In March 2020 my personal experience of the COVID-19 Emergency, which is - as I write this article - currently ongoing in my homeland, Italy, and worldwide, had completely transformed human social and economic activity and impacted deeply on my family and cultural life. The pandemic had developed 3-4 weeks ahead of what was to unfold in the United Kingdom. At that time, I was writing an essay for the environmental arts therapy post graduate training course, and the pandemic became the most pressing concern for myself as an art therapist. The importance of seeking to examine questions around creativity and nature in relation to social isolation, and the emerging collective trauma, also connects with my professional experience as a psychotherapist and field officer in humanitarian aid and development projects.

In this reflection I will focus on some key concepts: collective trauma, psychosocial support, community-based intervention, psychological first aid, resilience, creativity, arts-based and nature-based intervention.

Art Therapy and Environmental Art Therapy as resources to address collective trauma

Collective trauma can be defined as the psychological reaction to a traumatic event that affects an entire society.In academic literature this term has mainly been applied in the context of natural and humanitarian disasters. It differs from individual trauma, because it implies shared experiences within a group or community, with the permanence of shared memories among people who are survivors, and also among witnesses or in the further generations, who recollect the emotional narration and/or direct effects of the trauma.

Collective trauma is also considerably different from individual trauma, because it always has an impact on the perceived quality of personal boundaries and individual connection with places (both natural and urbanized): bodies, contacts, spaces and places suddenly become unsafe, with a deep sense of identity loss. In the case of natural or humanitarian disasters, people’s habits and routines are suddenly disrupted, and must undergo different rules and unusual behavioral praxis. Many people may experience a disturbing sense of self integrity erosion, community disappearance, sadness or mourning, even when they are not directly exposed to hazards or affected by events. These feelings are often mixed with disbelief, resistance to provisions and rules, suspicion towards other people, social stigma, survivalism, and rage against the system or mass media which are unable to fully inform, advise and protect citizens. As an individual, and as a citizen, one often does not know how to behave safely in daily life, because one does not have any pre-existing parameters to help one deal with this new situation.

According to the World Health Organisation (WHO)(2019) adult emergency-affected populations show a general increase in symptoms of psychological and mental disorders, ranging from the more severe (psychosis and severely disabling forms of PTSD (Post Traumatic Stress Disorder), anxiety and depression) to moderate and mild forms of PTSD, depression and anxiety, as well as distress and individual psychological reactions. The good news is that, in this scenario, collective trauma can be addressed with arts-based and nature-based creative experiences. There is evidence of the use of art therapy in particular in studies related to field interventions after natural and humanitarian disasters. Art and creativity-related interventions can build safe spaces to address collective trauma and build community resilience (even if there is less evidence related to this specific sector of health emergency, due to its rarity).

Ehrenreich & McQuaide (2001: p.78) highlight the possibility of using ‘expressive techniques’ as a range of “techniques which do not require the ability to explicitly label emotional states”, and that can be used in support interventions in case of natural or humanitarian disaster. This kind of intervention can be used over different periods of time, from several days to a year or more after the disaster, both with children and adults who experience difficulties in answering direct questions related to their experience or in describing feelings in verbal form. According to studies related to psychosocial interventions in humanitarian crisis’ (Ugurlu et al, 2016) art therapy activities seem to have a positive impact on anxiety, depression and post-traumatic stress disorder, mitigating their effects and symptoms in daily life, and creating a concrete possibility of relief.

In a case studyPowell & Steiker (2017) conducted in Tuscaloosa, Alabama (USA), after a series of tornados, the authors analyzed the themes that emerged from expressive interventions in schools:

• Creating safety;
• Fear: understanding and coping;
• Anxiety: understanding and coping;
• Sadness: understanding and coping;
• Anger and aggression: understanding and coping;
• Bullying: understanding and coping;
• Self-esteem and taking action;
• Me, my emotions and my community.

Being able to address all these valuable aspects is fundamental for people affected by a disaster because it allows victims to explore the complex range of emotions (both positive and negative) perceived after a trauma, to gradually reinforce personal abilities and the capacity to manage those difficulties, and to build resilience.

The application of Art-therapy and Expressive-based Therapy in disaster relief assistance and counselling is described by Byers (2011), showing how art therapy can foster a sense of healing. It therefore contributes to reducing stressful and traumatic experiences in individuals, and in providing culturally sensitive post-disaster support to the whole community.

It is important to keep in mind that Art Therapy interventions in complex scenarios of natural catastrophe or humanitarian emergency do not usually emphasize art techniques and art materials. There is, in fact, a much deeper focus on the connection between internal/personal space and external /natural space, on the lived experience, on the creation of safe boundaries (habitat), and on the facilitation of a creative process within a basic setting, or in a group. This specific focus offers the possibility, and ensures the effectiveness, of community-based psychosocial interventions to individuals and groups, that facilitate a connection with the habitat and use natural materials to improve connection with emotions, mental health, and a sense of participation and collective empowerment.

How can creativity-focused interventions support the community, during a crisis?

Usually, the net of basic interventions implemented during a disaster or emergency is defined as psychosocial, because the event causes psychological andsocial consequences which interact with each other. Psychosocial intervention includes all actions implemented to strengthen the affected community and to promote resilience in its members, seen as the capacity for coping with distress by positively connecting and supporting each other, and re-building the social system from the bottom up.

The aim of psychosocial interventions has been defined by the Turkish Red Crescent (2008: p.1) “as a body of multi-disciplinary services provided at every phase of the disaster cycle” that aims at:

“preventing any likely post-disaster psychological disharmony/disorder;
restoring and rehabilitating relationships both at family and community levels;
ensuring that people recognize their capacities and are strengthened in the normalizing process;
increasing communal coping/relief/recovery skills in probable future disasters and emergencies;
providing support to relief workers”.

Psychosocial intervention in disaster or emergency scenarios is strongly linked to the specific effects caused by the disaster, to the environment, and to the social, cultural, political and economic systems in which the disaster or crisis occurs. It is therefore necessary to have a culturally sensitive, inclusive, participatory and environmentally adaptive approach, modeling the intervention frame (which tends to be Eurocentric or Western culture-centric) to the local culture and to educational, social and mental health values and practices, both from the point of view of the target groups and of the individuals involved.

“Cultural variations from one country to another and even within a given country may also alter the course and consequences of disaster. They certainly are important in planning a response to disaster … Patterns of family structure in a community and social divisions along class, ethnic, religious, or racial lines may affect patterns of mutual aid (or of mutual recrimination). Different cultural groups have various beliefs about death and injury and about health and mental health and may respond in unexpected ways to outside medical and mental health professionals.” (Ehrenreich, J. H. & McQuaide, S., 2001, p. 6).

In the series of Guides to disaster risk reduction “Stay safe and be prepared”(UNESCO, 2014a), UNESCO experts stress the importance of artistic and expressive activities, as an important way of supporting psychosocial well-being after disasters, in particular with regards to children and adolescents, who may find it difficult to express their emotions verbally, or prefer expressive activities to verbal ones. This could also be applied to traumatized adults, who are temporarily experiencing a lack of ability (or of desire) to verbally express their emotions and feelings related to the event, in particular if the emotions are culturally perceived as negatively connoted or socially unacceptable. Speaking about your emotions through art can create a sort of “safety distance”, allowing the creation of a“narrative about terrifying events, regaining a sense of control and mastery, working through grief, finding and feeling support from peers, and normalizing unexpected and unfamiliar reactions.” (UNESCO, 2014b: p.44)

Creative, Expressive and Environmental Arts Therapy Intervention during a Health Emergency

The outbreak of an epidemic affects daily routines, both in private and in public life. Mental health and psychosocial wellness are hugely impacted. When personal freedom is restricted, the perception of the event is coloured by fear and anxiety, relationships with other people and the environment can be reduced and social behaviour can become avoidant due to emergency measures. When the social system is shaken, a whole community is not able to ensure basic needs and equal rights to all citizens. A “here and now” example of health emergency are the social distancing measures currently in place worldwide.

What can the creative arts offer during and post lock-down?

The social and political response to the current pandemic is profoundly affecting our economic structures, relational norms and social patterns. In the UK, as in Italy and worldwide, mass arts responses have included a huge increase in online choir collectives, professional performers teaching and performing online and the national encouragement to use the visual arts to show support for emergency workers by painting and displaying images of rainbows – a symbol of hope and solidarity.

Counselling and verbal therapies have moved to online sessions, both in public services and for private initiatives. This has become a useful resource for the community, giving access to therapeutic support and care, whilst complying with social distancing. Art therapy online has some crucial differences to verbal psychotherapy, and the article by Sophie Benoit considers the visual arts and digital media in greater detail. During lockdown, not every person has equal access to materials, spaces, resources, technological devices and competences (if we do have this access, it’s our own social, cultural and economic privilege). Furthermore, not every house is a “good enough” place: personal difficulties of staying home range from lack of privacy and calm, to deprivation of freedom of doing and expression, to severe risks in the worst cases. It is therefore fundamental to plan interventions with equity, inclusivity, easiness and minimalism in mind. Minimalism is an accessible threshold, to step into an inclusive creative process in times of crisis: ‘Less is more’, as the architect Ludwig Mies Van der Rohe (1947) said.

To be more effective and useful, art therapy in this context could be designed and facilitated following the relevant principles of Psychological First Aid, as summarized by WHO (2011):

Assessing needs and concerns;
Listening, but not pressuring people to talk about their experience or trauma;
Comforting people and helping them to feel calm;
Helping people connect to information, services and social supports;
Protecting people from further harm.

Suggestions for facilitating experiences and activities

Connecting to natural elements through art, memories and imagination:
If access to outside is restricted due to isolation or social-distancing measures, this can cause distress and suffering. Useful alternatives for connecting to nature through creativity (even if indoors) can be: drawing and doodling nature as seen through the windows; drawing natural elements, as experienced and remembered; listening to recorded natural soundscapes and video with sounds/images; making collages or three dimensional artworks from scraps; journaling with pictures, images and postcards.

Re-creating a safe space with art:
Involves visualizinga calm situation or space, which is familiar and relaxing. Participants can choose a spot in their house, or in its surrounding environment, to recreate the situation or place, using sensory and natural art materials that can easily be found at home or collected nearby.

Collective art making:
This activity focuses on the possibility of simultaneously making art, being creative together, even if not physically in the same place. As it requires access to technology (at least a mobile phone and apps like Zoom or similar), it may not be inclusive and accessible to all people. In Italy, for example, the intercultural Theatre Company ‘Cantieri Meticci’ https://www.facebook.com/cantierimeticcihas set up a project which offers online weekly meetings, open to everyone interested in joining. During the experience, a professional reader shares poetry or narrative texts and people at home freely create artworks inspired by the reading, with the preferred techniques and materials and with the support of the Company’s artists. The participants can then share their work with the whole group, if they wish.

Flash mobs:
In many Countries this touching activity has been spontaneously organized, through social media, by citizens. At a precise time of the day, people looked out of windows and went out on balconies, singing, dancing and playing music. This is a powerful strategy to ‘cry out loud’, sharing and transforming distress in a creative, positive and socially acceptable way. The aim of the flash mob is to create a sense of togetherness despite physical distance. In some places people intended also to express gratitude and support for health-care professionals involved in the response to COVID-19 emergency.

Some of the activities above mentioned could also be used as follow-up practices in the post emergency period, and for risk reduction and preparedness activities. Follow up in post emergency period is vital for community wellbeing. It is in fact demonstrated that the surge of need for mental health support that appears during a disaster does not end with the immediate closing of the emergency, but it spreads along time. During the emergency, people can activate short-term survival responses, which makes it more difficult for them to recognize the emotional and psychological discomfort or to admit the need for targeted help.

Safe outdoor creative spaces for community:
The basic activity that can be facilitated in the post emergency period is the identification or creation of public spaces connoted as safe, where people can gather to simply stay together, play and spend time, or where creative and art activities can be safely set up (such as: groups, workshops). The perception of safety is fundamental in order to strengthen or re-build a community structure. This is a primary action after every kind of emergency, but could have a specific social and relational focus after a health emergency. Setting up creative activities in green outdoor spaces, that allow physical distancing and emotional tuning with natural rhythms, helps to reduce the distress related to the feelings of physical and health threats.

Kite making and kite flying:
This is an art therapy activity which has been implemented in border refugee camps described in the work of Kalmanowitz & Lloyd (2016) to explore the physical and psychological meaning of borders, to serve as a protective factor to enhance resilience and capacity to connect with life beyond the camp, and with the possibility of creating beauty in the present, moving forward to the future. Related to a post emergency scenario, the use of kites may enhance the sense of freedom of movement, helping people who suffered movement restrictions or deprivation.

Shadow Theatre:
Creating stories by using the shadows, in particular the shadow of bodies mixed with natural elements, and simple ordinary objects, can help both children and adults to elaborate emotions and trauma. It also helps persons who cannot use verbal or written communication to clearly express feelings and emotions. Shadow Theatre is a powerful and very poetic expressive language, very easy to use and to understand. The possibility of implementing stable circle-time moments, indoor and in nature, as ritual gatherings for storytelling through Shadow Theatre could be a way to facilitate narration of the difficulties lived during the locked down (symbolized by the darkness of the shadow), but also the positive moments and resources during this period (symbolized by the light and the freedom of creating beautiful compositions with elements).

Participatory Art and Land Art installations in public spaces:
After disasters, art therapists and artists can act as ‘community catalysts’ and create ways for people to gather, to dialogue and discuss, to advocate for rights and needs, to develop emergency preparedness plans, through socially engaged art. Participatory art installations also help to preserve shared memories of the event and create ongoing engagement, in order to keep attention on both needs and resources expressed by the community, after the initial rush of first response and aid. A powerful example of the importance and impact of participatory art in an emergency scenario is the Japanese Project FUKUSHIMA! (http://www.pj-fukushima.jp/en/), that lead to the creation of a festival focused on music and dance, and to the creation of an O-Furoshiki (big wrapping cloth), a giant patch-work made by Fukushima citizens with pieces of fabric, donated from all over the country.

Re-creating a safe space with land art:
This activity implies visualizinga calm situation or space, which is familiar and relaxing. Then people can choose a spot in the surrounding environment to recreate the situation or place, using sensory natural art materials collected nearby. As this activity directly recalls memories of situations and places that may have been impacted or destroyed by the event, the facilitator must be as delicate as possible, in particular when working with recent trauma and severely traumatized individuals. The visualization activity should therefore focus not directly on the story or experience of the individual, but on the story of another creature, such as an animal, a fairy-tale character, or a mythological hero.

Emotional Check-In with Natural Materials:
This practice implies exploring and observing the surrounding environment and choosing some thing(s) that “speaks” or captures the feelings and emotions in the present moment (symbolizing both positive and negative aspects of emotions and feeling). This could be an individual activity or a group activity. In the latter case the best choice is creating small groups (5/6 people maximum) so that each participant can feel safer and more easily express his/her feelings, or provide feedback and support to other group members.

Conclusion

By designing creative arts initiatives during an outbreak crisis, we offer a useful, practical and sustainable basis for helping people and the community to express, reconnect and reflect on feelings and themes such as vulnerability, loss, uncertainty, isolation, fear, survival, guilt and human connection. Arts-guided experiences can sustain the development of coping strategies, individual well-being and community resilience, during and after the lockdown phase. The activities described above can be guided during one-to-one and small group online sessions, or proposed as self-help activities, and are in compliance with the restrictive measures.

When the emergency ends, the disaster’s impact on daily life will become more evident and is perceived as lasting. This can create a wave of discomfort, bringing to light the reactions to trauma which were previously submerged by the need to face the emergency. For this reason, during the post lockdown period, the individual practice of creative arts therapy would be recommended, as it helps in managing intense emotions and post traumatic symptoms. Creative arts can facilitate the rebuilding of a sense of identity and integration of oneself with his/her own story. The arts can also make visible feelings of unity, ecological bonds with others, and reconnection to the natural life-cycle. Sharing creative experiences supports the social cohesion within the community, enhancing the social function of collective shared spaces.

As I write today, here in Italy we are currently at the very beginning of the so called “Phase Two”. That means a gradual loosening of the security measures, towards a more uncertain recovery phase. Concerning my private practice as Psychotherapist and Art Therapist, the emergency bought sudden changes and restrictions that impacted on the relationship with all my clients: some chose not to switch to an online mode, preferring to pause therapy. I see some clients with online sessions and facilitate creative work in distance mode.

My Studio-Atelier is still closed to the public: I am planning to reopen it (and to do so I am currently reorganizing the room, changing some pieces of furniture, to adapt the place to the new regulations on hygiene and safety). In the new setting I will have to maintain physical distance, wear a mask and avoid any form of physical contact. Some clients will not come back, others will. It will be an unpredictable future, and surely it has been strange until now. A client recently told me: “It’s a weird feeling in the beginning, but if we are able to change and adapt accordingly, we can still feel we are here together.”