key: cord-1050590-b78h1vge authors: Renzi, Alessia; Verrusio, Walter; Evangelista, Alessia; Messina, Maurizio; Gaj, Fabio; Cacciafesta, Mauro title: Using drawings to express and represent one's emotional experience during the coronavirus disease 2019 pandemic: a case report of a woman living in a nursing home date: 2020-11-24 journal: Psychogeriatrics DOI: 10.1111/psyg.12638 sha: 95a87640199df57be0649d798b833ba4765ddc6a doc_id: 1050590 cord_uid: b78h1vge nan In 2020, the coronavirus disease 2019 (COVID-19) pandemic has been one of the biggest concerns worldwide and specifically in Italy, the first European country to face the pandemic and all its dramatic consequences. From analysis of 35 563 deceased patients who were positive for COVID-19, official national reports showed that the mean age of people who had died from COVID-19 was 80 years in Italy. 1 Furthermore, 20.1% had two comorbidities and 62.6% had three or more, with the most frequent being cardiovascular disease, type 2 diabetes, dementia, and chronic obstructive pulmonary disease. 1 From this report, it can be concluded that frail older people appear to be at a particularly high risk of contracting COVID-19 and experiencing serious health implications. Accordingly, nursing homes-in which people with physical or mental disabilities, neurological diseases, or older people with different levels of cognitive function live together and interact closely with health-care personnel-represent a context that can be considered at high risk for epidemic micro-outbreaks. 1 For these reasons, the COVID-19 pandemic has required joint efforts to identify strategies and guidelines for infection prevention and control. Primary prevention, especially for older persons with comorbidities, has involved physical distancing and, when possible, isolation. In line with these measures, the Jewish Nursing Home in Rome has made efforts to promote physical distancing and self-isolation and did so even before the lockdown period, limiting relatives' access to the facility on 9 March 2020. However, as the infection rate greatly increased in Italy, so did the restrictions, leading to the suspension of in person rehabilitative activities and psychological counselling and restrictions on the use of common spaces in the nursing home. As a result, many of the traditional strategies for engaging older adults in social and rehabilitative activities cannot occur in their usual modality. Therefore, psychophysical rehabilitation professionals in residential facilities have faced challenges in developing activities that residents can perform in their rooms or with appropriate physical distancing. 2 The ultimate aim is to reduce the risk of loneliness and thus prevent significant negative outcomes, such as depression, cognitive dysfunction, loss of autonomy, cardiovascular disease, and increased mortality. 2 Here, we report the case of an elderly woman (age: 77 years old; Mini-Mental State Examination score: 30; Geriatric Depression Scale score: 6) who spent 3 months in isolation in her room in our nursing home as a prevention strategy during COVID-19 pandemic; this measure was taken as the best possible solution given her immunosuppressive condition. The patient provided informed consent for this report, and her anonymity has been preserved. Before the pandemic, the patient participated in the facility's proposed rehabilitative activities to some extent. She ate meals with the other residents, and she continued to pursue her principal hobby: drawing. During the long period of isolation, she maintained regular contact with her relatives through telephone calls, but her mood slowly began to worsen. During regular psychological counselling sessions by phone, she had difficulties exploring and expressing her feelings verbally. Therefore the psychologists proposed that she resumed drawing as a therapeutic strategy to represent her emotional condition and as way to spend time constructively. Figure 1 features the products of this initiative: three drawings realized during different months of the pandemic. Drawing 1 was made during her preventive isolation period, when no in-person rehabilitative activities were offered, and she could not participate in any activities with other residents (late March-April 2020). Drawing 2 was likewise made during her preventive isolation period, after in-person psychophysical rehabilitative activities had resumed but when shared activities with other residents remained prohibited (late May-June 2020). Drawing 3 was made at the end of her preventive isolation period, after shared rehabilitative and social activities, including supervised visits from her relatives, had resumed with caution (July 2020). In her first drawing, the patient represented exactly what she saw when lying on her bed: the white wall, the window, and the view through the window-the hedge, a perimeter wall at the nursing home, and the vegetation beyond the perimeter wall. She decided to give a name only to this drawing, titling it Beyond the hedge. This first drawing seems to represent her depressive feelings, as reflected by the decision to draw a scenario visible from lying on the bed, where she spent almost all her time. This drawing also seems to represent the distinction between the world inside and the world outside and between the loneliness experienced in isolation and the people spending time together, while physically distanced, outside (outside the room, outside the facilities). It also seems to express hope-hope to be soon outside the room, beyond the hedge, sharing social activities. In her second drawing, she represented a seascape with the sky, the beach, the sea, and the rising sun, but with a big grey skyscraper positioned on the shore partially covering the sun. This drawing seems to represent an initial recovery of her mood, with open space and possibilities; however, some obstacles remain, as represented by the big skyscraper, continuing to limit her life. During the period she created this drawing, the patient restarted in-person psychophysical rehabilitative activities, inside and outside her room, but without any contact with the other residents. Her third drawing seems to be similar to the second one, likewise representing a seascape; the sea is characterized by blue shadows and the surf of the waves. This drawing seems to show a better emotional state, with no obstacles reported. It seems to express positive emotions of serenity and peace. This drawing was created as she concluded her preventive isolation period and began participating in social and rehabilitative activities and sharing meals with the other residents, with caution. Furthermore, she began seeing relatives again during supervised visits. During psychological counselling sessions, the patient discussed these drawings, and they were used as stimuli for exploring her emotional condition during the pandemic to prompt elaboration on the difficulties faced. The use of technology-mediated modes of communication seemed to reduce loneliness only moderately, and as previously reported in a cohort study, older adults with frequent in-person social contact were less likely to report depressive symptoms than those who stayed in touch through telephone or email. 3 Maintaining frequent in-person social contact has obviously been difficult during the COVID-19 pandemic, especially for the most vulnerable populations. Therefore, the development of depressive symptomatology among these groups has not been surprising. With regard to the use of drawinga familiar activity for this patient-it concretely sustained her ability to explore, represent, express, and regulate her emotional condition. This is consistent with the broader literature regarding the therapeutic use of drawing and, more generally, the efficacy of art therapy. For instance, evidence from multiple studies has shown that drawing offers short-term mood benefits for adults. 4, 5 Therefore, this therapeutic technique may be particularly useful in helping patients explore and express their own emotions during a difficult event, such as the COVID-19 pandemic. Furthermore, it may prevent or repair depressive symptomatology, especially among people who must carefully limit their inperson social interactions. Characteristics of SARS-CoV-2 patients dying in Italy COVID-19 and older adults Does mode of contact with different types of social relationships predict depression in older adults? Evidence from a nationally representative survey Short-term mood repair through art: effects of medium and strategy Short-term mood repair through art-making: attention redeployment is more effective than venting We thank the Council of Casa di Riposo Ebraica di Roma (CRER); its President, Barda I.D., the College of Auditors; CRER's Commissioner, Dureghello R.; and CRER's general director, Coi M.. We especially thank the patient who created these drawings and gave her consent for the present report.