A Year after-Could We Move beyond Psychosomatics and Dissociation

Living in a global world that is continuously changing while creating the experience of fluidity, we are losing ground and, therefore, stability. It affects mental health across the life span. During the last 12 months from the first WHO notification of the novel coronavirus 2019-nCoV, humanity started to experience a dramatic change in the level of plans, norms, expectations. Besides fear for personal safety and health, the directed distancing increased the gap in everyday quality of possibilities for personal contacts and support. Losing the ground and experience trembling, we were inevitably facing blurred boundaries, insecurity and a direct attack on our will and who we are. Furthermore, a year after, we realize that we are in the fertile ground for the manifestation and experience of anxiety, panic, and numerous psychosomatic disorders. The whole of humanity is suffering. Hence, those coming from helping professions (psychologist, psychotherapists, social workers) dealing with mental health are experiencing the kick even harder. The research we are conducting is checking their wellbeing a year after.


Introduction
Only being in here and now, the ambush of catastrophic expectations could be avoided. As a result, we assume that we could stay grounded, aware, and dedicated to the Dialog, following the phenomenology of the field, co-creating up to our best what could be co-created, without letting ourselves down, while keeping flexibility and plasticity on the highest level. Now, being in contact with "what is and how it is", what is obvious in front of all of us is that the Covid 19 Pandemic re-created our understanding of the world and invited us to perceive and adjust to the "new reality". The pandemic year painted our world, defined our field. Keeping in mind Parlett's five principles of the field theory: Organization, Contemporaneity, Singularity, Changing Process and Possible Relevance [2] on the one hand, while keeping on the other the general human abilities

The context of here and now during COVID 19 pandemic
Already one year, we are dealing with COVID 19, and it seems that our capacities are torn apart. The context we are living in, and we have to keep in mind, is that the Republic of North Macedonia is passing through a period of transition of more than 20 years, searching for an identity that only results in renaming and constant process of never-ending negotiations. That all created a tension hard to bear among citizens. Besides that, the economic situation is day by day worsening, which creates a mind drain, which during the last five to six years gained the form of an epidemic.
From the phenomenological psychopathology point of view, it could be seen as a very troublesome period, where the state and its citizens were left without proper support after coming to the world as the new entity. The country and its citizens were left to survive, without recognition, and mainly with experience of unpleasant emotion. That is opening the door to panics activated in the separation from affective support (changing state, identity, and being faced with more than a decade lasting war period) while being overexposed to the environment, which is inevitable as a new state [4]. According to the experience from the mental health field, the epidemiological analysis is positioning panic and anxiety attacks as the leading cause for asking for psychotherapy help in the country. It seems that the citizens were living for two decades with exaggerated fear, which is having its peak during these pandemic years.
At the beginning of 2020, faced with COVID 19, all involved mental health practitioners in the Republic of North Macedonia highly dedicated themselves to support the citizens. Besides the Mental health institutions within the system, many Psychotherapy Institutes, as well as NGO's decided to share their capacities with those in need. Among those involved, European Accredited Psychotherapy Training Institute "Gestalt Institute -Skopje" (EAPTI GI-S) created the Action "Call Me # COVID 19". The Action was created to obtain psychological and psychotherapeutic support for those in need. It was offered in two languages, Macedonian and Albanian. All involved practitioners (more than 60) shared their field of expertise with the public, although they accepted all that asked for help and support, directly working with them or resending them to a more appropriate institution. The number of sessions conducted through this Action passed the number of 1000 sessions till the end of 2020. During that period, they received continuous professional education (supervision, training, and personal work).

The research context
The research context is the one that was present in terms of the COVID 19 Pandemic in the Republic of North Macedonia. The information coming from the EAPTI GI-S practitioners from the field was that most of those asking and gaining support were concerned about their lives or the lives of their beloved, with a lot of anxiety present. Besides that, sleep disturbances, tachycardia, a variation on the level of blood pressure, sweating, dizziness were also very much present, and exacerbation of the already present psychosomatic illness like asthma, ulcer colitis, etc. eczema, and some others. In addition, the calls where the basic need is support through the process of mourning were also very often. Compared with the Diagnostic and Statistic Manual of Mental Diseases V (DSM V), all those information clearly pointed to the evitable presence of anxiety disorders and panic attacks.
The DSM V defines a Panic Attack as a discrete period of intense fear/ discomfort that reaches climax rapidly. It is accompanied by strong autonomic arousal, presented by a diversity of somatic symptoms, from palpitations, to accelerated heart rate, air hunger, sweating, trembling, abdominal distress, chest pain, dizziness, etc. The psychological phenomena that could be observed are mainly those of de-realization and depersonalization and fear of death, losing control, and being crazy [5].
Being aware that long-lasting panic states influence our physical and mental health and wellbeing, we started the search for the meaning psychosomatics and dissociation are presented in DSM V.
According to DSM V, we could find that Psychosomatics, Somatization, or Somatoform disorders are missing and replacements for them, too. Namely, in DSM V, they are replaced with Somatic symptom Disorder and related disorders, which means that [5].
Somatization and Pain disorder (from DSM III and DSM IV R) could be seen under the Complex somatic symptom disorder, whilst Hypochondriasis is now Illness anxiety disorder, and Conversion disorder is a functional neurological disorder. The Body dysmorphic disorder now belongs to Obsessive-Compulsive and Related Disorders according to DSM V. Furthermore, the category called Complex somatic symptom disorder is called Complex because of the changes made in DSM-V. In the DSM-IV-TR, instead of the Complex Somatic Disorder, two diagnoses usually overlapped (pain disorder and somatization disorder), and today they are merged in the DSM-V. The pain disorder's primary symptom involves pain, and in the somatization disorder, there are multiple symptoms from various body symptoms [5]. In the DSM-V and there are three criteria to diagnose it. The first criteria are that at least one somatic symptom exists, which is distressing or results in significant disruption in daily life. The second criteria are that excessive anxiety, concern, or time and energy are devoted to the somatic concern. The third criterion is that the duration of the symptoms must be at least six months [5]. The illness anxiety disorder in the DSM-V is corresponding to the category of Hypochondriasis.
People diagnosed with this disorder are fearful since they concern about experiencing serious medical illness, although significant somatic symptoms are absent [5]. To be diagnosed, according to DSM-V, besides the previously mentioned fear, the person must show excessive illness behavior or maladaptive avoidance. In other words, the person must seek reassurance or continuously check for signs of the illness or the other polarity to avoid medical care. The third condition is that the preoccupation lasts at least six months [6]. The third category in the DSM-V is a functional neurological disorder. This disorder involves medically unexplained neurological symptoms. The person develops symptoms that suggest illness related to neurological damage, but medical/biological data show that there are no damages or abnormalities on the level of the nervous system or the level of any of the bodily organs. As it is explained above, the history of psychosomatics starts with this category. The word functional in the DSM-V was used because it is a common medical term for describing symptoms that are not explained by a medical disorder [5].
Dissociation refers to the convoluted psychophysiological process that modifies the approach and accessibility of memory, knowledge, ruins behavior (on the level of integration) and sense of self. According to DSM V, it refers to "a disruption, interruption, and/or discontinuity of the normal, subjective integration of behaviour, memory, identity, consciousness, emotion, perception, body representation, and motor control." Its core symptoms are depersonalization, derealization, amnesia, identity confusion, and identity alteration [5].
Going back to theory of emotion, inevitable is the theory of Walter B. Cannon. According to Cannon the transitory physiological response can be explained through the response of the autonomic nervous system to stress stimuli. He calls these reactions a fight or flight. Cannon and his associates observed body changes in various psychological conditions, especially in situations of danger. When perceiving a threat, instantly there is an activation of the amygdala and it activates the hypothalamus. The hypothalamus simultaneously activates two stress related responses. The first one stimulates the pituitary gland which activates the adrenal gland and causes the excretion of the ACTH hormone. The second stress related response that gets activated by the hypothalamus is the sympathetic nervous system which triggers physiological responses, such as increased heard rate, blood pressure, muscle tension, dilatation of pupils est. This physiological arousal could result further in fight or flight. If the organism stays for a long time in this activation and disturbed balance, consequences are inevitable. These consequences can start with some disturbances, light to mild diseases, disruption of health due to tissue-level damage and, ultimately, death [6,7].
In the continuation, the theory of Hans Salye, states that the consequences of the organism's prolonged activation start in the exhaustion stage of the General Adaptation Syndrome. The general adaptation syndrome is described through three stages: alarm, resistance and exhaustion. With every stage the chances of developing psychosomatic symptoms are increasing.
In the initial Alarm phase, the activation of fight-flight response activates, and with it the physiological arousal starts. This phase is marked by an increase in adrenal activity and all the inducted / consequent physiological changes. In the following phases of Resistance and Exhaustion, the production of corticosteroids by the adrenal cortex first peaks and then diminishes. In the resistance phase the body's reactions return to normal levels, although the body uses the storage of energy. If prolonged, the body enters in the third phase of exhaustion, and weakening of the whole immune system appears [6][7][8].
In the research of O'Connor et. all from 2013, these consequences of the prolonged stress situations were confirmed. Namely, it has been found that the prolonged stress, in this case recalling and writing about strong stress and traumatic experiences led to increased level of cortisol and increased respiratory infection [9].
The neurobiological model stated that there are three regions in the brain that are involved when we are talking about somatic symptoms. Anterior insula, the anterior cingulate and the somatosensory cortex are connected, and these regions are activated by unpleasant bodily sensations. Some people might have hyperactivity in these brain regions which are involved in the process of evaluating the unpleasantness of body sensations and this would explain why some people are more vulnerable to experiencing and noticing somatic symptoms and pain. Except unpleasant bodily stimulus and pain, the anterior insula and the anterior cingulate could be activated by emotional pain. Also, the anterior cingulate is directly related to depression and anxiety. These connections could serve in explanation of the relationship between the emotions and the bodily sensations [10]. The dissociation presents the umbrella concept for the following: • depersonalization/derealization (during these experiences, the reality testing is intact and are not connected to use or abuse of any substance), • dissociative amnesia (frequently consists of localized/selective amnesia for a specific event/s; or generalized amnesia for identity and life history, while notified is compelling impairment in social, occupational, family, and/or other areas of functioning, and it is not connected to use or abuse of any substance), • dissociative identity disorder (characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession), • other specified and unspecified dissociation disorders [11].
O'Sullivan in her book gently touched the connection between psychosomatic illness and dissociative seizure [12].
Being in touch with this, while noticing how what is present in the field overflows toward the helpers, we have decided to check it by conducting the research.

The research methodology
Based on all previously said, we got intrigued to check what is going on the level of tendencies toward psychosomatics and dissociation among the helpers in the field of mental health. Based on the actual need, EAPTI Gestalt Institute -Skopje, among the others, opened the free psychotherapy service for the citizens of the Republic of North Macedonia, both in Macedonian and Albanian. This Action named "Call Me #COVID 19" created high interest among citizens. Some of the mental health workers enrolled in the Action took part in research since the google document shared with those involved and other more senior therapists was open just for 24 hours, all to avoid sample bias.
Namely, the google document that carried psychological instruments used for the research was sent via email to 70 participants, to which 48 replied. At the beginning of the document, a short explanation of the research was given, and Informed consent was presented. Only by accepting it, the participants could continue with the research, posted on the next pages.

Sample
The sample of this research was convenient and was consisted of 48 mental health care workers. Most of them were females (N = 45), while three of them were males. They are coming from different towns covering almost the whole country. Mainly, they were psychologists (N = 23) and psychotherapists (N = 19), although some of them were social workers (N = 5) and special educators (N = 3). Some of them have finished psychotherapy training, while some were still psychotherapy students in training under supervision. The age range of the participants was from 24 to 57 years, with an average age of 33.6 years. Most of them were working online, where 26 of them were working just online, while the other 22 were mainly working in person following the prescribed procedures. When the research was conducted, most of them (N = 38) were not infected by Covid 19, although 20 of them have already experienced the presence of Covid 19 within the family realm.

The research instruments
The HI-test from the KON-6 battery (Kiberneticka baterija konativnih testova) constructed by Momirovic, Wolf and Dzamonja [13], is used for measuring the tendency to psychosomatic reactions. This test has been used several times on Macedonian population. The original language of this test is Serbian, but for the needs of this research, it has been translated into Macedonian, again following the translation procedure by Hambleton [14]. This test measures the efficacy of the system for regulation and control of the organic functions. It has 30 items, and none of them is reversed item. The items are measured on a Likert scale from ++ to --. ++ is 'I completely agree' and -'I completely disagree' . The score can be from 30 to 150 points. A high score shows a tendency to psychosomatic reactions, and low score shows a low tendency to psychosomatic reactions. To measure the internal consistency of this test for this sample, we used the Chronbach's alpha coefficient, which is very high (α = 0.933). That supports the quality of translation too.
The DELTA -test from the KON-6 battery (Kiberneticka baterija konativnih testova) constructed by Momirovic, Wolf and Dzamonja [13], is used for measuring the tendency for dissociation. We do not have information if this test has been used before on the Macedonian population, although the Hi-test from the same battery has been used several times. The original language of this test is Serbian, but for the needs of this research, it has been translated into Macedonian, following the translation procedure by Hambleton [14]. This test measures the efficacy of the system for regulation and control of the regulatory functions. It has 30 items, and none of them is reversed item. The items are measured on a Likert scale from ++ to --. ++ is 'I completely agree' and -'I completely disagree'. The score can be from 30 to 150 points. A high score shows a tendency for dissociation, and a low score shows a low tendency for dissociation. To measure the internal consistency of this test for this sample, we used Chronbach's alpha coefficient, which is very high (α = 0.932). That supports the quality of translation as well.

What do we want to know?
We want to check if there overflows from clients to mental health practitioners after one year of hard work during the COVID 19 pandemics. We tried to prevent overflows from all involved in the Action to go through continuous education, supervision, and personal work. Still, it seems that during the supervision, a lot of overflows was detected. That was the signal point for us to do the research -a year after.
We assumed that due to the continuous support that the practitioners are receiving in education, supervision and personal work, there would not be overflow from those asking for help on those giving help. Our hypothesis was: The mental health practitioners from EAPTI GI-S, engaged in Action CALL ME # COVID 19, will not increase psychosomatics and dissociation tendencies. Hoping that we could move beyond psychosomatics and dissociation since most of our clients are coming exactly with such tendencies, we conduct further analysis of the collected data.

What do we find out?
We find out that the tendencies toward psychosomatics and dissociation among health practitioners from EAPTI GI-S, engaged in Action CALL ME # COVID 19, are in the average, that is approaching the upper grades. Therefore, we are presenting the following findings:  19), we see that the total score on the psychosomatic scale is below the scale mean, which means that our sample consisted of mental health professional does not show high tendencies toward psychosomatic reactions. For the dissociation, we have even lower scores. We read from the table that we even have the minimum possible, which is 30, and that the maximum score is closer to the scale Mean than to the real maximum on the test. This is presented on the mean score as M = 49.92.
The low scores might be explained by the fact that our sample is young, the mean age is 33, and the fact that they have a high education level, specific education into mental health and continuous education. The significance of these findings is of great importance since from this, we see that the mental health professionals are taking care of their mental health so that they can provide services in terms of prevention and healing of their clients/supervisees. We have to remember that we need to put our mask first in case of an aeroplane emergency. With these findings, we see that our participants have their mask on.
We see these lower scores even on the level of the skewness for the scales psychosomatics and dissociation.
The distribution of the scores for both psychosomatic tendencies and dissociation has positive skewness, which shows a higher frequency of the scores on the negative part of the scale, and both are mesokurtic, which shows normality (see Figure 1). It has been confirmed with the Kolmogorov-Smirnov test for psychosomatic tendencies (K-S = .130.. p < 0.05) and for dissociation (K-S = .003.. p < 0.05). From this test, we read that the statistical significance values are statistically significant, which means that the distributions of the scales are not normal.  The following graphic (Figure 1) is representing, all the above stated. Further analysis shows that a positive correlation between the tendency to psychosomatic reactions and dissociation is present.
From Table 2, we read that there is a statistically significant positive correlation between the tendency to psychosomatic reactions and the dissociation (r (48) = −.791; p < 0.01).
All previously said brought to us gratefulness for the condition our participants are experiencing. However, we believe that we could follow up and gain more indepth results based on that.

Discussion
In the last period, the whole world has changed, and what we are living in today is much more than living in a fluid society where we are losing ground and therefore, stability. The COVID 19 Pandemic brought to us the experience of that dramatic change on the level of plans, norms, expectations. Besides fear for personal safety and health, the directed distancing increased the gap in everyday quality of possibilities for personal contacts and support. Losing the ground and experience trembling, we were inevitably facing blurred boundaries, insecurity [15]. It was a direct attack on our will and who we are. Almost unnoticeable, we deepen in the fertile ground for the manifestation and experience of anxiety, panic, numerous psychosomatic disorders, and severe psychological disturbances, among which dissociation is.
Faced with that, we act upon putting in action the five abilities we all possess. Namely, we respond to the situation with complete awareness about our interrelatedness, embodying the experiences we have passed through, with self-recognition of it, always experimenting with how we could improve it.
We manage to make it together, with full respect toward each and every different personal understanding. We succeeded to co-create the fully functional "Whole Intelligence" in action. To support it with statistical data, new research activities will be conducted, mainly qualitative, since what we have experienced till now during our regular supervision session, personal therapy sessions and workshops during the regular education or during the continuous education confirms the necessity to conduct qualitative research that will seed new insides. What we have conducted up till now is just the cross-section over the situation, that brought results that are positive for the wellbeing of mental health practitioners that took part in this research, and that is mainly coming as mental health practitioners from EAPTI GI-S. Without pretending to generalize the data, we want to reflect on it and put it into action for further testing. The disadvantage is that the sample is small, and it is coming from the same institute (same organizational culture, same program, trainers, therapists, supervisors) that is not showing the wider picture. Also, the necessity to conduct controlled research that will do cross-section over the situation with the general population, as well as clients that ask for help, is what is in front of us, since without it we lost the possibility to compare.

Tendency to psychosomatic reactions Dissociation
Tendency to Psychosomatic reactions .791 ** Dissociation ** p < .01. Nevertheless, from the data gathered by using specific instruments, we gained information that the participants in this research managed to resist to challenges and obstacles during very turbulent "here and now" and not to increase their tendencies toward psychosomatics and dissociation.
The questions that were asked here are: Could we explain it with the traditional collectivistic culture we are part of? Could we explain it with the good quality of the attachment and based on that better-developed quality for coping? or. Could we explain it with the excellent support system developed on the level of the group/groups they belong to professionally? Most probably, the correct answer is in between the crossing of these three. Briefly explaining them, first, we will come to the influence the traditional collectivistic culture is having in terms of nurturing contacts and ties within families. Being forced to stay at home, isolated from the outside surrounding most probably these ties positively impacted us, and at least created stable ground, so necessary during this pandemic period.
Secondly, the connectedness between family members influence the quality of the attachment, and as Bowlby noted, secure attachment is secure support for further exploration, that is definitely positively impacting the quality of resilience [16].
And finally, the previous two supported and impacted the quality of the group work the participants have experienced during their education and work as mental health practitioners (psychologists, psychotherapists and so on) during these turbulent times.
Let us go back to the five abilities we all possess, although not all of us are using them properly.
Parlett used to say that all of these explorations/ abilities could be seen as gates of a fortress, so if the aim is to enter in, then depending on the contact and context, the choosing will happen.
We started with what was and still is present in here and now, and we respond to the situation. Being fully present and open in front of all challenges and possibilities of the actual moment and situation, we encounter it (COVID 19 pandemic) and start ACTION CALL ME #COVID 19, instead of thinking, expecting or even worst creating catastrophic expectations. We want to accomplish.
We start to Interrelate among ourselves more frequently and more profound. Moreover, it reflects in relation with our clients. Standing and waiting on the contact boundary for what will emerge, we exchange the message that the uniqueness of co-creation is our strength, that makes bonds and relations more substantial and natural pure communication possible. Human to Human, creating the relations of trust, friendship and genuine love.
Embodying the experience of what it is and how it is, we did not withdraw and escape in the here and now. Contrary to that, the rise of awareness about symmetry between the mind and the body and vice versa (through our training and personal work) support us not to cry that we have to stay isolated because it is not true, and of being isolated, we could re-connect to nature. Acknowledging life as a precious gift as well as all gifts nature is offering, we are gaining wisdom through such connection, Self-recognizing ourselves for that, we manage to affect others, influence other people, and wider context. Being active through experimenting, learning through doing and reflecting on doing (actual work of psychologists and psychotherapists in the field and their regular supervisions) created space and time to explore, experience, create, and grow authentically. To bring the power of spontaneity and playfulness in the situation of highest risk is a sort of invitation to live without guilt and shame that are overwhelming, pushing us to believe that we have to pretend not to be the best we are could be.
We activated our abilities, and it seems that using them within the concept of the whole intelligence, we managed to stay up to our best capacities and not develop tendencies toward psychosomatics and further dissociation. The mean scores of those two variables are proofing that. Further it suggests that when using it and activating support systems (body, breathing, thinking, interpersonal support, and intrapersonal support [17], we could stay grounded while open for new experiences.
Activating the whole intelligence, we are activating our resilience and further our immune system [16] as a response to the virus that attacks us all on the global level. It is the best prevention to developing psychosomatic reactions, symptoms, or illness. Also, if we are present and supported, and there is a human being to whom we could contact and avoid the possibility to leave the contact and enter into numbness, we are preventing dissociation.
It is important to stress the connectedness between the tendency toward psychosomatics and dissociation, as presented through this research data. The red flag will have to wave if any of them start to rise.
Sharing the results with colleagues and deepening our understanding through qualitative exchange with them, we are strongly supported to keep the concept of the Whole Intelligence as a frame of education. Experiential Learning is what we declare and what we do. It is based on experimenting, learning through doing, and reflecting on doing, personal involvement and a lot of personal work -individual and group, as well as relational supervision. All of it holistically based and with recognition and acknowledgement.
Gestalt Therapy is exactly about that, and as our common ground, it supports us significantly. Nevertheless, we are open toward comparing and further improving, taking in consideration work of Hasler on well being [18] and Fava on Well being Therapy [19]. The last one could serve as a path for further improvement and new insights.
Hasler pointed on: "…Asian wisdom in combination with modern neuroscience …. " (18:259). That supports our work, since Gestalt therapy, although very open for further improvement, has already accepted holistic approach, integrating the winds of east and west for better sailing. What is needed more is continuity toward integrative and comparative approach, where inclusion of neuroscience is must.
For us now, being in the gestalt training as well as practising gestalt therapy create a solid ground for moving beyond psychosomatics and dissociation.

Conclusion
All previously said, was a summary of the last year passed, much personal reminiscing, professional exchanges, psychotherapy work in the field, as well as personal psychotherapy, and supervision on different levels from personal one on one to the group, as a participant, and as a lead supervisor. I will point just on one quote from a supervision session where the colleague psychotherapist said: ……. "and we (psychotherapists) have souls that need to be nourished". This quote provoked many exchanges, and the idea to research helping professionals was born. Now, concluding the results and being very grateful that besides arduous work, our participants managed to move beyond psychosomatics and dissociation, although most clients were bringing such issues for their work. DOI: http://dx.doi.org /10.5772/intechopen.99227 There is no inevitable conclusion. A lot of question marks are still pending. Also, the generalization of the results could not be accepted, due to: • the number of the participants in the sample, • the distribution between males and females (although females are predominant in helping professions), and • the average age of the sample, that just to remind is 33 years.
It seems more like a recommendation that could be sentenced as: There is no client wellbeing without the wellbeing of the therapist, and Carrying about myself, I am carrying for others.
And, it reminded me that our first workshop on the topic "I care for myself, I care for You" was conducted seven years ago. So, all these years, we are carrying for ourselves and each other. Furthermore, the continuity of that exchange gives us the possibility to continue further.
Certainly, when we conduct the research, less than half of the participants have been infected with COVID 19 or have experienced it within the closest family. Unfortunately, the situation was dramatically changing during the finalization of the article, although there are not death cases among them. However, numerous of them experienced loss within the family circle or friend circles. Till now, most of them gained that experience.
It will be interesting to check the impact of that experience. Till now, based on the support that was exchanged, we believe the results will be similar.
We all have learned a lot.
To trust ourselves, care about ourselves, care about others, protect others, and deeply value the other human being.
To value the contact.
To value the pain. The process of suffering could become process of growing if there is trust, support and possibility for exchange.
These last few sentences could be our recommendations to others. How we achieve it? We discussed it previously. Not easy, but with a lot of benefit and support to continue further.