Virtual Short-term Psychodynamic Psychotherapy for Health Care Providers During COVID-19 Outbreak in Iran

At early stages of COVID-19 pandemic in Iran, it became clear that due to first reports of significant mortality rate of patients (1), the whole society and especially health care system workers were facing an unprecedented situation in modern medicine era caused by a contagion. 
With regard to medical job settings, along with physical burdens, conditions made by new environmental threats during the pandemic can increase the perceived and felt stress by health care workers at a rate and intensity possibly higher than for other job settings (2).
Common examples are fear of contracting the disease or death (For the individual or close relatives), feeling of loneliness in quarantine and discomfort arisen from uncertainty of adopting appropriate treatment and caring procedures (in case of responsibility for COVID-19 patients). 
Previous research has shown that perception of stress is the source of onset/aggravation of mental disorders and also is the detrimental causal antecedent to job effectiveness (3,4). 
In this study, a reproducible plan was devised in order to prevent or attenuate debilitating effects of current situation. Psychotherapeutic interventions have shown promising and enduring results for treatment of anxiety and depression (Which are closely tied to stress and job performance), and major types of psychotherapy  do not largely differ from each other in that regard (5-8). For the purpose of intervention, dynamic supportive psychotherapy was chosen which requires that framework and specifics of the procedures/techniques be laid out preferably, based on research-based evidence.
Virtual dynamic group therapy can encompass discussed features and thus be one of the best options for intervention during lock-down periods. Due to limitations of the contagion, therapy meetings can take place on a free online platform and video communications can be transmitted simultaneously.
The procedure and content of a short-term virtual dynamic group therapy are discussed in this paper. This is a product of an action research project conducted by a health care task force which was introduced to improve mental wellbeing of involved hospitals’ professionals at early stages of COVID-19 pandemic in Iran.
Group therapy members consisted of two psychiatrists who were the group therapists and thirteen medical professionals who were working at COVID-19 wards at Iran University of Medical Sciences. They were residents or specialized medical doctors in fields of anesthesiology, neurology, psychiatry, emergency, and internal medicine. At the beginning of the sessions, participants agreed upon the duration of the group therapy and animosity of possible future reports. 
Virtual meetings were held once per week and each for 1.5 hours, starting from March 2020 and lasting for four months. Participants outside the meetings had the opportunity to contact group therapists and discuss important experiences.
In virtual dynamic therapy, two psychiatrists led the discussions focused on the issues which were deemed to be the source of conflict and stress for members. Notable themes which were brought up in meetings are listed in the following section. Moreover, therapists facilitated interactions among group members, observed the emotional responses of the participants and encouraged them to express their feelings verbally in reaction to their own or others’ experiences. Emotional support was the main part but dynamic interpretations were also offered. 
Provided results are derived from assessments which were based on clinical interviews and qualitative means of measurement implemented during the sessions and upon therapy completion. 
Some of the noteworthy addressed themes were as follows: 
-Fear of imminent danger with regard to health of the individual and close ones. 
-Uncertainty about the new viral agent and its contagiousness or required health care procedures.
-Experiencing frequent losses among colleagues and relatives as the pandemic consequences.
-Frustration due to unknown prospect of the pandemic in Iran; awaiting an end that might not come soon was exhausting for members.
-Hopelessness about availability/efficacy of current or future treatments and vaccinations.
-Generalized anger at lack of control over the new situations including mandated or voluntary isolation and being forced into accepting an unwanted lifestyle.
-Feelings of guilt arisen from attributing failures to shortcomings of oneself.
-Adopting pessimistic explanatory style.
-Confronting numerous ethical dilemmas including choosing between protecting the self or serving the society.
With the progression of sessions, participants expressed a gradual advance in coping styles and their attitudes towards the new hardships became more adaptive. Their defense mechanisms also moved away from primitive ones like denial (9).
Participants felt they were members of a friendly group and they could openly discuss their emotional experiences and also share general knowledge about COVID-19 in different specialties, when there were very limited sources of information. As therapeutic factors, the group experienced catharsis, acceptance, cohesiveness, empathy of members towards each other and hope for the self.
After the termination of sessions, participants reported improvements in their social functioning including interpersonal relationships with their co-workers and family members and also in amelioration and recovery of symptoms of anxiety and depression. In addition, members perceived themselves as more able to exert influence over life circumstances and believed they could independently cope with difficulties.
Our results demonstrated that the implemented procedure can be efficient in treatment and prevention of mental disorders during the pandemic and ergo there is merit in replication of it by practitioners.
In addition to symptomatic evaluation, results showed the existence of high group cohesiveness which as a predictor of psychological wellbeing is an indication of treatment success defined by elevating self-esteem and diminishing depression (10).
The fact that after group therapy, participants felt more in control of their lives would demonstrate that their self-efficacy had improved. Previous studies have shown that group therapy for depression would be successful when it improved the self-efficacy of participants (11,12). Self-efficacy is also positively associated with self-esteem (13), which as mentioned was expected to be elevated during group therapy.
It can be suggested that due to limited capacity of mental health care systems, identifying individuals who are at risk of developing mental disorders can ensure that possible interventions are prioritized properly and resources are allocated accordingly. 
In order to make similar interventions cost efficient, a therapy with short duration can be chosen. Researchers who performed discussed group therapy chose a 4-month period. There is abundance of evidence that short-term therapy (both psychodynamic and cognitive-behavioral therapy) can be effective and have long lasting benefits in treatment of depression and anxiety (14,15).
As mentioned, pandemic restrictions left no choice for the researchers but to hold the meetings online. Although this situation underscores the growing importance of tele-psychiatry, it produced some drawbacks. Difficulty in understanding emotions or nonverbal cues in communication, inability to recognize points of visual attention and environmental distractions were among them. 

Funding
No funding to declare.

Conflict of Interest
The authors report no conflict of interest.

Data availability 
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available as they contain information that could compromise the privacy of research participants.