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A severe COVID-19 Case Study: Psychological Intervention as a Part of

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Journal of Clinical Case Studies

Reviews & Reports

Research Article Open Access

A severe COVID-19 Case Study: Psychological Intervention as a

Part of Rehabilitation Programme in a Greek Teaching Hospital
in Athens
Dimitra Siousioura1*, Andreas Asimakos2, Stavroula Spetsioti2, Aspasia Mavronasou3, Anastasia Kotanidou4 and Paraskevi Katsaounou5

1
Clinical Psychologist, Intensive Care Unit (ICU), ‘Evaggelismos’ General Hospital of Athens, Greece

First Department of Critical Care Medicine and Pulmonary Services, Intensive Care Unit (ICU), ‘Evaggelismos’ General Hospital of Athens, Greece, National
2

Kapodistrian University of Athens Medical School

3
Clinical Exercise Physiology and Rehabilitation Laboratory, Physiotherapy Department, University of Thessaly, Lamia, Greece

4
Professor of Intensive Care Medicine, University of Athens Medical School, Intensive Care Unit (ICU), ‘Evaggelismos’ General Hospital of Athens, Greece

Associate Professor of Respiratory Medicine, National Kapodistrian University of Athens Medical School, Intensive Care Unit (ICU), ‘Evaggelismos’ General
5

Hospital of Athens, Greece

ABSTRACT
We report a case study of an adult man with severe COVID-19 who attended Psychological Intervention after prolonged hospitalization in the Intensive
Care Unit, intubation and finally, participation in Rehabilitation Programme of a Greek Teaching Hospital in Athens. To export results, a qualitative data
analysis were collected from Focused Interview, Psychological Intervention based on Short/ Systemic Psychotherapy and a quantitative data analysis
from the Beck Depression Inventory and further triangulation of qualitative and quantitative data took place. The study focuses on the psychology of
COVID-19 survivor patient, in line with complex needs, psychological effects and specific stressors, following a life-threatening disease. In the light
of a therapeutic ‘flexibility’ and finally of a combination of multi-factorial nature of the disease that requires integration and simultaneous exploring
of not only the physical, but also of the psychological needs of the patient.

*Corresponding author
Dimitra Siousioura, 45-47 Ipsilandou Street, GR-10676 Athens, Greece, E-mail: dsiousioura@yahoo.gr

Received: October 30, 2022; Accepted: November 08, 2022; Published: November 14, 2022

Keywords: COVID-19, Long COVID, Psychological Intervention, These symptoms include fatigue and muscle weakness, mental
Qualitative Analysis, Triangulation Method, Depressive mood, health issues (anxiety, depression, sleeping difficulties), cognitive
Intensive Care Unit, Rehabilitation (Rehab) Programme impairment including memory loss and concentration disorders,
shortness of breath, chest pain and poor quality of life [3,4,6,7].
Abbreviations:
I.P.: Intensified Patient Among the factors associated with poor recovery are comorbidities
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, and more severe acute illness [8]. Patients hospitalized, especially
5th Edition, (DSM-5), APA, 2013 those admitted to the ICU and intubated or receiving high oxygen
DSM-IVTM: Diagnostic and Statistical Manual of Mental mixtures, have severe symptoms for several months upon recovery
Disorders [4,9,10]. Advanced age and prolonged hospitalization are predictors
DM: Depressive Mood of poor recovery in patients admitted to the ICU due to respiratory
ICU: Intensive Care Unit failure [11]. Many studies reported physical, cognitive and mental
R. Pr.: Rehabilitation (Rehab) Programme health effects experienced by people recovering from COVID-19
who were several months after hospital discharge [7,12]. These
Introduction include symptoms: of anxiety and depression in 51 of 384 patients
The COVID-19 pandemic has claimed worldwide half a billion of (14.6%) to 367 of 1 617 patients (22.6%); post-traumatic stress
cumulative cases and 6 million deaths and numbers are still rising disorder in 7 of 97 patients (7.2%) to 31 of 100 patients (31%);
every day (https://covid19.who.int/). A significant proportion cognitive impairment in 19 of 29 patients (65.5%) to 138 of 179
of these patients, ranging from 10% in the general population patients (77%); pain in 431 of 1 616 patients (27%); and reduced
up to 76% in hospitalized patients suffer from a diversity of exercise capacity in 392 of 1 692 patients (22%) to 66 of 204
symptoms persisting for 5 to 12 months from disease onset [1-5]. patients (32.3%) [3,13-18].
J Clin Stud Rev Rep, 2022 Volume 4(11): 1-10
Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

10%-20% of people develop COVID-19 experience a variety of The Psychological Intervention:

mid- and long-term effects after they recover from their initial I. Provides care of people who exhibit psychological symptoms
illness. These effects are known as post COVID-19 condition or associated with long COVID experience, due to the extreme
‘long COVID’ [19]. changes brought by the illness in every aspect of their life,
making them different and isolated from the rest of the
A new study suggests that 20% of COVID-19 patients increases the ‘normal/healthy’ population [33,34].
risk of psychiatric disorders (within 90 days). Also, Researchers II. Explores the impact of a life-threatening disease to the
from the NIHR Oxford Health Biomedical Research Centre and psychology of patient’s needs and expectations, after the
the University of Oxford, Department of Psychiatry have reported invasion of a sudden event of disease and finally, after a
that: ‘Sufferers of ‘long COVID appear to experience mental survival of it.
health issues and that COVID-19 survivors are at an increased III. Focuses on the profound human relationship, where the
risk of psychiatric disorders’ [20]. Also, 10% of people, after the Therapist is there to give the patient time and space needed
pandemic of COVID-19 will develop mood and anxiety disorders, to comprehend and, at the same time, feel his psychosomatic
and/or posttraumatic stress disorder (PTSD) (trajectory- based and existential needs [35]. It seems that loss of physical health
approaches that explore clinical effects to “stress and potentially and pain through their stages treat/redefine [32].
traumatic events”) [21,22]. Also, depressive symptoms are IV. Analyses in depth into the emotional exploration of the latent
correlated with the severity of COVID-19 and results from the needs, as well as of the failures in fulfilling these needs,
study by the WHO (2021) enhance the need for deep understanding after the chronic complications of it, permanent functional
for patients with persistent psychological stress and symptoms impairment. Patients with this deficit, like I.P., often feel a
associated with COVID-19 diagnosis [23,24]. sense of inferiority and experience their self as helpless and
unable to control it. At this discouragement state, they become
Early in the course of the pandemic medical associations worldwide increasingly unable to face their problems and isolating
issued guidance emphasizing the necessity of Rehabilitation themselves from every source of support [36,37].
Programmes (R. Pr.) in order to ‘optimize functioning and reduce
disability in individuals with health conditions in interaction with Case Study
their environment’ (WHO Rehabilitation Definition, https://www. A 64-years-old man participated in the study, after his survival from
who.int/news-room/fact-sheets/detail/rehabilitation) [25]. Even COVID-19, at the Department of ICU of ‘Evaggelismos’ General
after discharge from Rehabilitation Programmes (R. Pr.), post Hospital in Athens. He was diagnosed with severe COVID-19 (Post
COVID patients suffer from significant reduction in physical COVID-19 symptoms assessed by the CAT) and after a prolonged
function, and the ability to perform daily activities [26]. The hospitalization at the Department of ICU of ‘Evaggelismos’,
National Institute for Health and Care Excellence (NICE), the eventually he recovered [38]. Then, he referred to 8-week period-
Scottish Intercollegiate Guidelines Network (SIGN) and the Royal Rehabilitation Programme (R. Pr.) (after-effects of COVID-19/
College of General Practitioners (RCGP) in the UK defined this post hospital discharge) of ‘Evaggelismos’, for 2 sessions per
cluster of symptoms persisting for more than 12 weeks as ‘post- week. The (outpatient) R. Pr. is an integrated multidisciplinary
COVID-19 syndrome’ [27]. The latest ERS statement integrates assessment and care from recovering of COVID-19 and includes:
these definitions to describe patients with ongoing symptomatic supervised exercise training, education, breathing control, dietary
or post COVID syndrome using the term ‘long COVID’ [28]. advice, and Psychological Intervention (3 extra sessions). He
Also, guidelines of Evidence Based Medicine’s guidance on post- remained intubated 2 months period and after that endotracheal
infectious syndromes is useful for treating long COVID [29,30]. tube caused him discomfort, asphyxiation and inability to talk.
Many studies reported that long mechanical ventilation causes
The diagnosis of a sudden life-threatening disease, like COVID-19 difficulties in the patient’s ability to return to daily activities, 1
and after long COVID symptoms, causes fear of the unknown, year after the ICU hospitalization [39,40]. Especially, a study
of the unpredictable and finally, fear of death. In other words, it with patients aged 60 years and above, refers negative change
causes weakness not only on the physical but also on an emotional in health –quality of life, in 57 of 106 patients (6 months after
level. The unpredictability of the disease and the urgency of hospitalization because of COVID-19) [41].
treatment lead to feelings of loss at all levels. Long COVID often
refers to physical/functional deficiency. It is a multi-factorial Thus, long COVID symptoms had affected negative his ability
burdening disease, proportional to its nature, i.e., to physical and for daily activities and tasks, like shopping, fishing, jogging,
psychological factors involved. Patients are imperative to acquire a even one year after infection and at the same time loneliness,
new lifestyle, quickly and directly. They feel deprived of health, old anger and self-isolation arising from it. Long COVID symptoms
ways of behavior, undisturbed sleeping, pleasurable activities, as were traumatic stressors, rendering him passive and weak. This
well as other losses which are expressions of the previous healthy is because as he tried to adjust to the disease all alone, without
self. So, the primary goal of any form of psychological intervention support of his family members, he often quitted from engagement
and psychotherapy is to increase tolerance to ambiguities of the with emotional and social aspects of his life, and eventually loses
disease and finally, accept it (low frustration tolerance) [31,32]. control of it. The patient’s demographic and clinical characteristics
are presented in Table 2. He signed an inform consent and his
So, the aim of the following case study is to investigate all these participation in the Psychological Intervention, as a part of R. Pr.,
psychological stages and challenges, after COVID-19 diagnosis was based on his personal request. He refused to take medication
and long COVID symptoms on an adult man. He participated in for depression (medication-free depressed patient). The study was
Psychological Intervention, as a part of Rehabilitation (Rehab) approved by the Scientific Council of ‘Evaggelismos’ General
Programme voluntary, after long hospitalization and 2 months Hospital in Athens, Greece and was registered at ClinicalTrials.
intubation in ICU of the Department of ‘Evaggelismos’ General gov PRS (ID: NCT04935437).
Hospital of Athens. Psychological symptoms had been present before his participation
in R. Pr. (Table 4). The patient also was informed that:

J Clin Stud Rev Rep, 2022 Volume 4(11): 2-10

Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

a. The Therapist was Clinical Psychologist, specialized in Reason for Referral Rehabilitation Programme:
Clinical & Health Psychology, supervised by a mental expert Psychological Intervention (3
in Liaison Psychiatry & Psychology [42]. Some important sessions/ patient’s own request)
characteristics of the Therapist are presented in Table 6. Social Network No friends
b. He should give information, through a self-report, Beck
Depression Inventory, for his emotional- depressive state, Currently Living with His wife
before R. Pr., after R. Pr., and follow-up (1 year later) Family ‘Role’ The ‘weak member’ after
assessment [43,44]. He also was informed that the Focused COVID-19
Interview involved psychological effects of COVID-19 in Physical Activity Reduced exercise capacity
his everyday life [45,46].
Acute COVID-19 characteristics
c. The regulations of the psychotherapeutic process were:
confidence, free associations, as catharsis and non-guided Intensive Care Unit Admission 3 months
topics of discussion [32,47,48]. Intubated 1.5 months
Endotracheal tube 1 month
Table 1: Characteristic Phrases of Patient (I.P.)
Rehabilitation Programme 2 months
Phrases
Long/Persistent COVID-19 Peroneal nerve palsy in the right
‘Many nightmares and fears, like that: they didn’t give me water, I Symptoms foot
saw someone outside the door, an enemy… they build my Knees…’
Muscle weakness
‘Septic Shocks led me to a depressive position and traumatized
me… I accepted that I’m going to die Impaired mobility and ability
to carry out activities of daily
‘I was often irritable and get nervous because I had lost loved living
activities, like fishing, joking…’
‘I feel sad when I think that I was near the death’ Table 3: Characteristic combined Techniques in COVID-19
‘Doctors, all medical team supported me, replaced my family…’ patient (I.P.)
‘Doctors, all medical team supported me, replaced my family…” Techniques
“After COVID-19, I’m the weak member at home’ The Technique of ego strengthening: patient healthy personality
‘When I have negative thoughts, I want to underestimate myself…’ traits are detected and then utilized as support frameworks (to
family, friends, partner, colleagues, and groups). Also, the important
‘Before COVID-19, I was immersed into the problems of my wife attributes in everyday life are reassessed to distinguish from the
and daughters and I was losing control; I need to find myself’ unimportant, and patient’s priority in life are arranged [32].
‘Only people who love will stay by your side…’ The Technique of reframing and rational reasoning: patient’s history
‘Family isolation hurts’ is presented along with an alternative [102] and understanding
the self and significant others [103]. Reframing is “a common
‘I realized the value and the gift of life and I appreciated essential
technique of all-systemic-family approach models”, and aims at
things, such as health.’
the presentation of an alternative-positive side of problem of the
‘COVID-19 reminded me that there is life for me out there.’ particular disease [69]. Emphasis is placed on factors contributing
to psychosomatic health of the patient, due to the challenge of the
Τable 2: Demographic and Clinical Characteristics of Patient physical illness [38]. As in enhancing the expression of all emotions
(I.P.) that precede the disease and in investigating them, as well as healthy
personality traits that are exploited as backups for the development
Parameter Value of personality. Their recognition functions as a positive motive
Sex Male against the sense of helplessness, caused by the disease, reinforcing
the sense of self-control and power in life.
Age 64
The Technique of self-transcendence [37]: the difficulty and pain
Nationality Greek
caused by the disease is regarded as an opportunity for personal
Level of Education College-Technological school development. Existential quests that emerge due to the disease
Occupation Retired policeman for the meaning of life, transience and death, play an important:
therapeutic role.
Marital Status Married
The Technique of the fighting spirit [104]: this technique has been
Children 2 applied to cancer treatment. It focuses on the personal meanings of
Medical History No history of other disorders the disease and at the same time on the patient’s mobilization for
No history of antidepressant the disease crisis management, improving motivation to fight, will
or other therapy No previous and quality of life [105]. The expectation for greater control over
history of psychiatric disorders decisions for patient’s lives is encouraged by addressing the “here
and now” reality and the optimism, targeting a normal life.
Diagnosis Severe COVID-19
Mental Health History No history of other disorders.
No history of antidepressant
or other therapy No previous
history of psychiatric disorders
Current Problem Psychological - Moderate
Depression as a process of grief
and adjustment to COVID-19
and long COVID symptoms

J Clin Stud Rev Rep, 2022 Volume 4(11): 3-10

Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

Table 4: Patient’s Psychological symptoms Materials & Methods

Symptoms I.P. was evaluated before R. Pr., after R. Pr., and 1 year later (follow-
up) (Table 5). Analytically, the characteristics of methodological
Psychological Symptoms
tools used for the collection of the data and the analysis were:
• Anxiety, worry and fear: his responses to stressors, within in
2-3 months of the onset of long COVID symptoms (serious
health issues that increase disability: permanent physical Focused Interview (3 sessions): The Focused Interview is
impairment) a research-methodological tool with a large range of forms
• Insomnia applications and it is widely used in qualitative research [49-51].
• Difficulty concentrating The interviewee is free to express their own subjective experience
• Low and Depressive mood is another response to above in whatever way wants on the condition of the disease, which the
stressors: hopelessness, feeling isolated, loss of self-esteem, interviewer communicates early in the procedure [49,52].
sadness, crying, lack of joy from previous pleasurable things
• Irritability Focused Interview to the I.P., before, after and 1 year later
• Lack of Motivation [106]
(follow up) participation, in R. Pr., was conducted by a Clinical
One or both of these criteria exist: Psychologist, specialized in Health Psychology, and took
• Distress that is out of proportion with expected reactions to the place in the hospital setting of the General Hospital of Athens
stressor ‘Evaggelismos’ (where she works) [49]. The material of the
• Symptoms must be clinically significant – they cause marked interviews is subject to qualitative analysis and is discussed with
distress and impairment in functioning
• Distress and impairment are related to the stressors and are not
a supervisor/ mental health specialist to increase objectivity. The
an escalation of existing mental health disorders content analysis of the I.P [53,54]. answers from the Focused
• The reaction isn’t part of normal bereavement Interview is based on Grounded Theory Methodology which its
• Once the stressor is removed or the person has begun to adjust objective is to exhaust all possible thematic categories (theoretical
and cope, the symptoms must subside within six months. frameworks) of the initial data (interview answers) [55-59].

Reference: The DSM-5 defines Adjustment Disorder as “the The main feature of Focused Interview that differentiates it from
presence of emotional or behavioral symptoms in response to an other types of interviews, is that it conducts an analysis of the
identifiable stressor(s) occurring within 3 months of the onset of patients’ situation, in a warm relationship between interviewer and
the stressor(s)” (American Psychiatric Association, 2013). interviewee, changing the nature of the relation from investigative
Reference: DSM-IVTM, 1994; DSM-5, APA, 2013, F. 309.0: to humane [60]. Also, rapport is a significant factor for the course
Adjustment Disorder with Depressed Mood (subtype). Specifically, of the interview [45,61].
this subtype is precipitated by an obvious stressor, cause distressful The criteria of the interview were the following:
symptoms, and are time-limited. a. the interviewer ought not to guide in order to allow the
participant to answer at will [62].
Table 5: Materials and Methods b. the depth and personal framework should be revealed by the
Tools interviewee through emotional and basic parameters of the
answers in order to determine if the experience is of central
Before R.PR. After R.PR Follow-up or peripheral importance
(1 year later)
c. the idiosyncratic associations, beliefs (thus assessing the
Focused x x x subjective dimension in the particular situation/ disease)
Interviews and ideas are to be extracted with regard to the needs and
Beck x x x experiences of each patient [63].
Depression d. it is necessary to cover predefined issues and thematic
Inventory categories as a point of reference and since the study refers
Psychotherapy x x x to a type of patients (clinical interview), (disease- oriented
Process and clarification questions about the situation of the disease)
and e. active listening, achieving balance between speech and
Table 6: Psychological Intervention listening, per patient [61].
Characteristics of Clinical Psychologist/Therapist
The following are some characteristic questions [53,55]:
Considers the patient as a unique personality with psychosomatic – What was the course of your adjustment to COVID-19?
needs.
– Do you identify any inappropriate extreme behaviors in
Performs active listening to the patient’s needs and wishes that are COVID-19 self-care?
related not only to COVID-19 but also to life in general. – How do you manage stress in your everyday life?
Contributes to a therapeutic relationship based on support instead of – Are you afraid of long COVID symptoms?
interpretations. – How does COVID-19 affect your body and self-image?
Reinforces the expression of COVID-19 experiences, as well as – Do you believe that long COVID symptoms affect the quality
verbalization of persistent and exaggerated negative beliefs or of your life?
expectations, to which the patient resists (DSM-5). – What role do you have in your own family, after COVID-19?
Encourages deep understanding of COVID-19 and its impact in his – What changes had made in your everyday life because of the
life, as this contributes to reality testing instead of idealizations. invasion of COVID-19?
Reinforces individualized responsibility, not only towards his Beck Depression Inventory (BDI) (self-report): standardized
disease, but also towards the patient’s everyday life.
in Greece for men and women. Self-report completed in 10
Explores the impact of family dysfunction in his depressive mood. minutes [43,64,65]. The inventory is consisted from 21 ITEMS,
and scores>10 meet the threshold for a diagnosis of depression,
J Clin Stud Rev Rep, 2022 Volume 4(11): 4-10
Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

with total score from 0- 63, as seen in Table A, Appendix A. & Table A: Appendix A: 21 items of BDI
in Table B, Appendix B. Many references confirm its reliability Items of BDI
and the validity for the measurement of Depression [66].
Sadness
Psychotherapy Process (3 sessions): Psychological Intervention Pessimism/Discouragement
started in the beginning of R. Pr. of 2021 and the meetings took place Sense of Failure
at ‘Evaggelismos’ General Hospital. The patient’s participation
Dissatisfaction
in the intervention was based on his own will. For the purpose of
maintaining confidentiality, names and records have been changed. Guilt
The procedure lasted 3 sessions (Characteristic Phrases of the Experience of Punishment
Patient) (Table 1), and Psychotherapeutic Techniques based on Self-Dislike
Short/ Systemic Psychotherapy. “Time” of past, present and future
in Short/ Systemic Psychotherapy and its interplay and relation to Self-Accusation
the “story” of the patient (I.P.) of the present case study may led Suicidal Ideation
him to realize the disease and the everyday life with “new eyes” Crying
as seen in Table 3 [67-71].
Irritability
In the meantime of R. Pr., the I.P., according to his choice, enters Social Withdrawal
the sessions. Therapist adopts/ constructs a positive approach of Indecisiveness
patient’s past history and memory. In other words, creates new Unattractiveness
‘stories and messages’ with positive aspects, introducing new
possibilities for change into a negative past of I.P. Thus, through Work Inhibition
‘hypothetical questions’is allowed to change his present depressive Insomnia
state to a “fresh attitude and interpretation of his past” [67,71,72]. Fatigability
For example, the following are some questions: ‘If you changed
Loss of Appetite
your ‘weak character’, what kind of limits would you have with
your own family, today?’, ‘If you learn to believe in you with all Weight Loss
your special characteristics, are you find new balances?’, ‘If you Somatic Preoccupation
know what you want in life, what your defences are?’, ‘If you
Loss of Libido
accept all parts of yourself, how could you cope/ manage, even
long COVID symptoms?’.
Table B: Appendix B: Scores of BDI
Therapist also explored mostly his feelings about the ‘facts’ and Scores Diagnosis
traumatic stressors, how his personality characteristics and family 0-9 Non Depressed
relations had contributed in these areas: 10 - 15 Minimal Depressed
a. his strength to support what earlier was presenting himself
with guilt, 16 - 19 Moderate Depressed
b. his willingness to leave from others’ shadow, put his own 20 - 29 Serious Depressed
terms/priorities, and 30 - 63 Major Depressed
c. his expectation to look deep inside him in order to leave from
weakness, not only on physical but also on an emotional level. Psychotherapy Process (3 sessions): Psychological Intervention
Moreover, therapeutic phases were formed according to the started in the beginning of R. Pr. of 2021 and the meetings took place
Sessions’ agenda: at ‘Evaggelismos’ General Hospital. The patient’s participation
a. Personality traits and coping with COVID-19: a bidirectional in the intervention was based on his own will. For the purpose of
relationship. maintaining confidentiality, names and records have been changed.
b. Patient’s personal and family history and the course of his The procedure lasted 3 sessions (Characteristic Phrases of the
adjustment to COVID-19 [73]. Patient) (Table 1), and Psychotherapeutic Techniques based on
c. Anxiety and fear of long COVID symptoms. Short/ Systemic Psychotherapy. “Time” of past, present and future
d. Fear of death and COVID-19 [70]: emphasis on “insight and in Short/ Systemic Psychotherapy and its interplay and relation to
emotional tone of the session - emotions are the golden route the “story” of the patient (I.P.) of the present case study may led
to change” [74]. him to realize the disease and the everyday life with “new eyes”
e. Self, illness and life priorities. as seen in Table 3 [67-71].
f. Medical staff, support/ communication skills and treatment
compliance [75]. In the meantime of R. Pr., the I.P., according to his choice, enters
g. Redefinition of the disease [76]. the sessions.
The following are some of combined Techniques in COVID-19, as Therapist adopts/ constructs a positive approach of patient’s past
a part of Psychological Intervention, applied to the I.P. (Table 3). history and memory. In other words, creates new ‘stories and
messages’ with positive aspects, introducing new possibilities
for change into a negative past of I.P. Thus, through ‘hypothetical
questions’is allowed to change his present depressive state to
a “fresh attitude and interpretation of his past” [67,71,72]. For
example, the following are some questions: ‘If you changed your
‘weak character’, what kind of limits would you have with your
own family, today?’, ‘If you learn to believe in you with all your

J Clin Stud Rev Rep, 2022 Volume 4(11): 5-10

Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

special characteristics, are you find new balances?’, ‘If you know The characteristics of the relationship between health-care
what you want in life, what your defences are?’, ‘If you accept professionals in R. Pr., intensivists in ICU, Therapist and the
all parts of yourself, how could you cope/ manage, even long patient (I.P.): His compliance to treatment plan was positive
COVID symptoms?’. (interest and acceptance to apply the suggested recommendations).
Moreover, his participation in R. Pr., was a result of a tailored
Therapist also explored mostly his feelings about the ‘facts’ and dynamic relationship with clinicians, intensivists and the Therapist
traumatic stressors, how his personality characteristics and family rather than a static process. When health-care professionals
relations had contributed in these areas: categorize patients as uncooperative or resisting treatment, they
a. his strength to support what earlier was presenting himself indirectly contribute to non-compliance. Thus, it is necessary that
with guilt, experts are not judgmental but sensitive to patients, and to promote
b. his willingness to leave from others’ shadow, put his own compliance with recommendations and care for patients’ health,
terms/priorities, and implementing strategies, like: self-observation, reinforcement,
c. his expectation to look deep inside him in order to leave from listening, empathy, encouraging support from group interventions,
weakness, not only on physical but also on an emotional level. and negotiation of the therapeutic plan with active and mutual
Moreover, therapeutic phases were formed according to the patient engagement (patient-centered care) [82,83].
Sessions’ agenda:
a. Personality traits and coping with COVID-19: a bidirectional Psychological characteristics of the patient (I.P.): he had
relationship. some personality traits that were responsible for his difficulties
b. Patient’s personal and family history and the course of his in managing everyday activities [84]. So, they lead him to burnout
adjustment to COVID-19 [73]. expressed by stress, alertness, anger, insecurity, brought by the
c. Anxiety and fear of long COVID symptoms. disease and even “masked”/depressive symptoms which often
d. Fear of death and COVID-19 [70]: emphasis on “insight and occurred with somatizations and crying (complex psychological
emotional tone of the session - emotions are the golden route needs of I.P., long after recovering from severe COVID-19)
to change” [74]. [32,80]. He didn’t know any other healthy way, other than through
e. Self, illness and life priorities. the above negative symptoms. Many patients under intense stress
f. Medical staff, support/ communication skills and treatment tend to behave in aggressive ways. Also, he was being vulnerable
compliance [75]. because of an existential shock: he experienced fear of impending
g. Redefinition of the disease [76]. death, a borderline feeling. This psychological burden was
The following are some of combined Techniques in COVID-19, as presented to all sessions, as even trauma, due to the serious and
a part of Psychological Intervention, applied to the I.P. (Table 3). threatening disease and long length stay in ICU.

Procedure Depressive reaction to the diagnosis of COVID-19 and

In the present case study, a research strategy of Triangulation treatment of long COVID symptoms: Beck Depression
between the different methods took place, using qualitative tools, Inventory (BDI) shows: he was moderately depressed before
such as Focused Interviews and Psychotherapy sessions combined R. Pr. and Psychological Intervention. Depressive mood and
with quantitative tools, such as Beck Depression Inventory. The somatic factors (fear of death, illness) are consequence of a process
data collected were analyzed in order to identify common findings. of adjustment to an infectious disease, like COVID-19 and long
Triangulation is a multi-method research approach of human COVID symptoms which are very challenging stressors [85-
behavior, which increases confidence in the final research findings 88]. Depressive mood (loss of pleasure and physical activity,
[77-79]. Also, it helps to compensate the potential weaknesses of feeling of worthlessness, insomnia, poor concentration, agitation,
each tool separately [77,78]. Moreover, Triangulation describes the obesity) and his sadness feeling (affective factor) developed long
use of various methodology tools for measuring a phenomenon, after his hospitalization when he begun to realize the demands
like a disease, aiming at the reliability and the validity of a study of long COVID symptoms. Specifically, depressive mood was
and is particularly effective, when a case study is investigated present –for a short period- before his participation in R. Pr and
[45,78,79]. in the initial phase of diagnosis, he goes through the typical stages
of grief [32]: a. denial and anger identical with injustice and
Results dysfunction brought about by his sudden disease, b. depression
Significant correlations came up, which can be divided into the as a process of adjustment to the disease and c. acceptance as an
following areas: emotional process of multiple stages, depending on the stage of
life, the demands of the disease and the individual’s personality
Treatment compliance: plays an important role to the degree to traits, in general. Many patients redefine it as a blessing [89,90],
which his behavior was in line with the instructions of clinicians self-awareness and thankfulness for life. When the individual
and the Therapist of R. Pr., regarding regimen, consistency, proper undertakes personal responsibility, the disease is incorporated into
nutrition, exercise, managing stress and traumatic stressors (through the individuals lifestyle and the burden is reduced [91].
psychotherapy sessions). Before the participation in the R. Pr.,
his psychological difficulties were apparent and manifest: a. with Discussion
lack of interest, hopelessness, helplessness brought by permanent The course of adjustment to the complications of a serious disease,
deficiencies of long COVID symptoms, b. with prolonged stress, like COVID-19, is often damaging with potential effects, not only
c. with intense stress caused by accumulative psychosomatic at an organic, but also at a psychosomatic level. The urgency of
parameters involved in disease treatment. After it, these feelings treatment and life change undermines the structure of the ego.
transformed into hope, relief and positive expectations through There is no longer the “whole” person as the disease caused
identifications with clinicians and the Therapist (therapeutic physical failure [32]. Being aware of the difference (the identity
insights) [80,81]. of the previous healthy individual) points out the loss of the
previous identity and shakes self-esteem. Charmaz believes that
chronic complications of a serious disease, create the world of
J Clin Stud Rev Rep, 2022 Volume 4(11): 6-10
Citation: Dimitra Siousioura, Andreas Asimakos, Stavroula Spetsioti, Aspasia Mavronasou, Anastasia Kotanidou, et al. (2022) A severe COVID-19 Case Study:
Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

chronic disease, an inner natural “world” of the experiences of [99]. Thus, the disease becomes a driving force for a deeper
the disease, in contrast to the world of healthy [92]. Many mental understanding of the self and others (illness as moral occasion),
problems had emerged, after the outbreak of COVID-19 and long which mobilize sources of power to manage the difficulties [100].
COVID symptoms which are needed planning of Psychological Finally, instead of fear of death, he was thankful because he had
Interventions for acute life events, like health emergencies [93]. a 2nd chance to life and celebrates it [101]. He was a survivor!
Mental health clinicians working with life- threatening diseases
So, people with a history of long COVID symptoms develop and demanding environments, such as Covid-19 and long COVID
often somatic handicap, like the patient (I.P.) of the present study. symptoms, could include multidisciplinary teams in order to intake
This permanent stressor put him into greater risk for developing patients who have:
adverse psychological symptoms. a. some pathological personality traits [84].
b. possible psychopathology
More specifically, before his participation in R. Pr., he was c. are ‘at high risk of developing persistent neuropsychiatric
moderately depressed (Table 7), the most common clinical disorder deficits following recovery from acute disease’ [102].
in patients not only with long COVID symptoms, but also with d. pre/ COVID-19 risk behaviors, such as smoking, lack of
other chronic physical illness [32,94]. In the initial phase of long exercise and of healthy diet
COVID symptoms, his depression mood was a process of grief e. overreact to stress (stress-reactive coping styles) and develop
and adjustment to the disease which- if present for long periods- negative emotions in stressful situations, leading to loss of
needed treatment [85]. His personal history of a threatening disease self-control (distressed personality) [32].
disease, such as severe COVID-19, long length of hospital stay
(ICU), intubation, endotracheal tube, and problems in his family Over time, patients with a history of serious disease and long length
unity led him to accept the participation in the Psychological of hospital stay, especially in an ICU, like the patient (I.P.) of the
Intervention, as a part of the R. Pr. The psychological burden present study, come across complicated psychological challenges
of these stressors was presented to all sessions in a clear way: and a continuous process of adaptation with a new lifestyle that is
depressive mood due to unresolved mourning, borderline survival not self-evident. Instead, it depends on psychosomatic parameters,
and fear of death. every-day changes and life events. The proposed Psychological
Intervention, as a part of R. Pr., focuses on this evolving process
Table 7: Results of BDI and simultaneously investigates the sequence and links of all
Results these intermediate psychosomatic variables, relationships and
emotions with the final therapeutic outcome. So, in the present
Before R.PR. After R.PR. Follow-up
study, our aim was to:
(1 year later)
a. present and analyze in depth all these stages and therapeutic
18 (M.D) 11 (MI.D) 4 (N.D) processes, accompanying the diagnosis of a severe COVID-19
and long COVID symptoms of an adult man,
Furthermore, within his family context (wife and 2 adults b. explore his emotional reactions, long after the diagnosis of
daughters), there was severe dysfunction. There wasn’t emotional COVID-19 (when he begins to realize the reality and starts
interaction and support between them. Family context is related the process of adjustment), with emphasis on depressive
with the disease, as a powerful health predictor, because it mood, as a consequence of the above processes, and
functions as a motive for effective self-care of disease (physical c. recommend Psychological Intervention as an integral part of
activity, healthy eating, reduction of smoking), reinforces will Rehabilitation Programme for COVID-19 patients because it
and reduces patients’ grief [95,96]. Instead of the above stressful combines medicine- that is the realistic aspect of the illness-
situation, he managed to build positive interactions between him with the psychology of the individualized patient needs, as
and health-care professions, as a substitute of his family. They well as the idiosyncratic patient manifestations. The above
related with a therapeutic target with his demands and priorities, integration not only contributes to effecting management of
indicating in that way an aspect of therapeutic relationship with the disease but also to quality of life, which are neither self-
him. In this sense, on one hand, he could express his needs even evident nor self-regulated.
in question of health changes, while on the other hand, he stressed
the need for a collaborative/human medical relationship, able to Finally, further new evidence is required about long COVID,
optimize the final therapeutic outcome. since is still “enigmatic”. And research must continue about the
combination of psychological with the caring of medical aspects of
Through psychotherapy sessions, he realized the importance COVID-19 and long COVID symptoms, not only in ICU, but also
of redefinition of his disease (based on pre/existing healthy in multidisciplinary Rehabilitation Programmes (R. Pr.), as well.
personality traits). He stated that his survival from COVID-19
led him to positive feelings that he always had, such as strength, Acknowledgements
courage and fighting spirit. So, they acted as counterbalance and We thank the patient who consented to participate in the present
as a secondary unconscious benefit, however difficult it may be study.
(reconciliation with the difficult parts of himself, such as his
serious disease). Moreover, realizing his vulnerability, was able References
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Psychological Intervention as a Part of Rehabilitation Programme in a Greek Teaching Hospital in Athens. Journal of Clinical Case Studies Reviews & Reports.
SRC/JCCSR-194.

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