The COVID-19 (coronavirus) pandemic was the worldwide public health crisis of the twenty-first century. The present study aimed to explore lived experiences of trauma survivors. So being focused on the most prevalent trauma of that time of COVID-19, individuals who directly got infected with the deadly virus, such as survivors of COVID-19, were selected as the sample of the study. The impact of COVID-19 on their attachment patterns and emotion regulation strategies was explored. Semi-structured interviews of four (Male=2 and Females=2) survivors were conducted. The non-probability purposive sampling strategy was used for sample selection. Analysis of transcripts was done using Interpretative Phenomenological Analysis (Smith et al., 2009).  Themes included manifestation of COVID-19 (psychological reactions; physiological symptoms; challenges during COVID-19; change in life due to COVID-19; and other's perception and attitude towards victims); attachment patterns (premorbid attachment patterns and impact on attachment patterns during COVID-19); and coping strategies (problem-focused coping, emotion-focused coping and religious/ spiritual coping) have emerged. It was expected that COVID-19 would bring negative changes because the global pandemic happened suddenly and unexpectedly, took many lives in a short time duration, and left people in a state of crisis and threat, but unexpectedly, the results revealed that COVID-19 had brought positive changes as well. In conclusion, COVID-19 greatly impacts attachments, relationships, emotions, and overall life. Gender differences were also observed in trauma survivors. Further research should focus on developing pre-planned therapeutic interventions in such sudden and unexpected scenarios.
Keywords. COVID-19, Trauma Survivors, Attachment Patterns, Emotion Regulation Strategies
The COVID-19 (coronavirus) pandemic of 2019 has been declared one of the worst pandemics of the twenty-first century. By the end of February 2020, the Coronavirus had entered Pakistan, and a complete lockdown was imposed on 23rd March 2020, resulting in the closure of industries, offices, and educational institutions. WHO (World Health Organization) has classified the COVID-19 disease epidemic as a pandemic (WHO, 2020).  Pakistan had around 260,000 confirmed cases of COVID-19 as of July 23, 2020, with roughly 5,700 deaths (CSSE, 2019).  The pandemic was perceived as a truly traumatic event in some circumstances, and some studies have found that it added to the development of PTSD in the global population (Masiero et al., 2020; Rossi et al., 2020).   PTSD (post-trauma stress disorder) is a mental disorder that develops after being exposed to a traumatic or stressful incident and is classified as a Trauma and Stress-related Disorder (American Psychiatric Association, 2013).
PTSD causes severe distress and disability in survivors, family members, frontline respondents (police, public health and medical specialists, and others), and even common individuals. A higher level of PTSD (Post Trauma Stress Disorder) is associated with experiencing or witnessing COVID-19. Infectious illness epidemics cause a specific sort of psychological trauma that can be classified into three stages (Liang et al., 2020). Immediately experiencing and suffering from symptoms and traumatic treatment is the first stage in which respiratory failure, difficult respiration, altered consciousness states, threatened death, tracheotomy, and other serious traumas are common in individuals who have severe COVID-19 symptoms (Xiao et al., 2020).  The physical, emotional, and cognitive links that bind us to one another are referred to as attachment styles (Bowlby, 1969). After birth child starts understanding and relating to people through which attachments form (Cozolino, 2008).
According to the growing body of literature, the way we operate in our world at the social level after trauma; is a tremendously complex issue (Bowlby, 1969).   People with secure attachments have effective regulation of their negative emotions and are more optimistic about dealing with complex situations when they confront threatening or stressful situations (Nielsen et al., 2017). In contrast, people with insecure attachments have difficulty in emotion regulation (Jurist, 2005). The emergence of the attachment system is the key to the emotional, controlling approach, due to which we learn to approach trustworthy others when we confront a threatening situation. According to growing evidence, people tend to seek attachment representations when confronted with real or symbolic threats (Mikulincer & Shaver, 2003).
Emotion regulation is the process of increasing, maintaining, or decreasing one or more than one constitutes emotional reactions, whether unconscious or conscious (control or automatic) (Gross, 1998). COVID-19 patients experience significant stress and physical symptoms during the whole disease crisis. Treating mental health requirements is critical, and the psychological aspect of people cannot be undermined. Therefore, in practice, the first step is to gain a thorough grasp of the psychological challenges that patients are experiencing (Yan et al., 2021). Psychiatric symptoms and comorbidities related to infectious COVID-19 were assessed in the review research. People who got an infection and those who didn't get an infection were studied. PTSD and depressive symptoms were higher in COVID-19 patients. Symptoms of psychiatric patients also became severe during the pandemic (Vindegaard & Benros, 2020).
The COVID-19 epidemic severely affects mental health worldwide; however, individual reactions may differ. During a pandemic, that participants who had anxiety, cyclothymic, and depressive features in their temperaments had a higher emotional impact. At the same time, certain personality characteristics served as protective factors against mental distress, such as male gender, security, and avoidance-based patterns of attachment (Moccia et al., 2020).  In recent times, as COVID-19 has been the most prevalent trauma worldwide. Millions of lives have been significantly altered, and a global, multilevel, and demanding coping-adjustment process is going on (Feeny et al., 2000).
COVID-19 has caused dramatic changes in the life of those who have experienced it themselves. Given the prevalence, there is a need to raise awareness about the challenges experienced by survivors of COVID-19. Therefore, the goal of this study was to look at if there is any impact on the attachments of survivors and how survivors have coped with the worldwide trauma to see if the theoretically expected patterns emerge. Little has been done to describe emotional strategies, and further research should be done to better comprehend various adaptive strategies. Therefore, the present study was done keeping in mind the following objectives:
The sample of the present study was comprised of four COVID-19 survivors (Male=2, Female=2) from Lahore, Pakistan. For the selection of the non-probability sample, purposive sampling strategies were employed. Willing individuals with a minimum age range of 20 years or above who were diagnosed by accurate laboratory test at least one month after the traumatic event's termination were included in the sample (according to DSM-V criteria for PTSD). Individuals with physical disabilities were excluded. Those who were not tested positive by the authentic laboratory were excluded. Those who had less than one month's duration since trauma termination were also excluded.
The research was conducted appropriately by taking approval from the Board of Studies, Government College University, Lahore. To make the study more culturally validated according to Pakistan, an interview schedule was developed for the present study with the help of relevant theories after a thorough review of the literature. After peer review, it was approved by an expert. The final draft was constructed after expert review. The approved interview schedule was administered to four (04) participants, two males and two females. Each participant signed written informed consent, and they were assured that their confidentiality wouldn't be compromised, and information would be used only for education and research. Participants were asked open-ended questions related to their attachment patterns and emotion regulation strategies about COVID-19 during the survival period of illness. Phenomenology as a qualitative research design was used to explore the in-depth experiences of COVID-19 survivors. Interviews were recorded in audio tape format. Audiotape interviews were transcribed, and meaningful interpretation verbatim was done by thoroughly analyzing the content (line by line) several times. Coding and themes were generated based on an ideographic approach, and then clusters were made based on theme coherence. Data were analyzed, and themes were formed using interpretative phenomenological analysis. Throughout the process, the researcher had to get down to the participants' level to comprehend their life experiences from their perspectives. Several steps recommended by Smith and Osborn (2007) were followed for data analysis. Ethical considerations were followed during the whole study.
This study aimed to explore the phenomenology of attachment patterns and emotion regulation strategies of COVID-19 trauma survivors by using interpretative phenomenological analysis. Four main superordinate themes include manifestation of COVID-19 as trauma, pre-morbid attachment pattern, impact on attachment patterns during COVID-19, and coping strategies (see Figure 1).
Manifestation of COVID-19 as Trauma
The COVID-19 (coronavirus) pandemic is the main global health crisis of the twenty-first century and the most challenging condition we have confronted since World War II. COVID-19 is experienced as traumatic by everyone. All the participants have reported many psychological symptoms or reactions due to COVID-19. Psychological symptoms were more prominent in individuals immediately after being tested positive. As one of the survivors of COVID-19 has reported, I was shocked when I got tested positive for covid. Everyone got tested, but only mine was positive. Truly speaking, I was shocked… I said, sister! Everyone got their test negative, I just tested positive.
Female survivor participants also reported fear as I had felt weak even afterward… means a sense of fear; you can say… like before eating anything, before going anywhere outside, I always thought that I might not feel something weird again… I just don’t want to go through this trauma again. Male participants have experienced fewer psychological symptoms as compared to females. The most common symptoms in male survivors were stress and fear. A male participant reported that it was like I was not much worried about my health, I was more worried about my mother's health because she was also having symptoms and when she got tested, it was also positive, which means… I was worried about her that she might not get severe symptoms.
Even knowing that it will recover in two or three weeks or having a closed loved one suffering from a similar situation couldn't lessen the distress level in people due to COVID-19 who once tested positive. For example, a female COVID-19 survivor has reported that it's very difficult… Although my husband also had covid, we were together, but weird like means… I…, couldn't understand what had been happening in life, it felt like… we knew that it was covid, nothing much to worry about… it would be recovered in 14 days, everything, but no…, it was a very depressing phase.
Other psychological symptoms that female survivors experienced during COVID-19 include mood swings, depression, fear of testing, fear of COVID-19, fear of death, boredom, anger, distress, nervousness, loneliness, isolation, sleep disturbances, and loss of interest. Physiological symptoms that participants reported include fever, weakness up to the level where one is unable to walk independently, body aches, muscle stiffness, less energetic (reduced stamina), fatigue, tiredness, chest pain, breathing difficulty, stomach issues, damage of the immune system, vomiting and taste issues which resulted in the loss of interest in food. For example, participants have reported that I had a fever and much weakness (FS1, Pg. 1, 5). I had such severe body aches like my hand…I was unable to straighten my arms, or if I was laying even during rest, I was having pain.
Male survivors have reported that I had a high fever, didn't feel hungry at all…and severe weakness. Taste issues were very common, even though I still feel…my taste issues were chronic and still going on. I had lost my taste. Else for one month, I had fatigue and weakness. After that, it recovered.
The most widely spread COVID-19 has come with many challenges for people all over the world. The most common challenges participants have reported related to the diagnosis and transmission of the coronavirus. As a female survivor of COVID-19 has reported, I didn’t know I had covid.
Comorbid medical illness was another challenge during the COVID-19 pandemic. If someone was already having some medical issue, it was making them more vulnerable to getting COVID-19 and more chances of difficult survival through it. A female survivor participant has reported that I am asthmatic, so whenever any patient, you know…used to come. So it was like if they are dying, patients, they die, but it was like … when I had an asthmatic attack for the very first time, then I…I felt how humans have craved for one to breathe.
The COVID-19 pandemic has changed the life of every single individual, but it has strongly changed the life of those who suffered themselves and whose close family members have suffered. As the participant has reported, I didn’t talk to anyone; even I was not talking with my friends; they used to call me… sent text messages to me, I didn’t receive their calls, I was much depressed, I had a fear inside me, I was not able to speak.
Another participant has reported suffering due to a change in environment, restricted activities, and inability to communicate; my husband has separated my room…even though he didn’t allow my daughters to see me, for 14 days, no one was allowed.
Change in thinking and behavior related to acceptance and precautions, respectively, was also reported by participants after having self-experience. I would say we should stay safe. Right… and means if any patient came to you, and told you something about himself, then you should understand his feeling of that time.
Everyone has denied COVID-19 since its emergence. People in Pakistan also have been stigmatizing those individuals and families where the presence of the coronavirus was confirmed. Most of the individuals had felt rejection, avoidance, and hesitation by society and the community at large. A female survivor participant has reported that People hesitate. Another female survivor has also reported that other people who live around you when they get to know that you have had covid, don't want to meet you to save themselves…don't come close to you.
Male participant has also reported that people perceive COVID-19 as unreal, and due to this unacceptance of facts, they also don’t take precautions. People don't believe that covid exists; when you tell them that patient has covid, they wouldn't believe…they would say that it's just a breathing issue or any other disease, it's a cough…so people don't take it seriously. In the meantime, there was also a positive response from some people. Their family members have fulfilled their needs and were provided with support and care by their close family members.
Positive Aspects of COVID-19
Negativity was spread everywhere during the COVID-19 pandemic. Despite all the negative facts, it was very difficult to look towards positivity to maintain strength and consistency, but there were still some people who took out positivity from this negativity. Increased sympathy for others, humble attitude towards other people, improved relationships, resolved conflicts, family support, increased family time, emotional support as well as care, healthy diet patterns, and gratitude for having family doctors and availability of medical care are some pandemic-related positive aspects that people have reported during interviews.
As a male survivor participant has also reported about family support, there was nothing something like this in my family…they all took much care…don’t know about others that how did they have coped…because we had a family system like…that you had to take care of others… So…you cannot end these social values.
Premorbid Attachment Patterns
Psychological and social relationships of participants with different individuals were explored from their early perceptions before COVID-19. Most participants have reported secure attachments with others, while few have reported insecure patterns of attachment. The death of parents or absence of parents made it difficult for the participant to cope with the stressful situation of COVID-19.
Participant 1. (Survivor, Female). She has reported a secure attachment with her parents but closer to her father. Moreover, her attachment to her mother increased with age. She was a very desirable child, most awaited and pampered by her parents. She was never scolded by her parents. She has a somewhat insecure relationship with her husband. She also did not have a congenial relationship with her in-laws. She has a small limited social circle and few friends but strong bonding and emotional sharing with them. As she has reported, I was the only sister, so my family history is…that my father…he doesn't have any sister…so he wished for a daughter… then I was born…so my life was…I was much pampered…my parents have never scolded me… so far my mother…when we were in our childhood, she used to beat us… but now when we've grown up, we have increased love for my mother. So far my husband… when he is being complied then… Right…otherwise conflicting). Relationship with friends and family was reported as, I have just two friends since my school… generally, I have a good bonding with each person but my best friends…they are just two.
Participant 2 (Survivor, Female). She has reported a secure attachment with her parents but is closer to her father. Her father died due to a heart attack some months ago before COVID-19. She missed her father a lot. Her father's death made the COVID-19 situation even more stressful for her. She found her husband very loving and caring as well. She was very social and liked to spend time around people. She has a good relationship with everyone, including relatives and friends. My friendship… was with my father… (Father died a year ago) so I had a difficult time (crying)… Just after that, I got covid… Alhamdulillah! I'm also good friends with my mother but now when I go home… I don't feel the same thing… My husband is very nice, and caring, he took much care of me. Relationship with friend and family was reported as everyone is very nice. My relationship is also very good with everyone.
Participant 3 (Survivor, Male). The participant has a secure attachment with his parents. He used to share all his emotions with his parents. He has a huge social circle and good relationships with friends, relatives, and family at large. Relationship with parents was reported as, very nice…very nice with both of them… Normal as father and son, mother and son have…same like that… I used to share my emotions with my parents. Relationship with friends and family was reported as, I have good social circle…and very nice attachment with friends…and with family… it is also very nice.
Participant 4 (Survivor, Male). The participant has a secure relationship with his parents. He used to share everything with his parents. He used to be very friendly with everyone. He also has a good relationship with friends and family at large. Relationship with parents was reported as, I have very good attachment… as I have been living in the hostel, but I have very nice attachment with them, if there is anything, I used to share with them… Always. Relationship with friends and family was reported as, with the grace of God…with everyone…I have a good connection… very friendly with everyone.
Impact on Attachment Patterns During COVID-19
The newly emerged COVID-19 epidemic profoundly influences the psychological health of individuals and society at large. Some participants have experienced a negative change in attachments, while others have reported a positive change in attachment during COVID-19. A female survivor participant has reported that her attachment to friends changed during COVID-19:
Before COVID-19, I had just two friends at my school; generally, I have good connections with every other person but so far, my best friends… they are just two, I have a very strong bonding with them means… They wouldn't call me any day… I feel like if there is something wrong… I just can't live without talking to them. During COVID-19, I didn’t talk to anyone… even I didn’t talk to my friends… they used to call me…
message me… I didn’t receive their calls… I was this much depressed.
During COVID-19, my mother used to call me from Sialkot, then… I didn’t want to talk to her… I have like strange… I was feeling like that… like a strange feeling… that my… I don’t want to talk.
Some people suppress their emotional expressiveness when they confront stressful situations, while others express themselves. For that purpose, they seek attachment with a close family member when confronted with a stressful situation. It also happened during COVID-19. As the participant has reported, I would just say no one should have covid… and in case one has… family should be around him. Results showed that survivors, who had a secure relationship with their partners before COVID-19, have approached their partners for emotional regulation in times of distressing situations as in COVID-19 illness as well. In contrast, attachment avoidance was observed in those who previously had somewhat insecure relationships with their partners. They did not approach their partners for emotional regulation during times of COVID-19.
Participants have reported that they have been struggling to manage their relationships due to all of the stressors that were present during COVID-19. For example, a female survivor participant has reported a secure relationship with her husband before COVID-19 as, Alhamdulillah! Thank God, how much I would thank God, it won't be enough. My husband is very nice… very caring. Alhamdulillah! I have a good understanding of my husband. I used to share everything with him without any kind of hesitation.
Partners were a source of relief, and mutual understanding was seen during a COVID-19 crisis if the relationship between partners was secure previously. My husband took much care of me. He has provided me with everything in the room. I had my husband with me so when he was coming to my room, he would say, I sit here. I used to say just give fruits that he use to bring for me. He would say, I may set your room. So, he used to open the door and stand aside… has been watching over me… he would ask for video calls… then watching over me on a video call that how am I.
On the other hand, another female survivor participant has reported a somewhat distant relationship with her husband before COVID-19 as, so far with my husband… it’s like… when he complies… then right… otherwise angry… my personality is as I used to say that… when I gave my 100% to someone… he should do the same for me… but not everyone owns a personality like this… he is like that… though he is sometimes caring when being with his family, he behaves in a way that… he would completely go into ignorance phase… and then I would be angry… which further aggravate arguments.
Spouses were not a source of relief during COVID-19 if the previous relationship lacks security, understanding, and reciprocity. My husband also had covid… we were living together but strange means… This means I wasn't able to understand what has been happening in life… he was with me during the whole COVID-19 duration but even then, I had been feeling like life has just stuck… nothing seemed well.
Coping strategies are ways to deal with the situation that is being experienced by an individual. The most common coping strategies that the participants reported during and after the stressful situation of COVID-19 include i.e., Problem focus coping strategies, Emotion focus coping strategies, and Religious/ Spiritual coping strategies. People have used problem-focused strategies to deal with the stressful situation of COVID-19. Their perceptions about COVID-19 have also changed after surviving it or seeing their family members going through that difficult situation and suffering. Problem-focused coping strategies were also increased after self-experience. As the participant has reported that, masks, sanitizers, we used to have masks, and sanitizers daily… all the time… other than that, social distancing… tried to keep us at a distance as much as we could… this was the care, nothing else.
Although, due to taste issues, it was difficult to have a healthy intake healthy diet and maintain a proper diet, participants tried to eat properly to boost up their immunity; a female survivor participant has reported that, although I have eaten a lot… I didn't want to… but still, I was eating because I knew that I would have to do my job afterward… then there… in the hostel, you know… it's not possible… if you get it you may eat… otherwise, you have to order food from a restaurant.
During quarantine, it was difficult to spend time. So some individuals use social media and mobiles and try to engage in other activities to cope with their stress. As a female survivor participant has reported, I have been laying… have been using social media… but I didn't want to… I've just watched TikTok sometime. A male survivor participant has also reported that I used to spend most of my time on the internet. Nothing much… it was just… watched videos on my mobile phone etc.… Right… or if at home, taking part in communication/gossip.
During COVID-19, some participants reported feeling very down emotionally besides illness. So, they seek emotional support from their families to regulate their emotions in that stressful situation. Some participants have also suppressed their emotions because they do not want to make their loved ones stressed about them. Emotional, expressive suppression was reported by survivor participants as, No! I didn’t talk to anyone… I didn’t tell my parents… means my mother… she is a hypertension patient of hypertension… so I didn’t want her to know… and being only child… if everyone knew that, then I might be recovered but something would have happened to them that’s why… I didn’t tell my parents.
Family support and medical support were also available, which helped in emotional coping during the stressful situation of COVID-19. As a male survivor, the participant has also reported that we have kept himself strong mentally and emotionally… this disease is like that… if you panicked, you would be caught more into it; that's why we didn't panic… other than that, family support was present… and some doctors were very supportive, so we were mentally relaxed).
Participants have also used religious coping to cope with stress. Muslims immediately turn toward God in times of stress, and we seek help from him when the situation becomes out of control, and we feel helpless. In the COVID-19 pandemic, many people have also felt helpless. As a female survivor participant has reported about spirituality and religious practices, said prayers… read Holy Quran… etc. Alhamdulillah! Thank God… not much I can say that… level of trust I have in God… I believe that God always gives ease with difficulty… same happened during covid days. COVID-19 was novel for everyone and proved stressful due to its influence on people’s lives. Some people try to cope with the situation, while others become emotional whenever stressful events happen in human life.
Gender Differences between Survivor Females and Males during COVID-19 Pandemic.
Comparison based on Gender during COVID-19
Increased psychological reaction
Decreased psychological reaction
Perceived less challenging
Perceived more challenging
More positively evaluated themselves
More negatively evaluated themselves
Impact on attachment pattern
No change in attachment pattern
Comparatively stable emotionally
Note. Differences based on Gender during COVID-19.
The crisis of COVID-19 has wreaked havoc on people's minds. Governments have been imposing various measures to preserve social distance to combat the pandemic. However, compliance and coping are influenced by a variety of interpersonal factors. Therefore, this study aimed to explore the phenomenology of attachment patterns and emotion regulation strategies of pandemic survivors.
COVID-19 has adverse effects on the mental health of all the participants. All participants have reported that they have experienced various psychological symptoms not only during illness but continuously afterward, i.e., stress, anxiety, depression, fear, helplessness, exhaustion, anger, and many others. Hao et al. (2020) conducted a study on COVID-19 patients in the recent past. The outbreak had a higher psychological impact on COVID-19 patients than it did on psychiatric patients or the control group (healthy individuals). Among them, half of the patients were experiencing severe PTSD symptoms. People who had been infected with COVID-19 had significantly higher levels of depressed mood, physical symptomology, and anxious behavior.
The pandemic of the recent COVID-19 disease is a global health emergency. Along with the immediate impact on the health providing system and patients, this pandemic has the potential to negatively damage millions of people's mental health (Bleil et al., 2021) All participants reported that they were low on psychological health during the pandemic and illness. Everyone has experienced psychological distress, but victims of COVID-19 were more afraid of transmitting the virus to their loved ones and making them ill as well. Yan et al. (2021)  conducted qualitative research in which the psychological difficulties of COVID-19 survivors were derived from three themes as: mental distress behind the wall, living in limbo, and psychological pressure of being a carrier throughout an illness crisis.
Participants have reported that they were more stressed and afraid of the situation after being first-time victims of COVID-19. Everyone has reported that stress, anxiety, and fear were long terms and they always prayed that they may not be caught COVID-19 ever again. Mental distress persisted even after recovering from COVID-19. Psychological factors like stress have been linked to the higher incidence of viral respiratory infections; these findings could have more than a theoretical value, as they could directly alter the immunological response to COVID-19 (Pedersen et al., 2010).
Literature validated results as a study on COVID-19 patients was undertaken a year ago. According to the findings, COVID-19 patients were found to have high levels of post-trauma stress (PTS) and depressive symptoms. Own poor health, females, and family members of COVID-19 victims were all linked to a higher vulnerability of poor mental health (Vindegaard & Benros, 2020).
Physiological symptoms were shown to be common in conjunction with psychological problems. Participants have reported that they have experienced physical symptoms during the disease and a few months after recovery, such as fever, severe weakness, taste issues, throat infection, body aches, stomach problems, chest pain or difficulty breathing and immune deficiency, etc. The World Health Organization also lists respiratory symptoms such as cough, fever, and breathing problems as symptoms of COVID-19 (WHO, 2019).  Similar symptoms were reported by participants.
The COVID-19 pandemic was very challenging for everyone, both at the individual and national or international levels, but it was even worse for those who contracted the virus. The most commonly reported challenges for survivors were related to diagnosis and transmission of the coronavirus, presence of prior medical illness, and in the case of caregivers, increased level of responsibilities and inability to understand patient's needs were challenging. All the participants have reported diagnosis-related issues.
Both positive changes (healthy diet patterns, sympathy, and helping behavior for others) and negative changes (change in daily life/ routine activities, real or threatened loss of loved ones, increased responsibilities, workload, and so many restrictions) were reported by participants during a COVID-19 pandemic. Supporting each other and taking care of each other in times of crisis were also reported as social values learned from the culture of our country, which people have implemented during COVID-19 in Pakistan. Resilience studies showed that most people can overcome these obstacles and that some experiencing growth and good transformation. Even though adversity has obvious negative consequences, adverse experiences might likely provide opportunities to develop adaptive techniques that foster resilience and growth when faced with stress (Bleil et al., 2021).
During this novel disease of COVID-19 stigmatization of COVID-19 victims individuals and families was also very common in Pakistan. As indigenous research was conducted to investigate the stigma faced by patients (who were admitted to hospital) with the COVID-19 disease in the city of Pakistan, Lahore. Patients reported pervasive feelings of stigma, particularly regarding public perceptions and disclosure. According to the findings, rejection, stigma at the social level social, harsh, demeaning attitudes by other people, confidentiality beaching, lacking respect/trust, and the influence of diagnosis (COVID-19) were the main themes that emerged from the qualitative responses (Imran et al., 2020).
Given the fact that attitudes like stigmatization have plagued the response to the COVID-19 pandemic in some places (Marcinko et al., 2020). [Bowlby (1969) stated that in addition to separation from an attachment figure, the "attachment system" can be triggered by factors such as illness, fatigue, pain, hunger, and vulnerable environmental situations. Therefore, attachment patterns were also focused on in the present study. Participants have reported that they have developed insecurities regarding their attachment figures during COVID-19. Therefore, they used to hide their distress related to health and general life.
Emotional suppression was practiced by everyone. Children used to hide their emotions from their parents and vice versa. It can be supported by previous literature, as Bowlby (1969)  claimed that illness can trigger attachment behavior, and attachment insecurity was associated with high health anxiety (Reiser et al., 2019). Anxiety related to health is a key predictor of maladaptive reactions to illness outbreaks (Asmundson & Taylor, 2020).
Some participants hid their feelings and emotions intentionally, while others had difficulty communicating. Previously evidence was found through research conducted in Italy, as stated: certain characteristics of attachment patterns are associated with an increased vulnerability of mental distress in reaction to a COVID-19 epidemic, giving an idea that this could be a significant protective of precipitating factor in certain individuals (Moccia et al., 2020).
Participants have reported having post-traumatic mental suffering even after recovering from COVID-19. Post-trauma stress (PTSS) was reported at 7% in the general population in individuals exposed to the COVID-19 pandemic in China. The disease’s direct effects could cause it, the procedures necessary to contain it, or even indirectly through having contact with directly affected persons (Liu et al., 2020).
During COVID-19 many people have also experienced a disturbance in their relationships. The COVID-19 outbreak has caused serious and long-term relationship issues. People were unable to fill the communication gap created by their illness and the pandemic. Participants have also reported that they had difficulty in communication during the illness duration. Studies showed that attachment avoidance among partners was linked to decreased problem-solving compatibility and family dimensions. Findings suggest that the characteristics of the spouses with whom individuals had to live with during the COVID-19 pandemic will influence the impact of a pandemic on the functioning of their relationships (Overall et al., 2021).
Participants whose family was not supportive and those who were not living with their real parents during COVID-19 had more difficulty in regulating their emotions. Some females have reported that their in-laws were not supportive and were more stigmatized due to COVID-19 illness. Victim blaming was also very common during COVID-19, which further made victims suffer. It's also possible to see how, even if they're necessary to stop the spread of COVID-19, measures like social distancing, curfews, and home isolation can exacerbate attachment anxiety and insecurity (Bartolucci & Magni, 2017). [
The emotional control strategy was also very common in dealing with COVID-19. Participants also have emotional expressions during COVID-19. They have not shared their distressing emotions about the traumatic situation (such as COVID-19) with their parents, which was hard to manage because their in-laws were also non-supportive.
The COVID-19 pandemic was traumatic for almost everyone, and it has also affected the attachment behavior of the participants. Premorbid attachment patterns have well explained the behavioral actions of the participants during their illness and pandemic situation. Styles of attachment may be considered among the primary factors leading to regulations of emotions in stress-causing situations, such as when confronted with the stress of COVID-19. Different emotional reactions to both negative and positive life experiences were observed in individuals with various styles of attachment, as well as different ways of dealing with them. Individuals who said they had trouble controlling their emotions (poor regulators) exhibited increased anxiety, sadness, and PTSD (Mikulincer & Shaver, 2014).
Literature supported results as a study found that insecure attachment was connected to psychological problems via the pathways of low expectancy of support and poor regulation of emotions (Cloitre et al., 2008).  Various challenges greatly impact the psychological health (both relationally and emotionally) of individuals, couples, and families. In recent times of COVID-19, there has been an underlying sense of anxiety and uncertainty exacerbated by conflicting signals about health and safety (Stanley & Markman, 2020). 
Through attachment theories, one can understand attachment patterns and behavioral reactions as a result of COVID-19. Attachment theory is a technique for describing how people interact with one another. Humans are social creatures with an inherent system that drives us to seek comfort from others when we are stressed or in need (Bowlby, 1973).  When a person is confronted with a real or imagined threat, the attachment system becomes activated, causing the person to re-establish intimacy and connection to regain a sense of security (Mikulincer & Shaver, 2014).
Participants have also reported that they had extreme difficulty in communication during illness due to COVID-19. Various challenges greatly impact the psychological health (both relationally and emotionally) of individuals, couples, and families. In recent times of COVID-19, there has been an underlying sense of anxiety and uncertainty exacerbated by conflicting signals about health and safety (Stanley & Markman, 2020).
When people are confronted with a terrible situation, they begin to make sense of it. On the survivor's side, searching for meanings actively from their experiences is part of the coping process. “Why I?” “Why at this time?" and "What is the learning part in this event?" can be examples of this meaning’s search (Crossley, 2000). Similarly, participants reported the pandemic's situation when they tested positive for COVID-19.
Emotional management was also a big challenge for COVID-19 survivors during a worldwide pandemic. Due to the novelty of the situation of COVID-19, people were unable to understand their situation. Emotional suppression was also very common during COVID-19. Most of the participants were unable to understand the situation of COVID-19 and hence, had difficulty in assessing and regulating emotions. Similarly, Ehring and Quack (2010) investigated emotion control issues in trauma survivors. As a result, the intensity of post-traumatic stress symptoms was linked to all variables assessing emotion regulation difficulties. The variable "lack of emotional clarity" produced the most conclusive results.
In the traumatic situation of COVID-19, participants were overwhelmed by helplessness, so religious and spiritual coping was very commonly practiced. All the participants were Muslims who share the belief that ALLAH Almighty is watching over them and protecting them. They also believed that illnesses and recovery come from God, so religious practices were also a source of relief during that time. Culture and religion significantly influence trauma recovery (Tuval-Mashiach et al., 2004).
People have used different coping strategies to deal with the traumatic, unusual, difficult, and stressful situation of COVID-19. Using a phenomenological method, this study gives a complete and in-depth comprehension of the lived experiences of COVID-19 survivors while highlighting the pandemic's impact on their attachment patterns, and emotion regulation strategies. A positive mindset, healthy bonding with others, positive self-reflection, and coping strategies are extremely significant for psychological growth in any crisis such as a COVID-19 pandemic.
In the practical domain, this study suggests that psychological interventions should be combined with medical treatment in such situations rather than just being bound to medical interventions alone for the treatment of physical illness as of COVID-19. It will be helpful for counselors, students, and clinicians who have been dealing with people who have experienced trauma to understand the phenomenon. Further, it can help clinicians and counselors to clarify understanding and decision-making on whether explored factors should be included in the therapeutic process while implementing interventions for trauma survivors.
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