Context
The impact of the COVID-19 pandemic on the mental health of the general population in the Islamic Republic of Iran has been profound. This narrative focuses on the experiences of individuals who have lost loved ones to COVID-19. Grief, a natural response to loss, becomes even more challenging during these trying times. Acceptance of the loss is the ultimate stage in the cycle of grief. However, the pandemic has presented unique challenges that affect individuals' ability to cope with their loss. Adhering to the official safety regulations issued by the Ministry of Health, survivors have encountered various situations, including:
Reactions following the death of COVID-19 patients, which put family members in a difficult position due to the fear of virus transmission and the attached stigma.
Grieving and fear of virus transmission during corpse handling, leading to limitations in the burial process.
Prohibition of traditional burial ceremonies, funerals and social gatherings to remember the departed loved ones, in compliance with social distancing regulations.
Family members who were in close contact with COVID-19 patients in their final days had to undergo a mandatory quarantine period of 14 days to prevent the transmission of the virus. This resulted in the grieving family members going through a difficult period of loss and grief with minimal support from relatives and acquaintances.
Challenges
Several challenges were encountered in providing support to the grieving individuals.
Some survivors did not feel the need for counselling sessions, particularly if their lost loved ones were in the elderly age group. They believed that death at that age is natural, although they were unable to perform traditional mourning rituals.
Cultural beliefs in some families led to the notion that enduring the loss and experiencing grief is a natural process that can be managed individually, regardless of its chronic or complicated nature. They did not believe in the concept of pathological grief and considered individuals suffering from grief as loyal, receiving social rewards. Hence, they did not perceive the need for counselling for themselves or their family members.
Fear of virus transmission deterred some survivors from attending counselling sessions at health centers. Although they recognized the need for psychological support, they believed that visiting health centers would put them at risk of contracting COVID-19. This prompted the provision of online counselling sessions, while some families requested group sessions.
Delivering mental health and psychosocial support services (MHPSS) and ensuring continuity
Innovative solutions
To address the prevention of complicated grief among survivors, two interventions were implemented.
Guidelines were developed to assist hospital staff in delivering bad news to survivors while considering emotional, cultural and religious aspects. Additional guidelines were created for divisions responsible for handling bodies and ensuring safe burials, taking into account both safety protocols and cultural sensitivities. Practical arrangements and funeral guidance were provided to individuals and families, considering the restrictions imposed by social distancing regulations. Temporary home quarantine measures were also addressed for those left behind.
Structured psychological counselling services were established for survivors. The objective was to facilitate the grief process and enhance coping with loss. A training package for grief counselling, comprising five counselling sessions, was developed by the Department for Mental Health in collaboration with the Iranian Psychiatric Association and the Iran University of Medical Sciences. Clinical psychologists from the primary health care system, working in health centers, delivered the counselling sessions. Workflows were designed to ensure safety and online training sessions were conducted to enhance the capacity of the health staff. Trained psychologists called individuals and invited them for face-to-face counselling sessions at health centers, adhering to the Ministry of Health's safety standards.
Referral and training of service providers
If at any stage an individual was diagnosed with a mental disorder or deemed to be in a psychiatric emergency, such as being at risk of suicide, they were referred to general practitioners for initial assessment and, if necessary, to a psychiatrist for further evaluation and treatment.
To ensure the provision of effective mental health services, service providers underwent comprehensive training. This training was conducted via two video-conference sessions, each lasting approximately three hours. The trainers consisted of five university-affiliated psychiatrists and clinical psychologists who were actively involved in the development of guidelines and training materials.
The trainees included mental health staff from all 63 medical universities across the country, covering all 31 provinces. Some universities opted to have multiple trainees, particularly those located in larger catchment areas. As a result, certain universities had up to 10 psychologists trained through these video conference sessions. This extensive training aimed to equip service providers with the necessary skills and knowledge to effectively support individuals who experienced mental health challenges during the COVID-19 pandemic.
Lessons learnt
The implementation of psychological counselling sessions yielded valuable insights.
Many survivors lacked social support to express their sorrow and grief, making counselling sessions their only opportunity to ventilate their emotions and find relief. They eagerly participated in the sessions and acknowledged their positive impact.
The counselling sessions proved instrumental in detecting psychiatric disorders and identifying cases of domestic violence and substance use disorders.
Some families required additional services, such as social support or financial assistance, while others sought help to meet their basic needs.
References
Complicated grief: what to expect after the coronavirus pandemic
Grief counseling and grief therapy, fourth edition: a handbook for the mental health practitioner
Grief during the COVID-19 pandemic: considerations for palliative care providers
Prolonged grief and depression after unnatural loss: latent class analyses and cognitive correlates
Treatment of complicated grief
Treatment of individuals with prolonged and complicated grief and traumatic bereavement
