Patients’ Experience on a Supportive Group Therapy in an Italian Psychiatric Residential Facility During the COVID-19 Pandemic

Introduction

More than 4.2 million confirmed cases and 126 000 deaths due to the COVID-19 pandemic make Italy one of the most stricken nations in the world (1). In this respect, Italy was the first European nation that entered a nationwide lockdown during the COVID-19 epidemic. In a recent, interesting cross-sectional survey on the impact of quarantine on mental health of the general population in Italy, it was reported that anxiety and depression symptom prevalence was respectively 24.7% and 23.2% (2). Moreover, 42.2% of 1515 participants also had sleep disturbances. Being female, an increased time spent on the Internet and an avoidance of activities through peer pressure increased the likelihood of at least one mental health outcome.

Starting from March 7, 2020 (the start date of the first lockdown in Italy), the recurring waves of the epidemic largely affected routine activities of the Italian Departments of Mental Health (DMHs), traditionally structured in accordance with a community-based model of care (3). In this respect, social and physical distancing led to a relevant reshaping of several mental health interventions, especially in outpatient and day services, together with the strong advice to implement phone calls and video conference-based visits (4). However, hospital and residential activities have been maintained, albeit strongly remodeled and conditioned by the fear of contagion. According to the Italian Society of Psychiatry (5), the COVID-19 pandemic has led to a drastic reduction in levels of care, which may produce a severe impact on the mental health of both psychiatric patients and the general population in relation to the consequences of the expected economic crisis and of the putative, remittent ongoing wave of the epidemic. In this paper, we reported the subjective perspectives on a supportive group therapy conducted in an Italian psychiatric residential facility for intensive treatments (“the Santi Center”) during the second wave of the pandemic in the fall of 2020 (ie, from October 15 to November 30, 2020), using the words and experiences of patients, overall included in the first issue of the “Santi's Magazine.” Specifically, here we reported some of the most significant passages.

In detail, on October 15, 2020, COVID-19 confirmed cases in Italy were 382 097, and deaths due to the epidemic were 36 372. At the end of our supportive group intervention (ie, November 30, 2020), confirmed cases were 1 608 803 and deaths 55 570.

The Santi Center is a psychiatric residential facility of the Parma Department of Mental Health, in Northern Italy. The format of our supportive group therapy included weekly face-to-face meetings led by professional facilitators (ie, psychologists, nurses, and a psychiatrist). Each session offered educational opportunities to talk about a topic related to the group's needs (such as improving knowledge in patients’ mental disorders, coping with symptoms and negative emotions, increasing social skills, increasing understanding about antipsychotic medication), bringing together people with similar psychological and experiential conditions under the guidance of mental healthcare professional. The common experience among group members meant that they had similar worries, feelings, everyday problems (including social isolation due to the COVID-19 pandemic), treatment decisions, or treatment side effects. Specifically, all group participants were affected by clinically stabilized psychotic disorders (schizophrenia, schizoaffective disorder, and bipolar I disorder with psychotic symptoms). Supportive group therapy sessions were weekly conducted. Each meeting lasted 60 min and was focused on specific clinical issues with eminently psychoeducational and supportive techniques (6). In particular, there were group sessions about psychosis (eg, main psychopathological features, diagnostic criteria, coping with symptoms), psychopharmacological therapy and side effects of antipsychotic medication, management of negative emotions (such as anxiety, anger, fear, and sadness), improvement in social skills and contrast to internal and social stigma.

All participants (8 out of 12 patients admitted to the Santi Center at that time) gave their written informed consent to anonymously publish their personal experiences on the Santi Center supportive group therapy (also included in the “Santi Magazine”). Local relevant ethical approval was obtained. The current paper has been also written in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Patients’ Perspectives

Patients suffering from psychiatric disorders generally find group therapy very beneficial (7). Although there was not something novel about the methodology applied in our supportive intervention, participants’ perspectives were uniformly positive. The greatest benefits of participating in our support group therapy included: feeling less lonely and isolated; reducing distress, fear of contagion, depression, and anxiety; talking openly and honestly about worries and feelings; improving understanding of mental disorder and experience with it; improving skills to cope with symptoms and social situations; getting practical feedback about treatment options; staying motivated to manage chronic conditions; gaining a sense of empowerment, control, hope, and resilience, especially in a time period plagued by the pandemic. Here are some of the most significant subjective perspectives about our supportive group intervention.

A: “… In October 2020, I was hospitalized at the Santi Center due to a relapse of my mental disorder. I felt the same as all other patients who were here and tried to find a new identity, their personal freedom and (why not) their happiness. Despite the pandemic and its restrictions, the Santi center provided interesting activities. In particular, the supportive group therapy offered by the Santi Center team psychologists had been very useful. It helped me to engage myself, to open up and also to get closer with other residents, even if it was for a short time (approximately 2 months). At the beginning I was afraid and not sure, but I however decided to participate. Since then, I got very passionate about it: sometimes it only takes a little to have positive stimuli and it doesn't need to think about it too much. Now, I want to thank everyone because they all were always helpful and ready to listen to me. This group activity was a cure-all and its utility is unequivocal. In conclusion, it was nice being here.”

D: “… It looks like yesterday when I first entered the Santi Center with all my fears and doubts. And now, it has been passed 2 months. I had to deal with what surrounded me, with the mental health professionals and all the other patients. The bounds we created are unbelievable: what I thought was abnormal become magically fantastic, because with all these individuals I managed to discover the path I was destined. A path that tested me many times but that together with the supportive group therapy sessions helped me and gave me the strength to fight my mental disease.”

S: “… During my 2 months of hospitalization at the Santi Center, I attended the supportive group therapy with other residents. In this group, we all participated actively, speaking up or listening to other people. The group activities were things such as saying your opinion about various arguments (included the COVID-19 pandemic), but also making up scenes or role-playings that were used as metaphors for real life events (eg, as we acted when we were on the phone to increase our communication skills). I liked this group so much. It didn't get me bored because it lasted for less than 90 min.”

G: “… The supportive group therapy consisted in 5 meetings offered every Monday at 5 p.m. in the Santi center conference room. This peculiar time of the day was chosen because it was after the nap so that everyone could participate. The first group session was about psychosis. The subsequent meetings were full of personal experiences, transforming our therapeutic journey not only in a place of information, but also in a place of freedom and fun. A Santi center team psychiatrist led a very interesting lesson on pharmacology and side effects of antipsychotic medications. However, we all shared moments of fun and relax, and we all became aware of the relevance of these topics (such as psychosis and how it always gives anxiety to the patients).”

Conclusions

The Santi Center residents learned the importance of telling their daily stories, their feelings, and personal experiences, even from the past. At the end of group therapy meetings, patients wanted to get away from their closed and restricted dimension and to be more open towards what surrounded them. To do so, they used a simple communication tool, that is, a magazine including their personal life stories that they learned to accept and share. “The Santi's magazine” was born within a playful dimension, but it seriously talked about a patients’ journey, with their thoughts, feelings, fears, and resilience within the current COVID-19 era and against both the infection and mental disorders which they were affected. In particular, this paper wants to document a real-world experience of a supportive group therapy offered to contrast the general paralysis of several mental healthcare interventions that too much often had affected our DMHs during the pandemic (8). Although beneficial effects of a support group therapy in individuals affected by psychiatric disorder were generally recognized within the field, the experiences of the patients as reported in the Santi's Magazine help to advance our understanding of the utility of group intervention also in a period infamous to humanity for being dominated by pandemic, fear of contagion and social isolation. Specifically, the way patients experienced this intervention should make mental health professionals aware of how supportive group therapy may be crucial in increasing the patient's resilience against a condition of psychological loneliness and terror due to the growing COVID-19 epidemic. This could serve as a therapeutic experience in other relevant traumatic situations, especially when individuals experienced social isolation and marginality (ie, wars, earthquakes, environmental disasters).

Finally, some limitations should also be acknowledged. First, our experience lacked psychopathological and psychological evaluations (such as those on daily performance or quality of life). Thus, further research using specific psychometric assessments is needed. Second, although we preferred a qualitative, subjective perspective, further studies using more stringent phenomenological methods are needed.