The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention

*Silvia Renata Lordello and Isabela Machado da Silva*

#### **Abstract**

The COVID-19 pandemic has claimed thousands of victims worldwide. To deal with loss is a formidable challenge for all, especially those who experienced losing their loved ones. The grief elaboration process is complex, and the pandemic adds some specific challenges, such as the restrictions to funerals and farewell rituals or the impossibility of saying goodbye due to the sanitary measures. This chapter presents a group psychological intervention aimed at people who lost their relatives to COVID-19. The therapeutic groups were carried out virtually through six sessions and brought together people from all over Brazil. Narrative therapy was the theoretical model adopted. The participants mentioned the moment of diagnosis as decisive for experiencing the disease's terminality and anguish, promoting guilt and anxiety in the family. In the group, the participants found space to share the painful experience, and throughout the sessions, they were able to develop coping resources. They mentioned strategies, such as activating the family and social support network, recalling legacies and moments they shared with the deceased, and elaborating farewell rituals adapted to the pandemic circumstances. The participants evaluated the group intervention as very important for reframing the pain of loss and restoring future projects since they counted on the help and inspiration of the other participants who went through this painful experience in similar circumstances.

**Keywords:** group counseling, support groups, grief counseling, traumatic loss, COVID-19

#### **1. Introduction**

One of the greatest challenges to Psychology that arose from the COVID-19 pandemic was the accommodation of several mental health demands. The cases of anxiety, depression, sleep disorders and so many other complications resulting from the collective trauma faced by the global population are undeniable [1, 2]. However, after more than one year of pandemic, especially in Brazil, where in May 2021 the tragic mark of over 450,000 deaths was reached, grief has been one of the most frequent and significant reasons for requests for interventions in mental health. The complex process of mourning involves several variables and, with the sanitary restrictions that have prevented meaningful rituals practiced in the culture from happening, the impacts have been intense. The purpose of this chapter is to present a psychological intervention experience aimed at people who have lost their loved ones to COVID-19. The sessions were held virtually and gathered people from different regions of Brazil, and also abroad, for six weekly two-hour meetings. The theoretical basis adopted was that of Narrative Therapy, for proving itself a conceptual model that has contributed significantly to redefine the experiences of loss and trauma.

#### **2. Death, mourning and meanings in narrative therapy**

Understanding death and losses in natural situations is, in itself, extremely difficult, for it invokes the theme of finitude of the materialized form in a society in which this theme is taboo. In the pandemic scenario, large-scale deaths, associated with deprivation of physical contact as a result of sanitary measures, require the bereaved to have even more resources to deal with adversity and get in touch with their own pain. In several situations, the thinking that prevails among people who offer social support is that the mourner should let go of the person who passed away, be involved in actions that distract them, and avoid thinking about the deceased. According to Campillo, it's reprehensible what modern thinking advocates about recovering from the pain of loss through the mechanism of moving on with life without a loved one, letting them go [3]. The postmodern proposal expands and enriches this vision, proposing a new look. In this conception, death is not considered an end, but an invitation to a new relationship, in which connections may keep on growing and improving even after death. White in his work "Saying hello again" develops this less hegemonic way of acting with people devastated by the loss of loved ones, because faced with this suffering, the author understands that one doesn't lose only a person, but with them also goes part of one's sense of identity [4]. The author's proposal is that the emptiness and paralysis that the mourners experience should move towards the recovery of the relationship with the departed. Listening to the experiences with those who have passed away and bringing the importance of their presence in the life of the mourner and their contributions to the mourner's sense of identity becomes a work with grief capable of promoting new meanings.

#### **3. Building a welcoming space: the conditions and attitudes for working with grief**

Imagine the pain of one who has experienced mourning in the conditions of the pandemic. Receiving the COVID-19 diagnosis is culturally represented as a sentence in which death is quickly considered. Therapists, from the moment of first contact with the mourner, already need to convey the idea of a space where they should feel comfortable. It is necessary to clarify that the participant is the one guiding the conversation, electing what to share and when to do so, characterizing a respectful and collaborative process [5].

For White, it is very important that the therapeutic interaction is centered on the person being assisted and not on the therapist [6]. According to White and Epston, the narrative method places the person as the protagonist or as a participant in their own world [7]. For the author, retelling a story is telling a new story. It is understood, therefore, that the therapist is the specialist in the process and the client is the specialist in the content, hence the importance of the questions and of the accommodating space without judgment or restrictions that may intimidate the spontaneous retelling of those who want and need to share their stories.

Campillo points out the importance of the double listening in the therapist's job in the case of mourning and of people who have undergone recent traumas [3].

#### *The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention DOI: http://dx.doi.org/10.5772/intechopen.98837*

What does that mean? While the therapist must give full importance to what the person wants to report from their traumatic experience, they must also be attentive to expressions that show how a person responded to this traumatic event. The double listening observes any sign of events, values and desires that the person shows, even when reporting the story saturated with problems, which is the description of trauma. Through the double listening the therapist plays the role of the external witness, who will seek to identify in the conversation words that imply other meanings, and in reflecting them to the participant, allow them to listen in their own words their desires, values, dreams, life principles, resources and everything that was observed in their narrative that was obscured by emphasizing the problem.

#### **4. Conversations of re-membering**

The main bases of this work of reconnecting with significant people is what White called conversations of re-membering [8]. This therapeutic practice was inspired by the work of cultural anthropologist Bárbara Myerhoff. The metaphor is based on the idea of a life club, in which there are members that are validated or canceled. Thus, the mourning process rescues the relationships built with the person who has passed away, considering the identities, life knowledge, legacies and mutual learning. White warns that they are not passive memories, but intentional engagements that promote identity marks. These conversations are based on two sets of questions for this mapping. The first set refers to retelling how the meaningful figure has contributed to the person's life, detailing how this connection has promoted this process, while the second set invites the person to see the contributions that they themselves have given to the life of this meaningful figure, detailing how this has happened.

It is important to mention that conversations in Narrative Therapy generate contexts for activating skills for creation of meaning. The process allows deconstructing ideas contained in the stories to find different conceptions, allowing new meanings for the lived experiences.

#### **5. Accommodating people who lost their families to COVID-19: mourning and their stories**

The pandemic declared in March 2020 in Brazil brought as one of its most nefarious effects the death of over 450 thousand Brazilians in the period of 14 months. Unfortunately, even with the advent of vaccination, control over contagion and the intense need for hospitalizations has not yet occurred and the number of deaths is still on the rise. Therefore, there are thousands of mourners who demand an urgent look at their mental health and help in the grieving process.

As members of the Committee for Mental Health and Psychosocial Support of the University of Brasilia, we offered a support group, with a proposal for six weekly two-hour long sessions, in which, based on the work of narrative therapy, we developed a welcoming space to people from all over the country and even abroad who shared the experience of having family members who passed away due to COVID-19.

The groups were open to anyone who was 18 years older and had internet access. We published invitations to the support group on social networks, the university's website, and the local media. It was offered for free. Those who were interested in participating fulfilled an online application form. After applications, the groups were divided according to the participants' age. Two psychologists acted as co-therapists and facilitators of each group, accompanied by undergraduate psychology students who observed the sessions and were responsible for their written records. The two authors of this chapter supervised both the psychologists and the students. The weekly supervisions were divided into two moments. In the pre-session, the team discussed the topics that would be approached in the following session and possible doubts or questions. In the post-session, the team discussed what had occurred in the session, the therapists' interventions, feelings, and resonances, as also plans for the next session. During the sessions, the supervisors were online available to assist the therapists in case of need.

We will now describe the procedure and report the experience, connecting it with the theoretical aspects on which we have based the intervention (**Table 1**).

In this proposition, the first meeting is crucial for the construction of a collaborative, dialogical proposal, in which members of the group can feel that their emotions will be welcomed in all their expressions. It is fundamental that in the online model, the bond and the creation of a welcoming virtual space are ensured so that all of them can feel belonging to this community that has signed up to share their painful experience with people who are able to understand it. In the groups we offer, it is very common for this moment to be one of openness and expectation. After clarifying how the group will work, it is common for participants to be anxious to reveal their painful processes of accompanying their loved ones, from the moment of diagnosis until death, revealing the hurtful, intense and fast period in which the disease develops and worsens. Participants usually bring impactful reports and, for the most part, describe the experience as traumatic, touching others with their emotional narratives.

This session clearly shows what Campillo points out about the need for people who experience recurrent trauma to be heard about everything they elect to share about the traumatic experience [9]. But at the same time, it is vital that in our listening as facilitators we notice the signs that the person continues to value their life, despite what they have experienced. The author states that no person is a passive recipient of trauma. As severe as the experience of loss may be, it is always possible to recognize a movement and this can and should be recognized by those listening. Even in the face of a trauma of great magnitude, people tend to take the necessary measures to protect themselves and preserve what they value.

The initial question of the session is intended to promote the narrative practice of double-listening, where we are interested in listening to more than one story [10, 11]. The tendency is that people present only a narrative of negative effects, which hides responses of resistance and resources, seeming to trap them in their impotence. Double-listening allows us not only to listen to the first story, centered around the effects and impacts of trauma, but to a second story, based on the


#### *The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention DOI: http://dx.doi.org/10.5772/intechopen.98837*

responses, on the strategies used, and on what they value in their lives. For narrative therapists, committed to an emancipatory action, this will allow to awaken the sense of agency and the discovery of a favorite story, which shows that despite the trauma, there is no submission and passivity [12]. A clear example, in the grief for having lost family members by COVID-19, is the attitude of wanting to be in a group, sign up, be present and bravely share their emotions. Another example is when one participant exposes how inspired they were by the attitude of another in regards to the responses and resources; they feel surprised and are able to see through the eyes of the other their own sense of identity recognized. The idea of Michael White (2006) was to deconstruct the "no pain, no gain" saying, creating a space in which is possible to relive less of the details of trauma and instead create a safe territory of identity for people to express their experiences. It is not avoiding the description or intimidating it, but warning about conversations about only one story.

In the second session, people who have not yet described their traumatic experience of loss are encouraged to speak. The beginning of the session happens with people speaking about how it felt to be in a group sharing so much pain and resources. Although the reports mention the pain experienced in listening to the traumatic losses, the group members recognize the positive stories even through adversity. As facilitators, we have also chosen not to emphasize the dominant discourses that are destined to tragic stories, highlighting the horror of death and lamenting the details of the rapid assisted degeneration. We invest, as facilitators, in the exceptions that compose the alternative story, such as the ways of expressing love and care, so delicately described by the participants when reporting their actions along this journey. Our questions and interventions always look for practical stories of hope and it is possible to see that in the retellings. For example, in one of our groups, a daughter blamed herself for not being able to say goodbye. Instead of emphasizing the practice of this ritual that is suspended by the pandemic, we revisited all the manifestations of celebration of her father's life, while she was in his company. These positive expressions took the daughter away from her helplessness and filled her with hope about how good it was to know that her father died having received so many gestures and words that showed her love.

This session is also dedicated to the narratives about which support they could count on at that time. According to Campillo, all support is valid, whether it includes people, communities, spirituality or others [3]. The conversations should center on how these resources worked in other situations and whether they could be used in this moment of death of family members by COVID-19. The kind of questions that are asked invites not only to investigate the support received, but also the way in which they are seeking this support and whether they are managing to formulate this request.

To illustrate, we observed that there are surprises around this network capable of supporting this moment. For instance, in one of our groups a person brought their outrage about the way the inventorying process occurs, with tight law deadlines which disregard the pain of the mourner. To help solve this, they counted on professionals who worked with their deceased father and who knew how to conduct this moment with great sensitivity, helping with practical resolutions as well as being emotional supportive. The group also frequently expresses how much some of its members have played this supporting role, by promoting identifications with stories and resources reported in the group. Even if no answers are obtained, it is very important to suggest reflection. In this regard, something else that appeared were networks which, instead of supporting, judge and prescribe behaviors for the experience of mourning, and which are also narratives that must be accommodated. At the end of this session, we propose a conversation of re-membering and how

they would like to introduce in more detail the people who passed away, bringing the metaphor of the life club and how it would be their action to make this person a member, seeking the permanent connection, regardless of their physical absence, and sharing their legacy. So we propose that this introduction be accompanied by photographs, objects, songs, and whatever else the mourner wishes to bring to represent the deceased person and illustrate their relationship with them.

The third and fourth sessions are dedicated to conversations of re-membering, which are mediated by sets of questions that retrieve stories and testimonies about the person who has passed away. According to White, the questions are specifically to create a space where those in the group can incorporate the presence of the deceased person in their own life and identity in a more enriching way [6]. Speeches that recommend forgetting the one who has passed, overcoming the pain and moving on seem to belittle the richness of the stories that are lived by people with their loved ones. So the questions turn to another aspect: recovering this connection with the deceased person, which allows them to see how much this person is present in their life and that this relationship remains after death, although they need other ways to relate. For this, we suggest that these people be introduced to us through photographs, stories, songs, objects, texts; in short, that they seek this connection so that, when telling about the person, they recover affective memories that also transmit values and legacies.

The participants work hard to share these narratives in the group and this moment is accompanied by a lot of emotion. Initially we invite them to retell how this significant figure contributed to their life, and following that, how this connection impacted their identity and who they are today. This first set of questions is very easy to detect, since the countless stories and adventures lived with these people quickly flood the session with laid-back moments. It is common for very beautiful narratives to emerge, narratives that describe scenarios of action, with adventures, strolls, family habits, recent and old photos that retrieve an account of many contributions from this person to life and to what they take as learning and transformation of themselves from this relationship.

However, this is not the biggest challenge of the conversation of re-membering. The most difficult, but necessary, is the second set of questions, which address the contribution that the participant left in the life of the person who has passed away. Here, the way in which this person contributed to the identity of the deceased person is also recovered. These are questions that many times were not considered by the participants. The power of this last set of reflections is in the concept of agency. The person who lost a loved one so far only saw a void left by their absence and saw themselves as a victim of this loss. But seeing the transformations they have promoted in the life and identity of the deceased person also shows the reciprocity of this transformation.

After the loss of a dear person by COVID-19, it is common for one to have their sense of self reduced and to feel lost about what to value. Invigorating this sense from their values and the restoration of their projects is the objective of this session. In some of our groups, we observed participants who managed to revitalize these connections based on our questions about this contribution: a mourner daughter made it clear that her deceased father had not known how to express gestures of affection and that it was in his relationship with her that he learned. Another participant pointed out how much her mother was able to understand that her strictness and perfectionism were unnecessary stressors and this was learned with her as a daughter. Other members of the group pointed out the deconstruction of prejudices and other forms of revision of values as a merit of living with the deceased, which led to the awareness of their active role in the contribution of values that were also transformed in the lives of those who had passed away. At that moment, it is clearly

#### *The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention DOI: http://dx.doi.org/10.5772/intechopen.98837*

observed that the bereaved person does not see passively the legacy of those they have lost, but sharpens the sense of agency, as they themselves have also promoted changes and left legacies in those who passed away.

A common point between the third and fourth sessions was the resonances that the members of the group shared, revealing how much they felt touched and inspired by the stories of relationships presented in these conversations of remembering. Many started referencing to images, songs, words that reverberated in them from the others' stories.

Session five has as its main purpose seeking community resources and networks which allow facing this moment and assist in the restoration of personal and family projects that can be remodeled in the face of the physical absence of that member. Group participants are invited to think about strategies observed in the group that dialogue with their own coping stories. In some of the groups that we mediate, people have identified themselves with forms of records that could eternalize the stories of the deceased, some with the goal of generational transmission, others of searching and getting in touch with their family ancestors. The way to deal with meaningful dates such as Christmas, Mother's Day, Father's Day, birthdays and anniversaries are usually challenges that lead the group to reflect a lot on the resources in themselves that they have made available to deal with these moments and that are very inspiring for others. This session always brings back very concrete experiences about the complexity of the grieving process and allows for very profound reflections about how this does not happen in a linear way or with determined times and manifestations. Accepting this ambiguity of feelings and expressions without judgment is always pointed out as a positive factor in the group, as the idea is not to prescribe guidelines or to assess crises as pathological, but to manage them in a healthy way with the collective understanding that their paths are personal and dynamic.

The sixth and final session proposes a more prospective look at the grieving process, including the theme of revitalizing projects with the strength of the loved one's legacies about whom we have talked so much in the conversations of re-membering. Instead of advising on forgetting and moving on, suggesting avoidance or distraction behaviors, it is in our life club, with the departed member re-associated, that the projects that restore the sense of identity and future projects will be outlined. This session has a conclusive tone, in which people revisit the way they arrived at the group and how they have developed over these weeks. We do not romanticize here an elaboration of grief or any miraculous change in the way of understanding their pain, but recognize this space as a dialogical opportunity that has allowed many constructions, each in their own way and anchored in their past experiences.

In general, the data collected from what was experienced in the group corresponds to what Campillo recognizes as principles of the grieving process within the narrative perspective: the conclusion that life and the relationship with the person goes on and does not end with death [9]. For the author, discussing the death provides opportunities for stories and experiences full of love that last for a long time after. The questions play an important role: they generate meaningful memories that in the future can be useful when reminiscing, and highlight creative thinking within the constraint of reality that would be fixed as time and proximity. The narratives allow us to seek for resources that are within ourselves and recover the flexibility of stories that transcend death. Promoting the act of membering again lives and relationships is also a very strong principle that manages suffering in a healthy way, refusing to limit it to the insignia of saying goodbye and being a fertile ground for the co-construction of stories of hope and love. According to Hedtke, loved ones who have passed away can continue to play a crucial role in our

'life club' [13]. Re-membering practices represent ideas that distance us from the notion of finitude, while supporting a continued symbolic connection with the departed person. This connection is respectful, as it facilitates a person's continued legacy in the context of the work with death [6, 7].

The sixth session allows us to recover these steps that were taken collectively to prevent the aggravation of a possibly complicated grief situation and to modify its effects, making room for the preservation of what is important to the person and, in a concrete way, identifying tools and skills which are necessary for this knowledge not to be submerged in the experience of loss, without our being able to see it. Such knowledge is built throughout life and is related to what we value. According to Campillo, everything we value in life brings purpose to live, gives us meaning and marks the path ahead [3].

We end the sixth session by asking them to give us a word on how they felt in this group, encouraging them to express themselves in writing. But the common oral feedback in the various mourning groups we offered mentioned how much the members felt affected by the each other's stories and the reverberation this promoted when they got in touch with their own content. These interpersonal learnings presented themselves as important therapeutic factors, as they clarified the participant's memories in relation to facts that at that moment they would not have selected to tell. Acknowledging several positive aspects of the process and gratitude for the members' trust in sharing such intimate stories, the session concludes with the clarity that the process does not end there and that the challenges are daily. The final moments represent exchanges of personal contact information, networking with group members and scheduling a new group meeting, usually on a date in the following month, for an opportunity to follow up on what was experienced in this dialogical space, when they begin to observe what was experienced there in their everyday demands.

#### **6. The therapist and the group of mourners: emotional mobilization and learning**

It is not possible to address this experience with a group of mourners without mentioning what this work is able to promote in therapists who are facilitators. Initially, it is important to highlight the challenge of living during the pandemic, which is faced both by the therapists and the group members, who are equally inserted in the pandemic collective mourning process. While this insertion favors great empathy, as we are also experiencing close and significant losses, it can also promote discomfort and paralysis in the face of so many touching contents reported by the participants in their trajectories of intensive care that were unable to prevent death.

Although this is a group whose main characteristic is dialogue and collaboration, the therapists do not play a leading role. In the role of facilitators, the therapists are experts in the process and invest in asking questions that help participants identify what White called absent but implicit, that is, finding insights into what people plan in their lives, but that they do not always identify in their stories [14]. In each session the therapists promote that, in this collaborative space, in which respect for the narrative of the other is always exercised, meanings are articulated that, when recognized, help create a platform that allows re-examining the effects of the problem, taking an alternative position and creating new lines of identity. To illustrate this process, we mention an excerpt from a letter from one of the participants of the group, who describes among so many positive and emotional impressions, a clear view of the process by mentioning:

*The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention DOI: http://dx.doi.org/10.5772/intechopen.98837*

"… I think the implementation of these groups is really effective, for it's through them that we open up our weakness, but in the end are surprised by our strength. And that's how I saw myself, having a space for speaking, listening, venting, building and rebuilding, of common ties, of gathering reasons and purposes to remain strong. Looking at myself and seeing myself is something I was already doing, but looking at myself and seeing my mother and seeing myself in her was something magical."

There are several aspects that we could illustrate about this short excerpt selected, but the main one is observing the attributes of identifying strength in face of weaknesses and the power of reconstruction and purposes. There is also mention of the connection with the deceased mother through the legacy and preferred identities, in which the problems and impotence of mourning give way to reconnection.

Regarding the therapists' assessment, the management of grief groups is reported as an indescribable experience, which at the end of the process allows several gains not only for the therapists, but also for the participants. We highlight here the importance of getting in touch not only with the content of others, but with oneself, seeing the emotional mobilization promoted by the tragic stories, but also the power of the process that sets all the pain in motion, aiming for resignification. And this involves all the actors in the process. To sum up, therapists verbalize the opportunity to transform and be transformed by the complexity of all the experiences that the group allows them to feel.

#### **7. Final considerations**

This chapter was intended to describe the experience of a group of mourners who had lost family members due to COVID-19. Seeing as this was about an extremely delicate and, at this time of pandemic, very necessary clinical management, it is considered that the social relevance of this work is indisputable. Death by COVID-19 is a reality that affects people all over the world and that requires initiatives from professionals trained to work in mental health. The positive assessments from the participants encourage our attitude to multiply and publicize the adopted methodology, seeking to inspire new experiences and encourage professionals to promote offers of these actions. Psychological work involving grief is not limited to the period of the pandemic, but will be necessary for a long time, due to what the countless losses represent. Assertive actions that rescue affective connections and resignification of relationships with deceased people may be a good path through sadness and longing.

Constructing and re-constructing narratives is an essential part of the process of understanding our experiences, attributing meaning to them, and becoming who we are [15, 16]. Therefore, narratives represent a valuable resource for professionals from different areas who seek to develop socially equitable relationships that place clients or patients at the center of the care process [16]. Narrative Medicine is an important representative of this trend. Rita Charon, also influenced by White and Epston, developed a theory based on the principle that "recognizing, hearing out, receiving, and honoring the stories of illness may give doctors and nurses and social workers to ease the suffering of disease" [16, p. 199].

Finally, although we believe the group's potential to develop resources that may contribute to preventing complicated grief, professionals must be aware of signs that suggest the need for additional referrals. If signs of suffering remain constant or seem to worsen throughout the sessions or suicidal ideation is present, referral for psychological or psychiatric treatment should be considered. Other risk factors they should keep in mind: a history of mood or anxiety disorders, alcohol or other

#### *Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological...*

drug abuse, the coping strategies used, attitudes towards death, the experience of multiple losses, scarce social support, conflicts with family and friends, and financial strains [17, 18]. Considering the high number of deaths faced during the COVID-19 pandemic, governments and civil society need to prioritize developing and promoting strategies to deal with the emotional and social impacts of losing one or multiple family members.

#### **Author details**

Silvia Renata Lordello\* and Isabela Machado da Silva Universidade de Brasília, Brasília, Brazil

\*Address all correspondence to: srmlordello@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention DOI: http://dx.doi.org/10.5772/intechopen.98837*

#### **References**

[1] Silva IM, Lordello SR, Schimidt B, Mietto G. Brazilian families facing the COVID-19 outbreak. Journal of Comparative Family Studies. 2020; 51; 324-336. DOI: 10.3138/jcfs.51.3-4.008

[2] Silva IM, Schimidt B, Lordello SR, Noal DS, Crepaldi MA, Wagner A. As relações familiares diante da COVID-19: Recursos, riscos e implicações para a prática de terapeutas de casal e família. Pensando Famílias. 2020; 24; 12-28.

[3] Campillo M. Terapia narrativa: Autoaprendizaje y Co-aprendizaje Grupal. Xalapa, Veracruz, México: Ediciones Ollin; 2009.

[4] White M. Saying hello again: The incorporation of the loss relationship in the resolution of grief. In: White C, Denborough D, editors. Introducing Narrative Therapy: A Collection of Practice Based Writings. Adelaide, Australia: Dulwich Centre Publications; 1998, p. 17-32.

[5] Anderson H. Conversation, Language and Possibilities. New York: BasicBooks; 1997.

[6] White M. Narratives of Therapists' Lives. Adelaide: Dulwich Centre Publications; 1997.

[7] White M, Epston, D. Medios Narrativos para Fines Terapéuticos. Buenos Aires: Paidós; 1990.

[8] White M. Maps of Narrative Practice. New York, NY: Norton; 2007.

[9] Campillo M. Aprendiendo terapia narrativa a través de escribir poemas terapéuticos. Procesos Psicológicos y Sociales. 2011; 7. Available from: https: //www.uv.mx/psicologia/files/2013/06/ Aprendiendo-terapianarrativa. pdf

[10] Denborough D, Freedman J, White C. Strengthening Resistance: The Use of Narrative Practices in Working

with Genocide Survivors. Adelaide, Australia: Dulwich Centre Foundation; 2008.

[11] White M. Working with people who are suffering the consequences of multiple trauma: A narrative perspective. In: Denborough D, editor. Trauma: Narrative Responses to Traumatic Experience. Adelaide, Australia: Dulwich Centre Publications; 2006; p. 25-85.

[12] Denborough D. Trauma: Narrative Responses to Traumatic Experience. Adelaide, Australia: Dulwich Centre Publications; 2006.

[13] Hedtke L. The origami of remembering. International Journal of Narrative Therapy and Community Work. 2003; 4; 58-63.

[14] White M. 'Re-engaging with history: The absent but implicit.' In: White M, editor. Reflections on Narrative Practice: Essays and Interviews. Adelaide: Dulwich Centre Publications; 2000.

[15] Hutto DD, Brancazio NM, Aubourg J. Narrative Practices in Medicine and Therapy: Philosophical Reflections. Style. 2017; 51; 300-317. DOI: 10.5325/style.51.3.0300

[16] Charon R. Narrative Medicine: Honoring the Stories of Illness. New York, NY: Oxford University Press; 2006.

[17] Mason TM, Tofthagen CF, Buck HG. Complicated grief: Risk factors, protective factors, and interventions. Journal of Social Work in End-of-Life & Palliative Care. 2020; 16; 151-174. DOI: 10.1080/15524256.2020.1745726

[18] Shear MK. Complicated Grief. The New England Journal of Medicine. 2011; 372; 153-160. DOI: 10.1056/ NEJMcp1315618

#### **Chapter 18**

## Uncertainty in Pandemic Times

*Liliana Lorettu, Davide Piu and Saverio Bellizzi*

*the unsecurity of knowledge was the same as the security of no-knowledge C. Bukowski*

#### **Abstract**

The Covid-19 pandemic has burst upon us as a general test for humanity, for which we were woefully unprepared. We all faced the pandemic with little knowledge and no experience. It is the first pandemic of our lives. Over this period, we have seen a range of conflicting statements, positions and behaviours. On occasion, the scientific community and health professionals have failed to speak with a single voice to convey the urgency of the situation, as their views got lost and scattered in rivulets of opposing theories ranging from denying to ringing the alarm. So many elements were in place for the 'perfect storm' to get unleashed … and it did. And as the pandemic wreaked its havoc, many health workers have paid a high price for their selfless dedication and professionalism. We have worked in the absence of clear-cut guidelines, in situations where even the cornerstones of medical ethics have faltered. On the other hand, the fruitful aspects of uncertainty also emerged.

**Keywords:** pandemic, uncertainty, risk, management, communication

#### **1. Introduction**

Uncertainty has always been inherent in human existence, part and parcel of our experience as we move through life. We are born with only one certainty, that of our death; we live our lives in the uncertainty of waiting. As in the ancient tale, we do not know whether 'the Lady in Black' will meet us at the market or at Samarra; she will decide.

As humans, we have a fundamental need to attempt to control and/or reduce uncertainty through the use of rules, norms, recommendations, prohibitions, safeguards, impediments, vetoes, even at the cost of limiting our freedom. However, the relentless change and transformation of society does not allow us to reach a stable condition of certainty. Evolution is continuous, and uncertainty follows evolution like a shadow. In the past, the concept of uncertainty was distinguished from that of risk, which denotes a state of measurable 'uncertainty' in which certain possible outcomes generate an undesirable effect or a significant loss and preventive measures can be planned [1]. Currently, the two terms are used interchangeably, and risk is often regarded as uncertainty [2], especially, as is often the case in today's society, when many risks are not measurable and thus increase uncertainty [3].

According to Bauman [4], postmodern society is a society of uncertainty, in which the ongoing transformations have led to an 'erosion of the certainties' of modern society, and a loss of collective identities.

Castel [3] argues that current uncertainty is the effect of the gap between a socially constructed expectation of protections and a society's actual ability to make them work. As humans we constantly strive to reduce uncertainty by continually changing our environment; however North [2] observes that 'there is no guarantee that we will understand correctly the changes in the environment, develop the appropriate institutions, and implement policies to solve the new problems we will face.' The use of science and technology is certainly an important attempt to manage uncertainty and channel it into defined and controllable patterns. However, while science often offers solutions, it is often itself a cause of problems as it can cause 'a flood of particular, conditional, uncertain and detached detailed results (…) impossible to survey' [5]. Moreover, we often do not know the implications and consequences of innovations once they leave the laboratory and interact with other innovations in totally unpredictable ways [6]. Increased awareness of the risks associated with human choices also entails the need to assign responsibilities for decision-making processes and their consequences [5].

However, uncertainty also has its upsides.

While it generates anxiety, uncertainty can also fascinate and stimulate the senses and the mind. Socrates has taught us that accepting uncertainty makes us wise. His thought based on 'the knowledge of knowing nothing', the awareness of a definitive lack knowledge, and therefore of uncertainty, becomes a fundamental stimulus of the desire to know and remains a very topical warning. Thus, uncertainty asks us to search constantly, to fight against dogmas and the status quo and is a source of possibilities to be explored.

We should highlight the fruitfulness of uncertainty. When we are uncertain, we are always much more open to change, including unforeseen change. We respond to change more quickly by reprogramming our reactions, coming up with new solutions and rapid decisions, especially when confronted with an unforeseen emergency.

The spread of the Covid-19 pandemic has caused an unprecedented humanitarian emergency and has projected us into a global scene fraught with uncertainty.

The Covid-19 pandemic has burst upon us as a general test for humanity, for which we were woefully unprepared. We all faced the pandemic with little knowledge and no experience. We feel as if Nature put us to the test through an unknown virus. The Covid-19 virus has revealed itself as an unknown enemy that knew very well the frailties and limitations of our humanity and was able to hit our weak spots.

This article describes the uncertainty linked to three aspects of the pandemic response: management, medical treatment and news reporting.

#### **2. Uncertainty in the management of the pandemic**

The current Covid-19 pandemic is the first large-scale pandemic we have faced in our lifetime. The previous major pandemic dates back to the period from 1918 to 1922, exactly 100 years ago, so individuals living today have no previous experience to refer to.

A major role in the management of epidemics and pandemics has been assigned to the WHO. The WHO has played this role. Although at times its positions have been widely criticised, it is worth pointing out that the WHO had to grapple with a pandemic spread by a completely unknown virus.

*The World Health Organisation (WHO) was established in Geneva in 1946 as a satellite organisation of the United Nations, with the aim, stated in its Constitution, of 'bringing all peoples to the highest attainable standard of health'. This objective is pursued through the WHO's own functions, which include, among others: to act as the* 

#### *Uncertainty in Pandemic Times DOI: http://dx.doi.org/10.5772/intechopen.99454*

*directing and co-ordinating authority on international health work; to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; and to promote co-operation among scientific and professional groups which contribute to the advancement of health* [7]*.*

*It may also propose conventions, agreements and regulations, and make recommendations with respect to international health matters and perform such duties as may be assigned thereby to the Organisation and are consistent with its objective. Each Member shall report annually on the action taken with respect to recommendations made to it by the Organisation and with respect to conventions, agreements and regulations. One of the instruments through which these functions are managed is the International Health Regulations (IHR) of 2005 (the first Regulations were adopted in 1969 and have since been revised several times). The IHR is an international legal instrument that aims to 'ensure the highest protection against the international spread of disease, avoiding unnecessary interference with international traffic and trade, by strengthening the surveillance of infectious diseases to identify, reduce or eliminate the sources of infection or contamination, improving airport sanitation and preventing the spread of disease vectors'* [8]*.*

*A Public Health Emergency of International Concern (PHEIC) is a formal WHO declaration of 'an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response'. A PHEIC is declared when a situation arises that is 'serious, sudden, unusual or unexpected' and 'carries implications for public health beyond the affected state's national border' and 'may require immediate international action'. Under the 2005 IHR, states have a legal duty to respond promptly to a PHEIC* [9]*.*

*The WHO should be notified whenever the answer to at least two of the following four questions is yes: Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international travel or trade restrictions?* [10].

*WHO Member States have 24 hours within which to report potential PHEIC events to the WHO* [10]*. A potential outbreak does not need to be reported by a Member State, since reports to the WHO may also be received informally* [11]*.*

*From 2009 to 2020, there have been six PHEIC declarations: the H1N1 (or swine flu) pandemic of 2009, the polio of 2014, the 2014 Ebola outbreak in Western Africa, the Zika virus outbreak of 2015–2016, the Ebola outbreak in Kivu of 2018–2020, and the COVID-19 pandemic of 30.01.2020* [12].

On 2 May 2021, a report by an independent panel, expressly requested by WHO Director-General Thedros Adhanom Ghebreyesus, confirmed the WHO's delay in declaring the new epidemic a 'public health emergency of international concern' (PHEIC) [13].

The report highlighted the time lost from 31 December 2019, the day the WHO received the first information from its China Country Office about a new 'pneumonia of unknown origin' reported in a press release of the Wuhan Municipal Health Commission, to 30 January 2020, the day the new outbreak was officially declared a PHEIC. Perhaps the PHEIC could have been declared as early as 22 January 2020, after the initial findings of the first mission of experts sent to Wuhan by the WHO, who spoke of human-to-human transmission of the virus, but also said that further investigation was needed to understand the extent of transmission [14]. Taiwan warned the WHO of possible human-to-human transmission as early as 31 December 2019, but the WHO did not give the information any weight [15].

The Emergency Committee (EC), made up of 15 independent experts as required by the International Health Regulations (IHR), was convened on 22 and 23 January, but failed to reach a consensus on the danger of the new outbreak, postponing the

decision to declare PHEIC. By that time, the virus had already spread to Thailand, Japan and the United States [16]. The PHEIC was declared on 30 January 2020, after a mission of the WHO Director-General to China and another meeting of the Emergency Committee. At that time there were 7818 confirmed cases globally in 19 countries in five WHO regions [17].

It is worth pointing out that this delay, which has been fully acknowledged by the WHO, stemmed, among other things, from uncertainties due to the lack of knowledge about the virus and has, in turn, created a cascade of further uncertainties.

The measures, recommendations and suggestions for managing the pandemic have not always followed a linear course, as they needed to be revised and updated as the scientific studies produced by the international scientific community provided increasing understanding and certainties about the virus.

*One example among many of the shifting recommendation is the advice on face masks. On 6 April 2020* [18]*, the WHO advised that masks were useful in combating the spread of the virus when worn by sick people and were indispensable for health workers, but cautioned against their use in the wider community setting, stressing that there was no scientific evidence that masks could help healthy individuals to avoid infection, and warning of the false sense of security they might create. The guidance acknowledged that it was 'possible that people infected with COVID-19 could transmit the virus before symptoms develop'. It also admitted that 'Studies of influenza, influenza-like illness, and human coronaviruses provide evidence that the use of a medical mask can prevent the spread of infectious droplets from an infected person to someone else and potential contamination of the environment by these droplets (from an article published in Nature Medicine on 3 April 2020)* [19]*, but added: 'there is limited evidence that wearing a medical mask by healthy individuals in the households or among contacts of a sick patient, or among attendees of mass gatherings may be beneficial as a preventive measure'. On 6 June, the advice changed, as it was stated that 'Masks alone are not enough, but they can help to protect oneself and others'. Therefore, they should certainly be worn in community settings 'because they provide a barrier to potentially infectious droplets'* [20]*. Then, in August 2020, the Director-General of the WHO himself launched the 'Mask Challenge'* [21]*, inviting people to send in photos of themselves wearing a mask via social media under the message that 'everyone has a role to play in breaking the chains of transmission'. In Italy, Legislative Decree No 125 of October 2020 imposed the use of masks 'in all outdoor places except in those settings where isolation from other people is guaranteed continuously'* [22]*.*

In Italy, as in other countries, the management of the pandemic required, among other things, the adoption of restrictive measures never experienced before. In light of the grave threat to public health, 'extraordinary' measures were taken, which also entailed limiting individual freedom. Some restrictive measures such as isolation and quarantine are well-known health measures, defined as 'ordinary' because they had already been used in the past, in line with current health policies and not in conflict with individual freedom. However, the scale of the threat posed to the health of individuals and communities by Covid-19, the scarce scientific knowledge about the virus, and the rapid spread of the pandemic also required the taking of 'extraordinary' measures. These measures, grouped under the generic term of 'lockdown', included, among other things, 'stay at home' rules and curfews, the blocking of numerous work activities, the closure of all schools for all age groups, the prohibition of certain behaviours and activities, social distancing, and the use of personal protective equipment. All this happened in the context of a general and widespread climate of uncertainty that affected individuals, communities, policymakers and health professionals, in the attempt to reduce the risk and the spread of the pandemic.

#### *Uncertainty in Pandemic Times DOI: http://dx.doi.org/10.5772/intechopen.99454*

The certainties about daily routines, work and personal life were lost, as were those about protecting our health. But the impact was not only on the daily routines of one's life, which for better or for worse give us a framework of certainty and predictability to which we can anchor ourselves. We also lost certainty of the future: for a long time, no planning for the future was possible because the seriousness of the health emergency had swept away all certainties about it. Everyone may fall ill and die. Covid-19 has proven to be a very 'democratic' disease, as it has affected all social classes, age groups, ethnic groups and religious denominations. Above all, the lack of knowledge about the virus initially prevented full understanding of its means of transmissions, the measures to avoid infection and the most appropriate treatment for infected patients. Fear of death became ever more present and tangible. Throughout our lives, we are all aware that sooner or later we will die, yet we all live as if we were immortal, banishing reflection on the end of life to a distant future. The pandemic has forced us all to revise our thinking and acknowledge that death could come at any moment. Many people have experienced the impact of the disease either directly or through a loved one. Many have lost a family member or an acquaintance, and had the feeling that 'the bombs were falling closer and closer and it seemed impossible to get out unharmed'.

In 2020, the total number of deaths from all causes was the highest ever recorded in Italy since World War II: 746,146 deaths, 100,526 more than the annual average in the period 2015–2019 (+15.6%) [23].

Our certainties concerning our 'health status', also promoted by major health education campaigns, have collapsed. Health screening programmes, disease prevention and monitoring, access to hospital services and to the national health service, arrangements for visiting and assisting relatives staying in hospital, have all been suddenly wiped away leaving behind an empty space of bewilderment and confusion. Many patients feared that they would not be able to access healthcare. Some died in an ambulance while waiting to be admitted to hospital, others in their own homes waiting for an ambulance, the fate of many was decided by 'the lottery of life'.

The disruption of healthcare services caused by Covid-19 has impacted a number of specialties such as cardiology, paediatrics, oncology, neurology and psychiatry. The fallout is likely to continue for a long time [24].

A European study on the relationship between Covid and heart attack highlights the impact of delayed treatment and of the fear of going to hospital, leading to an estimated burden of 20,000 excess CVD deaths in Italy [25].

The link between patients and their families and that between health care workers and caregivers was disrupted during the hospitalisation of patients, going counter to more than 20 years of research and care practices highlighting the benefits of the healthcare provider-patient-family relationship [26]. Many patients have died in hospital, alone and in pain.

In the early stages of the pandemic, uncertainty mainly revolved around the 'health dimension', as many questions remained unanswered, or received contradictory, incomplete, inaccurate or misleading answers. The enemy to be fought was a little-known entity. As the lockdown dragged on, uncertainty also extended to the 'economic dimension' as individuals were hit by the shutdown and restriction of economic activities and the resulting economic crisis.

In EU, 2,7 million citizens lost their jobs last year as a result of the pandemic (Eurostat data). In Italy, the employment rate fell by 0.9% [27].

Initially, we all believed and hoped that the restrictions would be temporary, but the hope was dashed as fresh waves of the pandemic led to the restrictions being extended, wreaking havoc on the economy and opening up frightening prospects for individuals and society. The sheer duration of the pandemic has generated a dramatic value conflict between the need to save lives and the need to protect

livelihoods, plunging many individuals into a dispiriting health and financial uncertainty, and putting into sharp relief a circular and unsolvable existential dilemma, since there is no work without health and no health without work [28].

The pandemic also caught our **policy-makers and governments** by surprise. They too, experienced the uncertainty dictated by the unknown enemy, the virus. Policymakers did not know the virus and were unable to give clear indications of 'what to do' to guarantee citizens' safety. Many of the measures taken turned out to be ill-advised, no measure was risk-free, and many measures accompanied by reassuring statements were later found to be wrong and unsafe.

In 2005, the WHO had recommended its Member States to develop and constantly update their own influenza pandemic plans. Italy drafted its Pandemic Plan in 2006 (Agreement of the Standing Conference of the State Regions and Autonomous Provinces no. 2479 of 9 February 2006) [29].

The lack of clear and reliable information as to the actual revision status of the plan has fuelled doubts about the response to the Covid pandemic, which has often been inconsistent in affecting public compliance with the restrictions.

Each country has addressed the pandemic in its own way, developing its own national response. After China, Italy was the first country affected by the spread of the virus, giving other countries some extra time to plan their response, also in the light of the Italian experience. However, the different social, economic and health characteristics of each country did not always allow them to learn from the mistakes and/or experience of other countries. Thus, no uniform response was implemented on the basis of a collective process drawing on and combining the different experiences. Each country appeared to act according to an almost neurotic 'compulsion to repeat mistakes'.

The pandemic has shone a light on the inadequacies of health policies, which, in the wake of the globalisation of modern society, have often applied the McDonald business model to the health system, impacting its resources, increasing inequalities and affecting the fragile and vulnerable [30].

During the pandemic, many policymakers have taken advantage of the Covid issue to raise their profile and boost their votes, instead of focusing on the good of the community. Citizens were often given information that quickly proved to be false. Several politicians openly recommended irresponsible or unsafe behaviour, capitalising on discontent and impatience with restrictions and undermining the principles of collective responsibility and solidarity. Others have attempted to politicise the management of the pandemic. However, the pandemic has always resisted any political labelling, constantly reasserting its disturbing independence and uniqueness.

Uncertainty has also affected **health workers** who, for the first time in their lives, were confronted with a pandemic caused by a virus that they had never studied in their textbooks.

Patient management, treatment protocols and the management of healthcare facilities had to press the reset button: for all 'it was the first time'. Medical procedures were developed in the course of the pandemic through trial and error.

In addition to the uncertainties regarding treatment, the doctors faced other uncertainties.

The rapidly rising patient numbers soon led to shortages of ICU beds and produced situations recalling 'disaster medicine' [30, 31]. Well-established standards and procedures for the access to and termination of intensive care, routinely followed by health workers, proved inadequate to the sharp upsurge in demand. This made it necessary to set aside the criterion of the appropriateness and proportionality of care, and to introduce criteria of distributive justice and appropriate allocation of limited health resources, often applying the criterion of 'greater life expectancy' to select patients. Uncertainty affected the procedures and guidelines but also the

#### *Uncertainty in Pandemic Times DOI: http://dx.doi.org/10.5772/intechopen.99454*

ethical principles of medicine, as health professionals were faced with new and unusual ethical challenges for which they were all unprepared [30]. Health workers faced the challenge with dedication and courage, attempting to make up for the scarcity of health care resources. They lost the certainty and hope of working in a safe manner; they knew that their work meant putting their lives at risk and those of their loved ones. Despite this, they continued to work and … die. In the early stages of the pandemic, health workers had inadequate personal protective equipment, while later they had to learn how to use it correctly to protect their safety at work. Health workers have been called heroes, but many have also suffered assaults [32]. In Italy, approximately 450 health workers died, mainly during the early stages of the pandemic [33]. Some cases of suicide were also reported. More than 100,000 health workers were infected. Although other European countries were also affected by the pandemic, the number of deaths among healthcare workers in those countries is lower. Fortunately, the infection and death rates among healthcare workers have come to an abrupt halt with the start of the vaccination campaign.

#### **3. Uncertainty related to treatment**

The etiopathogenetic mechanisms of the Covid-19 infections were not initially clear. Moreover, in the early months of the pandemic, there was a ban on performing autopsies on patients who had died with Covid. This decision prevented and delayed key insights on the etiopathogenesis of the disease, which in turn can help to plan treatment. In the absence of a clear and known etiopathogenesis, there were no reliable guidelines for the patients' clinical management.

Health professionals made reasoned choices in the light of the knowledge and experience available at the time, and modified their treatment protocols as clinical evidence and scientific literature became available.

In a situation of high uncertainty, various drugs were alternatively recommended or prohibited. The virus has repeatedly refused to be pinned down.

Each covid unit followed its own protocol based on the results available at the time. However, developing a set of treatment recommendations based on a scientific rationale to reduce the risk of serious complications while ensuring adequate treatment safety was all but easy.

On 30 November 2020, the Ministry of Health published a guidance document on the home management of patients with SARS-Cov-2 infection [34]. On 10.12.2020, the Italian Medicines Agency (AIFA) issued guidance on the treatment of patients in hospital and at home, establishing the standard of care in light of the evidence available at that time [35].

Although the vaccine is not a treatment but a prophylactic measure against the disease, the arrival of the vaccine in record time was an extraordinary achievement and a fundamental breakthrough in controlling the pandemic.

However, vaccines too were and still are surrounded by many uncertainties.

The first uncertainty concerned the guarantee of immunisation. After the vaccines were approved by the regulatory body, the uncertainty concerned the availability of vaccines in different countries and in different parts of the same country. Distribution was patchy at first, beset by logistic and supply problems, and many people did not know whether or when they would receive their vaccine. This contributed to maintaining a general climate of uncertainty, while we were going through the third wave of the epidemic.

Another type of uncertainty concerned the priority order for accessing the vaccine. In Italy, especially in the first wave of the pandemic, many elderly people died: an entire generation, a heritage of culture and love, was wiped out by Covid-19.

The elderly population was classified as 'fragile' and was therefore given priority in the vaccination campaign. Another priority group was healthcare personnel. These were the only initial certainties as to the order of access to vaccines. For the rest of the Italian population, access to immunisation was not uniform across the different regions.

Lastly, particularly serious uncertainties and concerns have been and are still felt about the efficacy and safety of the vaccine.

As to efficacy, the level of actual 'protection' afforded by the vaccines has been hotly debated and bitterly disputed, fuelling controversy over disparities in treatment according to the type of vaccine used. Eventually, the regulatory authorities, on the basis of clinical evidence, have clarified the real efficacy of all the available vaccines. However, the appearance of virus variants has ushered in new uncertainty.

As to the vaccines' safety, too, the uncertainties are still many and evolving. Although side effects, even serious ones, were to be expected, it has proven difficult to maintain public confidence in vaccination and dispel uncertainties. In addition, in some cases (e.g. the Astra Zeneca vaccine), the rules issued by the authorities have fluctuated wildly.

#### **4. Communication in a pandemic: the paradigm of uncertainty**

One of the ways we try to control uncertainty is through knowledge, by continuously searching for useful information to reduce it. However, it is not always possible to obtain the kind of precise information that allows us to reduce and/or control uncertainty. Often the information is insufficient, limited, distorted or inaccurate, and ends up generating more uncertainty. We can define this type of uncertainty as 'cognitive uncertainty', since it is linked to the inability of human beings to collect, process and select information and knowledge' [36].

Cognitive uncertainty has mushroomed during the pandemic and still today fuels and maintains the many global uncertainties generated by Covid-19.

In January and February 2020, the news coming out of China and from the authorities was little, fragmented and uncoordinated. On the other hand, multiple and contradictory voices soon started revealing to the world what was happening. Especially at the beginning, there was no system to coordinate and clarify the flow of information.

The huge amount of data fed to the public has been dubbed an 'Infodemic' by the WHO [37]. This shorthand term was first used to refer to the overabundance of information and news published at a continuous rate during the SARS epidemic. The word is a neologism coined in 2003 by a journalist from the Washington Post, and is defined as '*a rapid and far-reaching spread of both accurate and inaccurate information about something, such as a disease. As facts, rumours, and fears mix and disperse, it becomes difficult to learn essential information about an issue*.' [38].

The trend to attention-grabbing news has been pervasive. The aim of many has been to provide continuous information, to produce scoops, often without proper fact-checking. Moreover, various pieces of news, which were accurate when published, were soon after rebutted by fresh scientific and clinical evidence.

The media outlets have ridden the waves of the pandemic as extensively and emphatically as possible. The aim of the media has been to supply a constant stream of news stories, often paying little attention to fact-checking.

In order to provide breaking news and keep the public glued to their screens, headlines or social media pages, the media have reported data and figures taken from the latest scientific studies on the coronavirus, often without checking the authenticity of the information, for example by publishing data from not yet peerreviewed studies.

#### *Uncertainty in Pandemic Times DOI: http://dx.doi.org/10.5772/intechopen.99454*

TV talk shows have mixed and mingled scientists with businesspeople, politicians, ubiquitous opinion-makers and commentators, all expounding about issues such as Covid swabs, treatments and vaccination campaigns.

The scientific world has been flooded with an incredible amount of data and studies. Some of the major, highly regarded scientific journals have published several studies on SARS Cov-2 and Covid-19 only to withdraw them a few months later.

Often, both the scientific community and health professionals have failed to speak with a single voice to convey the urgency of the situation, as their views got lost and scattered in rivulets of opposing theories ranging from denying to ringing the alarm, giving in to the seduction of fame. Many have vehemently advocated a position only to then reverse it with disquieting speed and ease. Rather than communicators, they have been skilful weavers of uncertainty.

The authorities too have failed to provide clear information. Sometimes, even political leaders such as heads of state have given wrong information on scientific issues related to the pandemic, sharing fake news or engaging in questionable behaviour. The political world appeared uncertain in its attempt to reconcile fundamental human values such as health, individual freedom and the economy. Communication often seemed to fuel the conflict of values and, consequently, uncertainty.

In Italy, in March 2020, the government chose to present data and information to citizens via Facebook live streams of the Prime Minister and daily press conferences on television, by the head of the Civil Protection authority, in what Mario Marangio calls the 'Institutional Phase' of communication in the time of Covid [39]. Live briefings on social media were a first for government-to = citizen communication in Italy.

In terms of communication style, the briefings often resorted to war imagery, liberally using words such as 'war', 'battle', 'fight', 'attack', 'defence', 'curfew'; treatments and vaccines became 'weapons' against the 'enemy', and citizens were exhorted to rally together in the fight against the 'common enemy'.

This language actually fuels the widespread feeling of uncertainty, since war is by definition a time steeped in uncertainty. Anyone who raises a doubt or asks a question about the Covid strategy, even in good faith, is immediately singled out as colluding with the enemy, as a problem to be solved or a voice to be silenced. But this attitude does not help dispel the citizens' uncertainties and legitimate doubts.

The understandable uncertainty of scientists, policymakers and the media in managing the huge mass of data has fuelled a flood of misinformation, fake news and conspiracy theories, which have on occasion generated violent results, such as the setting of 5G telephone towers on fire, the chasing and damaging of ambulances, and Covid denialist movements such as the 'anti-mask', 'anti-vaxxers' and 'anti-curfew' groups.

As stressed by the National Bioethics Committee (CNB), accurate information is crucial to encourage people to comply with the restrictions: when individuals are informed of the facts and scientific progress and trust that the public authorities are acting with absolute transparency, they are generally more likely to comply for their own sake and that of others [40]. However, accurate information has often been lacking.

#### **5. Conclusions**

As discussed, uncertainty has been a major feature of this pandemic. The process of containing uncertainty and/or risk through rules, standards, measures or prescriptions, prohibitions and restrictions has not been easy. This process is necessarily flexible and fluid; it requires continuous adjustments as new clinical evidence emerges, and is still far from reducing uncertainty. The advancement of knowledge, which is a key factor in the process of reducing uncertainty, has been hampered by the changing nature of the pandemic, which has hindered the efforts to bring it under control. Science has once again proved fundamental in the response to the pandemic, thanks to breakthroughs such as the development of vaccines in record times.

Nevertheless, uncertainty has taken various forms and has given rise to a cascade of personal and social dimensions.

One consequence of uncertainty, on an individual level, is certainly anxiety. This is a complex psychopatological dimension characterised by the fearful expectation of a vague and terrible threat, stemming from real or perceived uncertainty, the loss of control over the external environment and the inner dimension. Anxiety differs from fear, which is an alarm response oriented to an identifiable and specific threat, and from distress, a condition of severe suffering, due to a catastrophic interpretation of reality and a sense of impending misfortune [38, 41]. These three conditions have often characterised the response of individuals to the pandemic disruption and the uncertainties it has caused.

Another particular dimension is the lack of trust. Trust is defined as '*reliance on or confidence in the dependability of someone or something. In interpersonal relationships, trust refers to the confidence that a person or group of people has in the reliability of another person or group; specifically, it is the degree to which each party feels that they can depend on the other party to do what they say they will do*' [41].

Sociology recognises that trust plays a role in informing and maintaining the social order and distinguishes three types: *systemic* or *institutional* trust, aimed at natural and social organisation; *personal* or *interpersonal* trust, aimed at others; and trust in oneself [42, 43].

The uncertainty surrounding the pandemic has undermined all aspects of trust. There has been a decline of trust in the institutions, which often seemed unable to protect citizens because of measures that were perceived as incomprehensible and unfair. There was often a widespread sense that official communication was distorted, incomplete or inaccurate. This led to the perception of being in a changeable and dangerous situation, with no clear answers. An unambiguous assessment of the facts, which is a basic element of trust, was not possible given the circumstances, but the lack of transparency in communication, the discordant and fluctuating positions also contributed to the loss of trust.

Interpersonal trust also weakened, partly because the social distancing rules imposed by the lockdown reduced the opportunities for interpersonal contact, enhancing the feeling of loneliness. Individuals focused on their self-interest, alienating themselves from the principles of solidarity and cooperation: the 'other' was often seen as a possible source of infection or demands.

Lastly, trust in oneself has been undermined by the persisting uncertainty and the individual and collective inability to bring the pandemic under control. Individuals have been burdened with anxiety and fears, losing awareness of their own and others' resources for overcoming the situation.

Moreover, distrust has heightened the difficulty in accepting the lockdown restrictions. Individuals had to balance the principle of individual freedom (understood as freedom in the choice of treatment and disease prevention measures) with the principle of solidarity, which must also take into account the health of others and requires the persons at lower risk to protect themselves in order to avoid infecting more fragile and vulnerable people.

#### *Uncertainty in Pandemic Times DOI: http://dx.doi.org/10.5772/intechopen.99454*

Mistrust has contributed to fuelling a number of violent incidents having various forms and targets. Health workers and health facilities have often been threatened by denialists who accused them of sowing terror and falsifying pandemic data. These attacks were accompanied by smear campaigns on social media and discrimination of health workers, suspected to have spread the virus.

Numerous violent episodes by youths have also been reported: they are a cause of social alarm because they are probably the tip of an iceberg and an expression of widespread disaffection which seems likely to continue in the future.

The situation that has arisen reminds us of the condition described by Durkheim as 'anomie': a situation of unease and malaise in a society where social norms are absent or weak and conflicting [42]. The individual dimension of anomie involves a profound state of malaise, whereby individuals are unable to choose what to do, do not know what others expect from them and do not know what to expect from others. The objective dimension, referred to the social context, involves a strong risk of disruption of the social fabric and deviance [44, 45].

More than a year (18 months) after the start of the pandemic, uncertainty persists despite the major breakthrough of the vaccination campaign. We seem to be playing a dangerous game in which the rules are constantly changing, and we are constantly falling short in our attempt to 'build certainties'. The development of vaccines in record time does not seem to guarantee safety. Moreover, the pandemic has heightened inequalities and vulnerabilities.

The strong global inequalities in distribution of the vaccines do not bode well for overcoming the pandemic, as they allow continued circulation of the virus and the emergence of variants. It is worth noting that these inequalities also carry risks for the people on the apparently favoured side.

The present feeling of loss of confidence bears an uncanny resemblance to that described by Stefan Zweig in The World of Yesterday [46], where the author reminisces of a world in which '*everyone knew how much he possessed or what he was entitled to, what was permitted and what was forbidden. Everything had its norms, its definite measure and weight*', which strongly contrasts with our current uncertainty. It is fascinating, although not surprising to note, that 'conditions' reoccur in the world and that the conditions of 100 years ago are quite relevant to today's world. It is disturbing to realise that so much suffering still awaits us because '*only he who has experienced dawn and dusk, war and peace, ascent and decline, only he has truly lived*'.

Even today, a year and a half later, the pandemic is not over; uncertainty is still pervasive, amid the hope and expectation of a return to a normality that will never be the same again.

However, we also have the certainty that human beings are able to respond and take action even in conditions of uncertainty, even when they fear their own death. This is proven by the work of Italian health workers, who have paid a high tribute to the pandemic, and have earned a nomination to the Nobel Peace Prize. Health workers have followed the path of the fruitfulness of uncertainty.

The lesson for us is that we cannot stop. We must start anew; with humility to learn from our mistakes, responsibility to pursue our duty, solidarity to reduce inequalities and reach out to those in need.

*Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological...*

#### **Author details**

Liliana Lorettu1 \*, Davide Piu1 and Saverio Bellizzi<sup>2</sup>

1 Department of Medical, Surgical and Experimental Sciences, University of Sassari, Italy

2 Independent Medical Epidemiologist, Geneva, Switzerland

\*Address all correspondence to: llorettu@uniss.it

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 19**

## Stress and Resilience among Medical Students during Pandemic

*J. Shivananda Manohar, Rajesh Raman and Bindu Annigeri*

#### **Abstract**

Medical students who are future physicians are faced with a lot of uncertainties during this pandemic. It includes both academic as well as clinical difficulties. Previous literature has revealed that the stress among medical students is higher when compared to their peers. The stress has even been more during the pandemic as their role during the pandemic is not clear. The purpose of medical training is to produce good doctors but not at the cost of the integrity of the individuals.'Moral inquiry' is a term used to represent the ethical dilemma faced by doctors during life-death situations. Helplessness faced by students during emergencies leads to moral inqury which in turn leads to more distress. Most of the Medical universities have responded to the pandemic rapidly, by switching to online mode in teaching. This unpatrolled response also has to lead to more stress among medical students. Resilience, by definition, is the capacity to bounce back productively during a stressful situation. Resilience can be viewed as a personality trait or as a fluid process that nurtures according to the situation and the individuals' reservoir. In this article, we have tried to emphasise the importance of Resilience.

**Keywords:** Medical students, Stress, Anxiety, Perceived stress, Medical training

#### **1. Introduction**

Medical training to become a doctor, a profession dedicated to the caring of patients can at times be detrimental to an individual's health. 'Stress' by definition is an unpleasant feeling or strain because of external demand [1]. Medical training itself can be stressful because of various reasons which include sleep deprivation, academic burden and exposure to life-death situations [2–5]. When compared with the general public, a medical student's satisfaction in life and mental well-being is compromised [6].

#### **1.1 Research method**

Here we are trying to present a narrative review. We have tried to focus on specific topics, rely on observations, recommendations, and conclusions. The terms we used for the search included stress, resilience, medical students, and pandemic. The original articles, systematic reviews, reviews and guidelines were included to prepare this article.

#### **2. Academic and clinical learning during pandemic**

During the pandemic there have been unforeseen changes in not just the pattern of their learning, but in their entire routine. Also during such an emergency situation, an institution's response to the pandemic in terms of academics is rapid, with committed delivery of academic services causing minimal disruption in this regard. This unpatrolled reorganisation may also be distressing for many students [7]. It has also affected the timeline of the training program. They are also under stimulated, being confined to home, with less than adequate interaction with peers. Clinical teaching, which is the centre of medical education has been totally compromised during this pandemic. They have had to rely on technology for all their learning and communication. In this context, some may have had hassles with internet connections. In addition to this, the enhanced screen time results in eye strain and sleep disturbances. When enquired about their attitudes towards e-learning, it was perceived by a majority of them (75%) that they were wasting their study potential due to the pandemic and resultant closure of the college. About 50% agreed that the pandemic had affected their personal wellbeing, and the same number was worried about being exposed to COVID-19 during their clinical training. A little less than 50% of the respondents felt that COVID-19 had no impact on their career and future specialty training and that their faculty had provided guidance for students during the pandemic. There are mixed responses regarding the acceptability of e-learning. Most do not accept that e-learning could help clinical training [8]. Although, the didactic lectures can be easily transitioned to the online mode, the human interactions which take place through clinical exposure cannot be substituted for. The institutional response to the pandemic is rapid in most of the places. The unparalleled reorganisation which may include academic as well as clinical, itself may be a factor to induce stress in the medical students.

Some universities have postponed the examination while others have resorted to online modes of assessment. Rapid restructuring of examination means those who are preparing for examination should contend with the new test format within a short period of time. Many institutions have considered alternative approaches like dropping grade point system and mandating pass grade only. This approach may negate the time and effort put by the students to achieve higher grades which will have negative impact on their future. Rescheduling exams for the final year students and recruiting them for the patient care earlier than expected – also have led to uncertainties [9].

Exposing final year students as frontline is also a concern raised in many countries. While, some universities have recruited them for patient care, others have completely stopped them from interacting with patients in the background of them yet being amateur doctors [10]. An earlier study conducted in 2019 has revealed that nearly 60% of students were willing to volunteer during an infectious crisis and among them, 91% reported that altruism is the motivating factor for volunteering. The question is whether altruism is the only factor to deploy them as volunteers. Earlier studies have also revealed that though there is a willingness to help, only 4% reported their preparedness in terms of skill. Hence, it is worth noting that though, being motivated to work during such situations is commendable, it cannot replace the clinical efficacy of trained professionals [11].

#### **2.1 Stress among medical students**

Though stressors like exposures to life-death situations and academic pressures are inevitable, it does not imply medical competence should be acquired at the cost of one's health. The medical profession is governed by the Hippocratic principle

of doing no harm. This also should be applied in training of future physicians so that they are better equipped to handle necessary stress and avoid unnecessary ones. This is especially important during the pandemic where uncertainty itself leads to stress, which in turn results in reduced empathy. The essence of medical education is not only to provide competence but also to preserve the integrity of the individual.

A systematic review of 29 studies of varying qualities showed a wide range of prevalence of 7.7–65.5% for anxiety among medical students in general, although the global prevalence rate of anxiety among medical students is 33.8% [12]. This is most prevalent among medical students from the Middle East and Asia. About one in three medical students globally have anxiety which is substantially higher than the general population [13].

The prevalence of depression (45.3%) and anxiety (48.1%) was found to be high during COVID-19, according to some researchers. More than half the trainees (57.3%) reported experiencing mood changes and difficulty in concentrating since the start of the COVID-19 crisis. One in four trainees felt inadequately supported, and about a sixth confessed to having considered a change in their choice of profession since the beginning of the pandemic in America. Temporary closure of the college and suspension of classes and education, impeding the quality of their education may have contributed to the anxiety [14].

A high level of anxiety and depression was found among medical students, of whom 31.3% exhibited a high likelihood of experiencing depressive symptoms, and 10.5% may have anxiety symptoms. A previous study performed among Libyan medical students during the early phase of the COVID-19 pandemic, found that 11% of medical students have anxiety symptoms, 21.6% have anxiety symptoms, and 22.7% have suicidal ideation.

Among Chinese college students, 0.9% suffered from severe anxiety and 2.7% experienced moderate anxiety symptoms during the COVID-19 outbreak. A metaanalysis of anxiety research studies on 69 medical students showed that 33.8% of them experienced anxiety symptoms when the results were pooled [15].

A recent meta-analysis done on eight studies on anxiety in medical students during COVID-19 showed an estimated prevalence of anxiety of 28%. But, this prevalence of anxiety of 28% is lower than the prevalence prior to COVID-19 for medical students globally, which was estimated as 33.8% in a meta-analysis. Most of the anxiety in medical students is related to academics and it is possible that online learning might have eased the burden of over-loaded academic programs. Also, keeping the medical students away from hospitals might have helped in reducing anxiety. Remaining at home with family might have also resulted in more bonding and the availability of support for medical students who might otherwise struggle to seek it. Being with parents and social support were found to be protective factors for anxiety [16].

The onset of the pandemic has brought about an anxiety of being infected and inability to handle a patient with COVID 19, inadequate clinical exposure and practical learning, compromised confidence in dealing with real patients as all learning is being virtual.

Some universities have prohibited medical students from any patient interaction, whereas others have engaged them for hospital-based roles as either students or early graduated frontline workers [17].

Medical students may pose unnecessary risk for patients, other clinicians and themselves because of an inadequate clinical experience. Being a part of a medical college alone does not substantiate these risks. However, encouraging medical students to participate in roles in which they have been prepared for may be more helpful.

The downside of all this is that, lockdown may prevent students from engaging in other activities such as exercise and interaction with peers, which are vital for the physical and emotional development of young people. Quarantine and lockdown may also limit access to psychiatric services, which could lead to an exacerbation of previously established anxiety disorders [16].

Resilience is relatively a new concept and there is not much research in educational field to make any pedagogical implication [18]. Resilience is one of the important skill which helps to adequately manage painful feelings, failure, and illness and these individuals have stable life satisfaction [19]. Prior studies have found that resilience acts like a buffer during negative life events, and also men are more resilient when compared to women. The concept of resilience has changed from it being a trait to being a dynamic process. Goodman et al. defined resilience as "the interactive and dynamic process of adapting, managing, and negotiating adversity". Resilience can change over a period of time as a result of development and one's interaction with the environment. Trauma affects people differently. Some people deal with it very soon, while others struggle with it for a longer time [20].

Self-efficacy and self-esteem are noteworthy factors in predicting psychological distress among medical students during the COVID-19 pandemic. It could also be influenced by factors like, female gender and suburban place of residence [21].

Resilience-It is not precisely clear how one goes about promoting resilience; this personality trait may depend on various factors, not all of which can be addressed by an institutional intervention. It is inversely related to stress, which implies that being more resilient leads to lower perception of stress. Medical students have higher levels of stress but, they are not more resilient than their peers matched by age and gender. Among medical students, there is a gender difference in perceived stress, resilience, and coping. Male medical students are known to have higher positive coping scores than general population peers and higher resilience, and lower perceived stress than female medical students. If resilience is considered predominantly as a personality construct, screening during entry to the medical school becomes vital. Emmy Werner conceptualised resilience as a fluid process, which is built through constant interaction with the stressors. Resilient students are more friendly, responsible and conscientious [22].

#### **3. Pandemic preparedness**

It is clear from the available literature that the medical students are not aware of the implications of working during the pandemic. The pandemic requires students to socially distance and also to wear masks while treating a patient, which can be confusing and traumatic to someone who has decided to have a career as a doctor and treat patients. Very young and inadequately trained interns and final year medical students being posted for COVID 19 duty might inadvertently put them through premature stress and we might have a generation of emotionally unprepared doctors who are not mentally prepared to face the new wave of the pandemic. More than seventy percent who were in the final year medical program felt that they were unprepared. Inclusion of topics like pandemic preparedness and disaster management in the curriculum is the need of the hour. Training in pandemic preparedness not only includes academic competence but also on logistic challenges faced specifically during the pandemic. Training in logistic preparedness include leadership courses in disaster response, emergency preparedness exercises, and problem based learning [23].

Suitable preparedness also involves awareness about the tools and aids available for maintenance of student mental health. While working during the pandemic,

#### *Stress and Resilience among Medical Students during Pandemic DOI: http://dx.doi.org/10.5772/intechopen.99001*

It is well documented that mental health sequel is equal to physical risk in the frontline workers. The difficult decisions made during the pandemic might directly oppose the moral and the ethical principles of the frontline workers. Challenges in providing the care include apportion of inadequate resources among equally deserving patients. It also includes aligning the duties among patients, family and friends. Providing care for severely unwell patients with the limited and constrained resources is also a challenge. 'Moral Inquiry' is a term used to conceptualise a psychological sequel resulting after witnessing events contrary to the personal beliefs. It includes the feelings of shame and guilt due to inability to have righted the wrong commitment. Medical students experiencing 'Moral Inquiry' due to unprepared exposure to trauma have already been documented [23].

To prevent the adverse mental events it is important to take measures to mitigate the distress. Medical colleges cannot continue to be stressful and lonely places. Newer initiatives and activities need to start happening for fostering an emotionally balanced generation of doctors who are capable of handling stress. Burnout, depression, lessons to take care of their own mental wellbeing and the importance of a healthy lifestyle should be advocated to all students from the beginning [23].

Rigorous programs that can identify and address mental wellbeing of students should start happening from the first year during induction programs. Mentoring is one method of fostering connectivity among the students apart from student support groups. Different year students can face different set of challenges and Stress in different years. Regular feedback and mental wellbeing assessments need to be done regularly for all students of different years so that tailor-made programs can be introduced in depending on the year in medical school for tackling different issues faced by the students. Studies which have attempted to train physician in stress management and resilience with a focus on attention and interpretations found that human attention inordinately and instinctively focuses more on threats and imperfectness. Assisting in cultivating attitudes of delaying judgement, gratitude, forgiveness, compassion, acceptance, and higher meaning: showed decreased burnout, increased mindfulness and quality of life. One of the most effective way is helping students in developing resilience. Resilient individuals believe they are in control of the environment and were able to distance themselves from dysfunctional situations. If we look at resilience as a dynamic process, it is very essential to include resilience-building strategies in the medical curriculum. These strategies include mental health screening, sensitive workplace infrastructure, peer support, focus on diet, nutrition, sleep, and lifestyle. Previous studies report resilience as an independent predictor of life satisfaction. Finally, medical education has to be redefined with more emphasis on building empathy and the inclusion of humanities as part of the curriculum [23].

The importance of physical activity cannot be more emphasised. In a study on physical activity during the confinement due to the pandemic, health promotion and reduction of stress were the most frequent reasons for being physically active in both genders. The men chose it for health promotion and women for reduction of stress. Women adapted their pattern of physical activity to the confinement better; they involved in doing strength exercise, HIIT and mind–body activities more than men did. In addition, more women than men enjoyed doing physical activity more during than before the pandemic. These results should be considered to promote physical activity whether strict restrictions of movement are imposed or not [24].

At the administrative level, mental wellbeing and emotional health should have stringent guidelines, adequate staff and a system for medical colleges to implement. This should be made mandatory for all medical colleges with periodic checks. All medical colleges should actively invest, with the required number of staff in the departments of Psychiatry and Psychology for the mental wellbeing of medical

students and bring out successful new generations of resilient doctors. Half-hearted cost cutting attempts at improving resilience of the new generation of doctors will not succeed after the COVID pandemic. Periodic interactive programs on mental and emotional wellbeing should be regularly organised. Training of medical students as gatekeepers for prevention of suicide can be helpful. Reverse mentoring and a platform for students to voice their grievances should be encouraged and started in all colleges. Stringent guidelines against substance use on the campus and periodic awareness programs need to be in place. These guidelines should be brought out by the national bodies that bring out recommendations for medical education, like National Medical Commission in India.

#### **4. Conclusion**

Since we do not have robust data as to what interventions work in helping in aiding Resilience we need to start using interventions in different age groups and studying them instead of waiting to find a meta-analysis which will give us a magic pill. We need to prepare to cushion the psychological well-being of a few generations of children that have had no adequate social contact because of lack of school. They were witnesses to prolonged lockdowns and deprived of play in natural areas. The most common reason for anxiety in a child may be a parent and this will be crucial in the assessment of the child and there needs to be interventions done for the parent, it might require a multidisciplinary approach [25].

Mental health specialists in most countries are lacking in numbers so how governments will mobilise balance advocacy activism and implement basic needs for mental health of a population will be an uphill task [26–30].

Resilience needs to be addressed keeping in mind culture ethnicity and religion in different countries as there may be different factors that may aid in Resilience in different cultures.

All ethical workplaces and universities dealing with students should have regular periodical assessments of students and the workforce for psychological well-being and burnout. They should take the guidance of local mental health experts to do this in a methodical way. National bodies of Psychiatrists and Psychologists should come out with timely recommendations and guidelines for such evaluations [31].

Three levels of response are required to address the ever-increasing stress among medical students. At the institutional level, it is the responsibility of the administrators to help promptly, appropriately, and sensitively. The institutions should also make sure that training is not stressful and should include steps to help students look after themselves. At the individual level, students should learn to look after themself and their well-being. Designing a curriculum that includes looking after oneself during stress is very crucial. The third level of regulation includes making intervention available, accessible for the needy.

*Stress and Resilience among Medical Students during Pandemic DOI: http://dx.doi.org/10.5772/intechopen.99001*

#### **Author details**

J. Shivananda Manohar\*, Rajesh Raman and Bindu Annigeri Department of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

\*Address all correspondence to: drshivman@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 20**
