The pandemic has profoundly altered social and work environments in many ways. Social distancing policies, mandatory restrictions, periods of isolation, and anxiety, together with the suspension of productive activities, loss of income, and fear of the future, jointly influenced the mental health of citizens and workers (Zhang et al., 2020; Santos, 2020; Galea, Merchant, & Lurie, 2020; Serafim et al., 2021).
In this article, we reported on emergency psychological actions during the early phase of the COVID-19 pandemic in a public mental health hospital in Brazil. This program lasted for 7 months (between May and December 2020), being structured considering the demands of various groups regarding requests to take a leave of absence and/or psychological support due to anxiety, fear, difficulties in concentrating on work, stress, and concerns about infecting themselves and their relatives, even though they were not acting directly on the frontline of the COVID-19 response. The medical team (physicians, residents, pharmacists, nurses, and psychologists), administrative staff, and general service workers (cleaning, organization, and security) participated in the clinical interventions.
Faced with the uncertainties of the COVID-19 pandemic period, combined with the growing volume of infected and dead people, including health professionals, the data analyzed here showed that most professionals, regardless of their area of activity, experienced mild to severe anxiety symptoms. Regarding stress, the professionals related to clinical activities—that is, those involved in patient care—although not directly related to COVID-19, had moderate stress symptoms, followed by general service workers, who mostly did cleaning work. These results show that even though these professionals were not directly on the frontline, this did not stop them from feeling psychological pressure. Although we had no previous data on the mental health of this population, one finding stood out: the presence of these symptoms culminated in an increase in the demand for psychological care, which led us to associate this demand with the pandemic. By then, we had already found data in the literature corroborating these observations (Zhang et al., 2020; Xiang et al., 2020; Wang et al., 2020).
In this context, a possible way to understand the stress response observed here, even though we did not use measuring instruments for this variable, would be the condition of vicarious traumatization, initially referred to by psychotherapists (McCann & Pearlman, 1990; Aafjes-van Doorn et al., 2020; Al-Mateen et al., 2015), and more recently as a response to addressing the COVID-19 pandemic (Li et al., 2020). However, the understanding of vicarious traumatization goes beyond the therapeutic process and is part of the scope of major disasters, problems, and emergency situations, in which the degree of damage exceeds psychological and emotional tolerances, indirectly causing several psychological abnormalities (Patel-Kerai et al., 2017; Serafim et al., 2020; Sinclair & Hamill, 2007; Zhang et al., 2020).
We highlight the study by Li et al. (2020), in which the characteristics of vicarious traumatization were verified in 214 people from the general population and 526 nurses (234 on the COVID-19 frontline and 292 not on the frontline). The results showed that vicarious traumatization scores for frontline nurses, including scores for physiological and psychological responses, such as anxiety and stress, were significantly lower than those for nurses who were not on the frontline. In addition, they observed that the scores of the general population were also significantly higher than frontline nurses. Li et al. (2020) also emphasized that, although vicarious traumatization is associated with a direct relationship between the professional and the victim, psychological stress should not be ignored, especially the vicarious traumatization caused by the COVID-19 pandemic.
When suffering from vicarious trauma, the professional may present a loss of appetite, fatigue, physical decline, sleep disorders, irritability, a lack of attention, numbness, fear, and despair (Al-Mateen et al., 2015; Creighton et al., 2018). Direct or indirect exposure to the phenomenon triggers chemical and electrical alerts in the brain, preparing the body to cope with tension and regain its internal balance. Thus, tension caused by this physiological preparation to “fight or flee,” mainly through the cortisol hormone, is important for the maintenance of life (Margis et al., 2003). However, excessive exposure to stressors can make this alert unregulated and sensitive to minor environmental changes, such as in the case of the pandemic, which has required constant adaptation and uncertainties; this can deregulate the homeostatic system in cases of anxiety and stress (Graeff & Zangrossi, 2010; Kyrou & Tsigos, 2009).
Considering the results of the evaluation of the psychoeducational program in this context, more than 70% of the participants reported that there was no reduction in fear (of getting infected or the death of a relative, for example). On the one hand, this result shows that the emotional panorama of the participants was significant, which suggests the need for more specific and direct actions such as the psychological first aid (PFA), indicated in emergencies (World Health Organization, 2011). The PFA focuses on education about traumatic stress and active listening, since the person can lose control of their physical and psychological reactions to the situation and experience high levels of stress and anxiety outside the usual patterns (Brooks, Rubin, & Greenberg, 2019). Moreover, since we do not have this objective measure, there may be an association between the intensity of symptoms and vicarious traumatization.
The purpose of the program reported in this study was to apply a set of actions to identify the psychological panorama of hospital professionals and propose actions that could produce an initial welcoming environment, disseminate information that can corroborate the level of knowledge about the severity of the situation, improve self-care behavior, and support those with greater difficulties at the individual level, considering that the literature emphasizes the relevance of identifying and providing intervention for vicarious traumatization at an early stage (Patel-Kerai et al., 2017; Xiang et al., 2020).
In this context, we emphasize that we developed a program during an emergency and our methodology was in line with the precepts of the literature. However, if these interventions were utilized in complex situations such as disasters or earthquakes, the complaints and needs of each affected population group would need to be known (Shanafelt & Noseworthy, 2017). Thus, on the one hand, the program was able to produce relevant information about aspects of the mental health of professionals, and it was perceived as valid, although it was not particularly effective at reducing the psychological symptoms of fear.
A review by Schnitzbauer et al. (2020) presented in its results the importance of developing individual protection standards for employees working in clinics in which there was an initial contact with patients with positive or inconclusive COVID-19 status. Thus, the reports on the fear of infecting relatives or friends and the need to receive information to avoid getting infected can be justified through the finding that, in addition to health professionals being a risk group, SARS-CoV-2/COVID-19 has numerous atypical clinical manifestations (Zhang et al., 2020). In addition, there is a set of uncertainties that can corroborate the manifestations of vicarious traumatization, as mentioned above (Li et al., 2020).
Finally, Wang et al. (2020) demonstrated that working on the frontline, receiving insufficient training, and a lack of confidence in protective measures were significantly associated with an increased risk of depression and anxiety. In our research, the group involving psychological reactions did not present significant responses related to symptoms that configured such psychopathological conditions.
This study reported on a psychological care program for professionals working in a hospital environment during the most acute phase of the COVID-19 pandemic, which is considered to have been permeated by important limitations. For example, defining a verification measure for each psychoeducational session certainly provided valuable information for adjusting each session. Having verified the level of vicarious traumatization would also have brought more robust data to this study. In addition, we did not use the DASS-21 in the final evaluation, which prevented us from verifying whether the anxiety, depression, and stress indices changed. However, given the emergency nature of the implementation, the demand for actions that need to be improved in the institutional scope was highlighted, becoming another area linked to outpatient mental health services to support psychology and neuropsychology workers, with this space being important in different institutions in various sectors.
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