International Critical Incident Stress Foundation, Inc.
International Critical Incident Stress Foundation, Inc.
Primary Author: Jason Walker Psy.D., Ph.D., CCAC
Adjunct Professor, University Canada West (Canada)
Miranda Phillips, Ph.D.
Dean, Lamar Institute of Technology (USA)
Andjelka Stones, Ph.D.
Distinguished Adjunct Professor, NorthCentral University (USA)
Sandra Harris MA
Hereditary Chief, Indigenous Trauma Specialist (Canada)
Introduction
We have faced the emergency of infectious disease in our history, however, the impact of globalization along with the rapid spread of pathological agents has created the perfect storm for a global pandemic. The complexity related to the ability for public health officials to control the spread of infections has significant political, economic, health, social and psychological impacts which have led to serious public health challenges[1]. The global health emergency poses a new challenge for trauma practitioners since the impact of life-threatening viral infection and the ensuing psychopathology will require an unconventional response.
In March 2020, the World Health Organization (WHO) declared the Novel Coronavirus disease 2019 (COVID-19) a pandemic impacting, at that time, over 110 countries and territories[2]. Following that declaration, and in some cases prior to, most countries around the world went into lockdown in an attempt to deal with an invisible enemy. Consequently, the psychological distress felt by first responders, medical practitioners, front-line workers and the general public has in many cases triggered anxiety, depression and acute post-traumatic stress disorder (PTSD). Research has shown from past large-scale events, the psychological distress experienced by those impacted is often significant and persistent[3]. Large scale disasters, whether natural (e.g., hurricanes), traumatic (e.g., mass shootings), or environmental (e.g., Deepwater Horizon oil spill) have resulted in an increase in anxiety, depression, post-traumatic stress disorder (PTSD), substance use disorder, domestic violence and other psychological and behavioral outcomes that are seen immediately following an event while also showing long-term negative outcomes[4].
Within the context of COVID-19, practitioners around the world are observing that rates of PTSD/PTSS have increased in the general population by over 4.6% in the month following the COVID-19 outbreak[5]. The implementation of mass confinement directives (e.g., stay at home orders, quarantine and social distancing) is new to North Americans and there is real concern about how people will react in the short and long term[6]. To date, it has been reported that typical of most traumatic events, symptoms range from poor sleep quality to night terrors and panic attacks[7]. Compounding these symptoms is the psychology of fear associated with mass panic and at times bleak outlooks as the number of cases of COVID-19 and associated mortality has increased.
Individuals who experience collective and complex PTSD and other related mental health diagnoses, may experience a feeling of certain “helplessness” especially within the first responder population[8]. It is possible that the fear and anxiety related to the possibility of becoming infected, passing infection along to others, death, and general helplessness may increase the rates of suicide worldwide in 2020. In essence, we are dealing with a world-wide Mass Casualty Incident (MCI) where we are collectively creating the playbook in real time. Needing to be isolated, restrictive movements and social distancing at this time can trigger feelings of fear and anxiety as well as other psychological trauma, and bring up situations that people have lived through and survived. These memory triggers can illicit mental health breakdowns or breakthroughs if people understand what is happening and can find resources to help them understand what is occurring. Often, they do not get the support needed and anxiety, fear, depression and unhealthy coping mechanisms might come in to play.
In a rapid review and meta-analysis on intervention to address anxiety, depression and stress during COVID-19 and social distancing, and studies have shown that self-guided interventions on average did not show the same degree of effectiveness as traditional guided individual or group therapies[9]. The techniques we often rely on for ongoing maintenance after a critical event that meet social distancing requirements are proving minimally effective.
The traumatic stress experienced during COVID-19 has identified serious gaps in the ability to rapidly conceptualize and mobilize a response, describing vulnerabilities related to mental health and traumatic stress as an ongoing “cardiac stress test”[10]. An immediate need exists for the trauma practitioners to focus on new stress-related disorders including intellectual and financial commitments to diagnostics, prevention, public outreach, mainstreaming into nonmental health services and COVID-19 specific trauma research. In essence, re-defining how practitioners respond to a new dimension of the MCI.
Evidence-based interventions and best practices to mitigate the negative side effects of acute collective stress and trauma within our communities and our front-line workers in response to COVID-19 are still developing. We understand that when writing this article, the world is in the midst of a global mass casualty emergency, creating extraordinary situations with both an immediate and long term need for trauma practitioners to provide intervention and postvention measures. As such, there is a need for the trauma practitioner community to actively address fear related behaviour individually and collectively during all phases of the COVID-19 pandemic. As the psychology of fear, stress and related aspects of symptomology spreads across the population, failure to address best practices for mitigating this growing threat to mental health will increase the indirect mortality from causes other than COVID-19.
Trauma practitioners should be aware of the range of the impact of psychosocial issues that have created unsettling concerns during COVID-19 and the related stressors[11]. There is now an enhanced need for trauma practitioners to assess and monitor debriefing participates related to a number of combined stress factors (e.g., exposure to infected sources, family members, loss of loved ones, social distancing), secondary stress factors (e.g., financial loss, loss of job), psychological impacts (e.g., depression, anxiety, sleep disorders, increased substance use, preoccupation with psychosomatic issues, and violence) and vulnerability (e.g., exacerbation of existing physical or mental health issues). The ability of the practitioner to provide education and a degree of normalization regarding these collective symptoms and stress reactions is an important factor towards more positive outcomes.
More than ever, there is a need for vigilance around suicide. There is evidence that deaths by suicide increased during the 1918-1919 influence pandemic[12] and also during the 2003 SARS epidemic[13]. Based on some limited studies regarding COVID-19[14] the impact of fear, self-isolation and social distancing and the stress factors noted above will worsen symptoms of mental health disorders that are associated with increased risk of suicide[15]. As we enter uncharted new territory, those vulnerable to mental health and psychological issues and suicidal behaviour will require more intensive measures for prevention, intervention and postvention. Emotional contagion or vicarious trauma is at its peak with the uncertainty, mass deaths, fear and anxiousness amongst the population. With the big emotion of grief and loss, sadness or anger and the need for connection, which is limited at this time, many people become more and more isolated, withdrawn or self-harm or harm others. Finding ways to connect with each other, helps with the big collective fears and anxiety, helps the body ease and the mind settle so that we can get through the stressful times.
For trauma practitioners who are engaged in unprecedented challenging times where the need to support many people at one time will require adjustment to traditional practice. By providing debriefing support services for those reaching out is as crucial as ever. As always, where possible, a coordinated, comprehensive approach with colleagues and agencies to provide on-going debriefing services should also involve ongoing monitoring of participants. The capacity of practitioners over the coming months will be stretched and the need for community-based debriefing is likely. Rapid development of technological solutions towards meeting social distancing criteria will play a part in the collective response – the efficacy of these interventions remain generally untested.
Self-care and development of formal and informal practitioner networks will be essential in developing robust responses to this crisis. The ability for practitioners to access credible, consistent and reliable information on current issues, resources and response is a key priority and as a trauma community we must dedicate resources to promote an integrated response as part of the general pandemic public health response. Along with the need for debriefing to take care of the vicarious trauma there is a need to recognize the vicarious goodness or kindness as well. There are many amazing stories of people volunteering, just phoning and having friendly visits with adults living alone, with families stretched thin and helping each other have the basic amenities. This collective kindness is also part of our personal wellness and social cohesion that is a community builder, strength-based aspect of our society.
The psychological impacts of COVID-19 create an opportunity for trauma practitioners to increase awareness, prevention, intervention and postvention measures to support of our front-line heroes and fellow community members. Prevention, intervention and postvention based on the CISD[16] approach will require modification and flexibility for success. A new standard of practice is unfolding before us. As such, there are many considerations for practitioners in the context of the CISD model that may be useful in your practice, realizing that best practices and research are being explored concurrently with this discussion.
[1] Lenore Manderson & Susan Levine, COVID-19, Risk, Fear, and Fall-out, Medical Anthropology: Cross Cultural Studies in Health and Illness (2020).
[2] Id.
[3] Y. Neria, A. Nandi & S. Galea, Post-traumatic stress disorder following disasters: A systematic review, 38 Psychological Medicine 467–480 (2008).
[4] H Javidi & M Yadollahie, Post-traumatic Stress Disorder, 3 Int. J. Occup. Environ. Med. 2–9 (2012).
[5] Luna Sun et al., Prevalence and Risk Factors of Acute Posttraumatic Stress Symptoms during the COVID-19 Outbreak in Wuhan, China, medRxiv 2020.03.06.20032425 (2020).
[6] Betty Pfefferbaum & Carol S. North, Mental Health and the Covid-19 Pandemic, N. Engl. J. Med. (2020).
[7] Javidi and Yadollahie, supra note 4.
[8] Nicola Montemurro, The emotional impact of COVID-19: from medical staff to common people, Brain, behavior, and immunity (2020).
[9] Ronald Fischer et al., Rapid review and meta-meta-analysis of self-guided interventions to address anxiety, depression and stress during COVID-19 social distancing.
[10] Danny Horesh & Adam D. Brown, Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities, 12 Psychol. Trauma 331–335 (2020).
[11] Pfefferbaum and North, supra note 6.
[12] Ira M. Wasserman, The Impact of Epidemic, War, Prohibition and Media on Suicide: United States, 1910–1920, 22 Suicide Life‐Threatening Behav. 240–254 (1992).
[13] Montemurro, supra note 8.
[14] David Gunnell et al., Comment Suicide risk and prevention during the COVID-19 pandemic, 2019 Lancet Psychiatry 1–3 (2020).
[15] Id.
[16] Ann M. Mitchell, Teresa J. Sakraida & Kirstyn Kameg, Critical incident stress debriefing: Implications for best practice, 1 Disaster Manag. Response 46–51 (2003).
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