Table 1.

Stages of the pandemic, themes raised and facilitators' interventions in CopeColumbia peer support groups.

Themes	Interventions	Primary sources for concepts and strategies
Stage 1: NYC Pandemic onset (March)
Anxiety and uncertainty: 1) Fear of the virus predominated early group sessions given little to no information on pathogenesis, course, modes of transmission, and clinical presentations of COVID-19, nor knowledge, development, or availability of effective treatments and vaccine. 2) Concerns for safety. Personal concerns about contracting the virus, but more so concerns about transmitting virus to family (spouse, children, elderly parents), concerns about limited PPE and hospital resources (isolation rooms, ICU beds, ventilators). 3) Concerns about competency, and novel work conditions included anxiety about redeployment and adaptation to telehealth for service delivery of non-COVID19 patients. For those on quarantine or working remotely, there was guilt about “not doing enough” or being present on medical units. 4) Increased work and emotional burden due to scope of cases: Unprecedented and swelling rates of patient admissions, severity of illness and frequency of deaths.	1) Labeling and validating emotions. Normalizing and validating the human experience of a range of emotions including fear, anxiety, frustration, guilt, and anger that may occur during unprecedented times. Reminder that each individual responds in their own way, and that there are no ‘right’ or ‘wrong’ reactions. 2) Control. Identify what we can and cannot control, focusing on the former (a key component of ACT philosophy). 3) Contribution. Identifying and recommitting to professional values, also respecting the diversity of what we each contribute; recognizing not everyone can serve on the front-lines. 4) Support: Critical to coping is social support and reminding HCWs that they are not alone; use of others in the peer groups allowed a focus on this strategy. 5) Self-care. Like oxygen masks on an airplane, HCWs must prioritize their own self-care in order to care for their patients. This is not selfish, but essential. Facilitators respected the diversity of needs of HCWs, also recommend limiting news exposure and stressing the importance of sleep and nutrition. 6) Resilience. Facilitators remind participants about their own resilience, defined as positive adaptation in the face of stress or disruptive change.	1) Barlow, D., Farchione, T., Sauer-Zavala, S., Murray Latin, H., Ellard, K., Bullis, J., Bentley, K., Boettcher, H., & Cassiello-Robbins, C. (2017). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. New York, NY: Oxford University Press. 2) Haley J. The Jossey-Bass social and behavioral science series. Problem-solving therapy. 2nd ed. San Francisco: Jossey-Bass; 1987. 3) Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavioral change (2nd Ed). New York: The Guilford Press; 2016. 4) Zinbarg, R., Craske, M., & Barlow, D. (2006-03). Mastery of Your Anxiety and Worry: Therapist Guide. New York, NY: Oxford University Press. Retrieved 19 Jul. 2020,
Stage 2: The NYC Surge (April–May)
Trauma, loss and grief 1) Managing trauma-related emotional reactions. This included numbing, distancing, anger, sadness; increased guilt and helplessness. 2) Grief. Unprecedented number of patient deaths compounded by personal losses; overwhelming sadness when facilitating (via phone or video) patients' last contact with family members. 4) Guilt. Guilt was expressed by personnel not working on the front-lines or who felt unable to do their jobs adequately given lack of treatments, limited PPE, etc. 5) Stress and managing work/life responsibilities. Volume of DNI/DNR orders; redeployment adjustment; increased burden due to loss of support resources for child care and other home-based help; stress of managing health care delivery and schooling of children; increased isolation and loneliness for those living alone and/or having prolonged quarantine. 6) Hope and support as PPE resources were delivered or adapted.	In addition to prior strategies, facilitators offered novel strategies to address the following: 1) Expected responses to grief and trauma. Education about the grief response or the trauma response—normalizing the breath of emotions and range of responses that could be experienced. 2) Safely riding out waves of emotions. Giving permission to “dose grief” and choose when to pause and acknowledge waves of feelings and when to stay the course with a task. 3) Recommitting to self-care. 4) Knowing and owning professional values. In the context of so much illness and death, identifying aspects of the job that are particularly meaningful and remembering why one chose medicine as a career. 5) Building community. Countering COVID-19 induced isolation by actively connecting to others and using the groups to demonstrate how team sharing can promote individual and group emotional strength and wellness. 6) Resilience. It became important to remind participants that resilience does not mean “snapping back” to how you were, but learning to integrate the experiences into who you are and growing with it, as well as recognizing individual strengths/assets. 7) Reframing what providing “help” to the medical center means. Not everyone can or should be on the front lines. There are many tasks that medical centers need completed to stay afloat and rotations are needed on the front lines as well as behind or away from the medical units. Those with medical conditions for whom the risk of illness outweighed the benefit needed to serve in different but still important capacities. Validating everyone's role and naturally occurring peer support became an important task of the facilitators.	1) Bonanno, G. (2010). The other side of sadness: What the new science of bereavement tells us about life after loss. New York: Basic Books. 2) Foa, E., Hembree, E., Rothbaum, B., & Rauch, S. (2019). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences - Therapist Guide. New York, NY: Oxford University Press. 3) Lloyd, J. Bond FW &. Flaxman PE (2013) The value of psychological flexibility: Examining psychological mechanisms underpinning a cognitive behavioral therapy intervention for burnout, Work & Stress, 27:2, 181–199 4) Shear MK, Reynolds, CF, 3rd Simon N M, Zisook S, Wang Y, Mauro C, et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry. 2016; 73(7), 685–694. 5) Smits, J., & Otto, M. (2009–06). Exercise for Mood and Anxiety Disorders: Therapist Guide. New York, NY: Oxford University Press.
Stage 3: Reintegration and recovery (June and July)
Delayed trauma and grief responses; anxiety and uncertainty, revisited 1) Ongoing adaptation and change at work. Living with ever evolving new realities and routines at work and home; anticipatory anxiety concerning challenges as the hospital reopens elective services and office-based care; mismatch between message of hope about reopening and acknowledgment of reality of persisting inpatient volume of COVID cases; uncertainty regarding the expected “second surge” and having to do this again. 2) Frustration and fear related to social and public health issues in the country. This included the politicizing of the virus; lack of national consistency in implementing recommended containment strategies for the public; delayed trauma and grief reactions; fear and anxiety related to civil unrest and racism.	Facilitators continued to focus on coping as new routines, information, and guidelines were/still are being presented by hospital administration and the government. 1) Review of coping strategies. Recognizing what is in one's control; valuing one's contribution; maintaining self-care and social support; finding meaning in one's work and values, building resilience. 2) Advocacy. Facilitators recognized the importance of addressing issues raised about systemic problems, identified in the workplace or community. Validation of HCWs' concerns and brainstorming potential solutions while facilitating ways to communicate to supervisors and administrators; focusing on what providers could do to address and change problems on a local (i.e., in a division or unit) and systemic level (department or center-wide) became important. 3) Giving voice to stress-related racial and social injustice issues. Facilitators framed groups as safe spaces to discuss not just COVID, but also experiences of racial and social injustice, and related coping strategies 3) Referrals. Provided resources as requested related to grief, trauma, loss, and a range of mental health problems that may have existed prior to COVID, but were exacerbated by the significant trauma. Referrals for mental health treatment were made as needed.	1) Hayes, S.C. (2019). A liberated mind: How to pivot toward what matters. New York: Avery Press. 2) Sue, D. W. (2015). Race talk and the conspiracy of silence. Hoboken: Wiley.
Stage X: the unexpected
Suicide of a HCW. Grief, sadness, shock, guilt, and anger.	In response to loss of a colleague, facilitators worked to distill psychoeducation to HCW and implement evidence-based strategies 1) Psychoeducation, including information about suicide risk, difficulty with prediction and prevention, and specific data regarding HCW/physicians being at increased risk of suicide. 2) Stress-diathesis model of suicide, including biological vulnerability. 3) Management of grief and bereavement reactions 4) Acknowledging and reframing guilt (“What did I miss”) and anger (“Why wasn't this person helped by the system?”) 5) Addressed Stigma related to help seeking of medical professionals, particularly physicians; emphasized the availability and importance of asking for help and seeking treatment; reinforced confidentiality in help-seeking and resources for accessing support.	1) Joiner, T. (2007). Why people die by suicide. Harvard University Press. 2) Turecki G, Brent DA, Gunnell D, et al. Suicide and suicide risk. Nat Rev. Dis Primers. 2019;5(1):74. Published 2019 Oct 24. doi: 10.1038/s41572-019-0121-0 3) Oquendo MA, Sullivan GM, Sudol K, et al. Toward a biosignature for suicide. Am J Psychiatry. 2014; 171(12): 1259–1277. doi: 10.1176/appi.ajp.2014.14020194 4) Dutheil F, Aubert C, Pereira B, et al. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One. 2019;14(12):e0226361. doi: 10.1371/journal.pone.0226361