Δ., Αθανασίου, Δ. (2020). _Μένουμε σπίτι....Συνδε-Δεμένοι. Προτάσεις για την ψυχολογική υποστήριξη οικογενειών, παιδιών και εφήβων κατά τη διάρκεια παραμονής στο σπίτι λόγω των προληπτικών μέτρων για τον κορωνοϊό - _ Covid -19. Αθήνα: Εργαστήριο Σχολικής Ψυχολογίας, Τμήμα Ψυχολογίας, ΕΚΠΑ
Yellowlees, P.M., Hilty, D.M., &Mucic, D. (2016). Global/Worldwide e-Mental Health: International and Futuristic Perspectives of Telepsychiatry and the Future. In: Mucic, D. & Hilty, D.M. (eds.). e-Mental Health . Springer. DOI 10.1007/978-3-319-20852-7_5
 Psychologist and Family Therapist
 Psychologist, teacher of psychology in secondary education, personal communication.
 Psychologist, psychodynamic psychotherapist, at Consultorio Familiare Ospedale Niguardan Milano.
 Psychologist, family therapist, at Consultorio Familiare Padova Centro.
 Why wasn’t it ensured that proper protective equipment was available everywhere after the very first cases? How did European health systems and governments prepare to deal with the emergency situation that was evident in China since last fall? Who will accept responsibility for the systematic weakening of the health system for the past ten years?
 It is difficult to call what doctors and nurses go through, fighting the corona virus “work”. The word “mission” describes it more closely.
 In Padova they have the program “Taking care of those who take care”. In Ancona, Italy, there is a group of debriefing for medical personnel coordinated by Dr. Mario Mari, psychiatrist (www.covidmarche.jimdosite.com) and similar initiative have been taken in many other towns.