Dear Editor,

in Termoli Mental Health Community Center, all social activities, including our social skill training group, have been discontinued during the lockdown in order to contrast COVID-19 pandemic in March 2020.  We thought that pre-COVID-19 social skills should be improved, so we invited our social skill group to share their experience with COVID-19 by exposing personal storytelling on the web [1]. We aimed to evaluate a narrative method in improving affective flattening and general social skills in outpatients with a diagnosis of schizophrenia. The “narrative medicine”, coined by Rita Charon, promoted a doctor-patient relationship [2,3]: a narrative approach might be effective in understanding what the patients need and how they feel. Stories added to the medical practice more respect for patient experiences [4]. All participants were recruited in a conventional social skills program, they participated for six sessions before stopping. The group was characterized by young adults (ages between 25 and 30 years old), 8 males and 2 females without a history of drug abuse or medical comorbidity. When the lockdown occurred, we asked patients to write daily storytelling about their experiences and emotions and send us their diaries; six people accepted (5 males and 1 female). One person did not participate due to a lack of home internet network. Every week for 2 months, the diary has been used to discuss their storytelling in the usual group in a web conference.

The diary has been composed as a guide to share emotions or feelings, and to stimulate storytelling about discomfort with restriction or news about the pandemic. Questions to answer were: “How are you today?”; “What happened about the Pandemic in the world?”; “What are you doing at home?”. For every week we asked about positive or negative emotions, we talked about pandemic events and stimulated their thoughts about the virus. We administered IES-R and PANSS to grade trauma impact on psychopathology before and after narrative intervention. Finally, we administered a satisfaction test with the following questions: (i) Did you enjoy this narrative experience? (ii) How did you feel during this experience? (iii) What do you think about COVID-19 pandemic? (iv) What do you imagine when you think about COVID-19 and lockdown?  In the beginning, patients displayed discomfort caused by restrictions and focused more on the question: “What happened about the Pandemic in the world?”, they gave answers, often based on conspiracy ideas; when the operators shifted their attention to the question: “What are you doing at home?”, the answers were often vague. Four out of six people adhered to denial ideas about the virus and privileged sources they read on social networks. “Virus is a story created by China” they said; “Trump has reason to say it's all an invention of lobbies”; “There are just economic interests”, “This is a virus generated in a lab”. The possibility to share their own ideas and to compare them with operators and other patients reduced paranoic ideas. Successively we invited the group to explore their emotional states and to recognize them with open questions such as: "Can you tell me an episode where you felt angry or tired or worried this week?" "And one where you felt happy?". During this phase, we compared the pandemic to a “Social Interaction Executioner” and we played in describing it. After two weeks, all patients easily described their activities during the lockdown and they expressed an interest in socialization and getting into a relationship. In the fourth week, operators introduced a second question: "What can we do to contrast the “Social Interaction Executioner”. The group externalized difficulties but they were encouraged to adopt a proactive approach to emotional flattening. Each patient proposed several “arms” to contrast the “Social Interaction Executioner” with a list of good proposals like for example: make a cake; take a walk near the house; read a chapter of a book/magazine/newspaper etc. In the end, patients showed more interest than before in understanding emotions. They realized the importance of socialization and defined negative symptoms as an Executioner of their emotions. The psychometric test showed a high score in IES-R (arithmetic average was 60) and an average improvement in PANSS total scores of 15. In conclusion, we applied a narrative method in a complementary way to classic social skill training [5,6]. The attention to personal storytelling could be a pragmatic opportunity to implement conventional strategies and to contrast affective flattening and negative symptoms in Schizophrenia. During the lockdown, we felt this approach more manageable than usual social training because it was more suitable for digital interaction.