Trauma-informed responses in addressing public mental health consequences of the COVID-19 pandemic: position paper of the European Society for Traumatic Stress Studies (ESTSS).

The COVID-19 pandemic has changed life in Europe and globally. The pandemic affects both individuals and the broader society across many domains, including physical and psychological health, the economy and general welfare. The measures taken to counteract the pandemic have significantly altered daily life and, along with the threat of contracting the coronavirus and uncertainties surrounding future developments, created a complex system of stressors with a negative impact on public mental health. This paper aims to outline the ESTSS strategy to address mental health issues related to COVID-19 and focuses on (1) trauma-informed policies, (2) capacity building, (3) collaborative research and (4) knowledge-exchange. To facilitate implementation of a trauma-informed approach and appropriate measures, ESTSS has developed a toolkit of recommendations on mental health and psychosocial assistance to be provided during the different phases of crisis and its aftermath. To promote capacity building, ESTSS offers a certification programme based on a curriculum in psychotraumatology and corresponding on-line training to the European community of mental health professionals. To assure evidence-based approaches and methods tailored to current circumstances, ESTSS has initiated a pan-European research project with international cooperation aimed at studying the mental health consequences of the pandemic, with a focus on psychological trauma and other stress-related reactions. To foster knowledge-exchange, the European Journal of Psychotraumatology (EJPT), the official journal of ESTSS, is publishing a special issue on COVID-19.

Introduction

A novel coronavirus disease (COVID-19) was first reported in China in December 2019 and quickly spread around the world, creating a pandemic. In the beginning of spring 2020, the rapidly developing pandemic turned Europe into one of the epicenters of the outbreak and of the global health emergency (WHO, 2020a). The crisis is often referred as a ‘marathon, not a sprint’, meaning uncertainty concerning the degree of its ultimate control, and possibility that COVID-19 will become a recurring seasonal infection. Various authorities and experts have described the situation as unprecedented not only because of the virulence, speed and scale of the outbreak, which has resulted in a high death toll but also because some preventative measures are having a negative impact on other important life domains.

According to emerging evidence, public mental health has become an area of great concern, and stress-related symptoms are highly prevalent (Ahmed et al., 2020; Brooks et al., 2020; Liem, Wang, Wariyanti, Latkin, & Hall, 2020; Lima et al., 2020; Rossi et al., 2020; UN, 2020; WHO, 2020b). Such a picture supports the general view that trauma is a major public health issue (Magruder, McLaughlin, & Elmore Borbon, 2017) and that public health should be a central perspective of psychotraumatology (Olff et al., 2019). Furthermore, as the crisis is occurring at a society-wide scale, it creates risks for development of cultural/societal trauma (Alexsander, 2003), which requires a complex, trauma-informed psycho-socio-political response for normalization of societal life after the catastrophe. In the context of the current crisis, trauma-informed and trauma-specific policies and care are gaining special importance as they provide a comprehensive framework for understanding and responding to complex stress- and trauma-related situations.

In this paper, we will first describe the COVID-19 related public mental health challenges in Europe, then summarize the literature on mental health effects of pandemics, then describe the need for trauma-informed responses and, finally, state the strategy of ESTSS to respond to COVID-19.

The COVID-19 related challenges and mental health consequences of pandemics

The COVID-19 crisis has created a complicated system of stressors affecting the whole of society in a multi-layered manner. Among others, the main stressors are abrupt changes in life circumstances; uncertainty about the future; deterioration of livelihood; restriction of social contacts; imposed quarantine; stigmatization, discrimination and fragmentation of communities; loss of loved ones; deprivation of culturally appropriate mourning rituals; and finally, the threat of contracting COVID-19. The widespread lockdown, self-isolation and quarantine measures have also raised questions about the protection of fundamental human rights such as freedom of movement. These same or similar issues have prompted commentaries during past epidemics, such as SARS, MERS, and Ebola (Brooks et al., 2020; Shah et al., 2020). Also of great concern are the issues of equitability of care and the crucial role of health-care workers, especially when basic safety equipment is lacking and they are facing life-threatening risks (Kang et al., 2020; WHO, 2020a; Williamson, Murphy, & Greenberg, 2020).

It is well known that in the case of disasters most affected individuals, families and communities demonstrate resilience and cope with exposure to stressors without major mental health consequences; at the same time, a rise in psychiatric morbidity and psychosocial problems is to be expected (McFarlane & Williams, 2012).

Although there is a paucity of evidence on the impact in Europe of pandemics of this scale on the mental health and psychosocial wellbeing of the general population and vulnerable groups, there are studies revealing the impact of past epidemics (e.g. SARS, MERS and Ebola) in other affected regions, such as Africa and Asia that support the above concerns. These studies reveal a high prevalence of mental health problems among affected people, existence of psychiatric co-morbidities during the early stage of manifestation, as well as long-term conditions among survivors, including depression, suicidality – especially among the older survivors, and PTSD (Batawi et al., 2019; Cheung, Chau, & Yip, 2008; Hung, 2003; Lee, Kang, Cho, Tim, & Park, 2018; Mak, Chu, Pan, Yiu, & Chan, 2009; Maunder et al., 2003; Mohammed, Sheikh, & Gidado, 2015; Phua, Tang, & Tham, 2008; Shah et al., 2020). In addition, emerging studies on the impact of COVID-19 reveal a high level of distress and increased prevalence of mental health symptoms among the general populations of the affected countries. This includes symptoms of anxiety, depression, adjustment disorder and PTSD, as well as hazardous and harmful alcohol use (Ahmed et al., 2020; Liem et al., 2020; Lima et al., 2020; Rossi et al., 2020). A recent review of the psychological impact of quarantine suggests a number of negative psychological effects such as confusion, anger and post-traumatic stress symptoms (Brooks et al., 2020). According to studies shedding light on the relationship between stigmatization and virus outbreaks, survivors, their families, medical personnel and social workers are vulnerable to stigma and related discrimination by their respective communities. This had a negative impact on their psychosocial wellbeing and mental health (Park, Leeb, Park, & Choid, 2018; Sim, 2016). Studies on medical personnel following SARS outbreak reported prevalence rates of mental health problems from 18% to 58% depending on the task they performed and coping strategies employed (Phua et al., 2008), and increased risk for moral injury and PTSD (Kang et al., 2020; Lee et al., 2018; Williamson et al., 2020). Studies on international migrant workers reported increased prevalence of mental health symptoms among them as well (Mohammed et al., 2015; Liem et al., 2020). Some authors describe past epidemics (e.g. SARS) as a ‘mental health catastrophe’ (Mak et al., 2009). The COVID-19 pandemic holds the risk of becoming another such mental health catastrophe given its speed, scale and death toll, as well as the effects of prolonged lockdown and uncertainty regarding closure. In light of available findings, early intervention and implementation of appropriate strategies to reduce the mental health and stress- and trauma-related consequences of the COVID-19 crisis gain critical importance.

The need for trauma-informed and trauma-specific responses

Available findings demonstrate that threats to physical health are interlinked with mental health consequences, and that mental health is an essential component of public health (Prince et al., 2007). Given this, there is a moral imperative to address the mental health and psychosocial wellbeing of the general population and vulnerable groups. Therefore, public mental health interventions (such as ‘REACH for Mental Health’) (Denckla, Gelaye, Orlinsky, & Koenen, in press) are needed. Special attention should be paid to psychological trauma and to the implementation of trauma-informed and trauma-specific policies, strategies and practices.

The notion of trauma-informed care emerged in the beginning of the twenty-first century to support the implementation of a paradigm of care for socially disadvantaged groups – survivors of adverse childhood experiences, people with intellectual disabilities, women survivors of violence, homeless individuals. This initiative was based on the conviction that there was an under-estimation of the impact of trauma on physical and/or mental suffering (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; Hopper, Bassuk, & Olivet, 2010; Keesler, 2014; Ko et al., 2008; Wolf, Green, Nochajski, Mendel, & Kusmaul, 2014). Trauma-informed care is a paradigm that recognizes the role of traumatic experiences in many mental and physical health-related conditions and recommends that specific policy principles be adopted by health and social care systems, organizations and schools to increase awareness of trauma in order to avoid re-traumatization and to facilitate recovery. Some authors consider trauma-informed care a useful framework for broader social policies and advocacy (Ardino, 2014, 2017; Bowen & Murshid, 2015), referring to the following principles: safety, trustworthiness and transparency, collaboration and peer support, empowerment, choice, and the intersectionality of identity characteristics (Bowen & Murshid, 2015; SAMSHA, 2014; Wolf et al., 2014).

We argue that the COVID-19 pandemic, as a crisis creating serious risks for public mental health, requires the adoption of a trauma-informed framework, which could provide effective guidelines to address the crisis from a public health perspective by increasing awareness of trauma-related issues, avoiding re-traumatization and bolstering prevention.

The adoption of trauma-informed policies, strategies and practices is important not only during the crisis but also in its aftermath to prevent or mitigate more severe public mental health consequences and support resilience of the affected individuals, families, communities and societies. Hence, it is vitally important to put in place trauma-informed policies not only for psychosocial and mental health-care responses to COVID-19 but also at a larger scale for crisis management. Table 1 presents the corresponding measures.

Table 1.

Trauma-informed and trauma-specific measures of crisis management.

Macro level (policies)	Trauma-informed	- Trauma-informed crisis-management policies[Among other relevant measures, addressing physical health protection-related needs of those disadvantaged groups, which are most vulnerable to contract COVID-19, i.e. refugees in Europe, etc.]- Trauma-informed mental health and psychosocial support policies[Among other relevant measure, addressing mental health and psychosocial needs of the most vulnerable groups, i.e. forced migrants, people below poverty level, people with mental illnesses, etc.]
	Trauma-specific	- Trauma-specific policies of mental-health and psychosocial care[Among other relevant measures, addressing a need in trauma-specific care of the most vulnerable groups, i.e. forced migrants, survivors of domestic violence, etc.]
Mezzo level (strategies)	Trauma-informed	- Trauma-informed quarantine strategies for forced migrants and other survivors of violence- Trauma-informed organizational culture in organizations and agencies involved in crisis management- Trauma-informed staff care strategies for medical personnel-Trauma-informed pre-deployment training for front-line workers (uniformed services personnel, journalists, local governance-structure representatives)- Culturally appropriate mourning and memorialization rituals adapted to the conditions of the pandemic
	Trauma-specific	- Trauma-specific professional guidance via mental health & psychosocial support guidelines, updated/tailored to the pandemic- Research collecting evidence on the pandemic-related needs and psychological reactions of the general population and at-risk groups, and on the effectiveness of trauma-specific interventions- Increased capacity of services providing internet-based crisis counselling and digital care- Relevant training and supervision for professionals adapting internet-based modes of counselling and therapy- Adequate staff-care and supervision for professionals engaged in crisis counselling and provision of care in the post-pandemic phase
Micro level (services)	Trauma-informed	- Trauma-informed support for vulnerable groups[Among other relevant measures, reducing their exposure to COVID-19 as a life-threatening stressor, by providing the personal protection means, such as disinfectors, gloves, masks, etc.]- Trauma-informed mental health and psychosocial interventions including psychological first aid- Trauma-informed pedagogy- Trauma-informed primary health care responses- Trauma-informed medical care for somatic problems
	Trauma-specific	- Trauma-specific evidence-based preventive interventions tailored to the needs of the general public and vulnerable groups- Trauma-specific evidence-based mental health and psychosocial interventions- Trauma-focused evidence-based therapies for people in need

The European countries differ in their capacities for psychotrauma care (Kazlauskas et al., 2016; Schäfer et al., 2018) and may need more or less assistance and efforts in the areas described above, but no nation should be left behind. Moreover, existing procedures for delivering evidence-based psychological treatments for trauma- and stress-related disorders need to be revised since the usual procedures often cannot be applied because of quarantine measures in many countries. There is a large body of evidence that Internet-based Cognitive-Behavioural Therapy (ICBT) interventions are similar in their effectiveness to traditional face-to-face treatments in case of a number of mental health conditions (Carlbring, Andersson, Cuijpers, Riper, & Hedman-Lagerlöf, 2018). However, internet-based interventions are not yet routinely implemented in health-care systems in Europe and, to change this, models of health services delivery should be updated immediately based on the available evidence (Wind, Rijkeboer, Andersson, & Riper, 2020). In addition, evidence regarding effectiveness of trauma-specific modes of internet-based treatment remains to be obtained. Importantly, psychotherapists are themselves immersed in the pandemic, so they find themselves in a peculiar position compared to other situations, and this requires novel approaches to staff care adapted to these new circumstances.

ESTSS responses to the COVID-19 crisis

Based on its mission to promote sharing of knowledge and experience about all aspects of psychotraumatology by fostering research and best practice, building networks, and contributing to public policy at the European level, ESTSS has an important role to support the management of the current pandemic-related crisis. In taking on this role, the society faces the challenge of preventing fragmentation of initiatives and fostering knowledge-exchange through different strategic steps. ESTSS has a good track record of activities in this regard, which includes the European Network for Traumatic Stress Guidelines on Psychosocial Care Following Disasters and Catastrophes (TENTS), the European Curriculum in Psychotraumatology, and the European Journal of Psychotraumatology (EJPT). Building on these experiences, ESTSS aims at a broad and inclusive response to COVID-19, adopting a multi-layered approach under the umbrella of trauma-informed principles.

The ESTSS strategy to tackle mental health issues related to COVID-19 focuses on (1) trauma-informed policies, (2) capacity building, (3) collaborative research, and (4) knowledge-exchange:

1. To facilitate implementation of trauma-informed policies, ESTSS has developed a special toolkit of recommendations:

ESTSS issued a set of recommendations on mental health and psychosocial care for implementation throughout different phases of the pandemic and its aftermath (see: https://mail.google.com/mail/u/0/#inbox/CwCPbnqlVpqkMqQPHlqTRqHRTxnNKqB?projector=1&messagePartId=0.1). The recommendations are based on the framework of TENTS Guidelines (Bisson et al., 2010). The structure of the document is built on the idea of comprehensive responses at the following three levels: macro (policies), mezzo (strategies), and micro (services). The micro-level recommendations include guidelines for immediate response as well as recommendations for actions during the prolonged (‘Living with COVID-19’) period of crisis, when the need for mental health and psychosocial services will likely increase due to the complex and multiple stressors and difficulties associated with the pandemic (Javakhishvili et al., 2020).

2. To promote trauma-informed capacity building, ESTSS offers a certification and corresponding on-line training:

In times of crisis as during the current COVID-19 pandemic, we need to promote mental health interventions. Based on the newly introduced system of the European Certification in Psychotraumatology, ESTSS provides capacity-building opportunities to the European community of professionals from different countries at individual and organizational levels (see curriculum: https://estss.org/estss-certification/estss-certificate-curriculum/). With the first group of countries joining this initiative in 2020, it seems to come at the right time.

3. To stimulate collaborative research, ESTSS supports a research agenda focused on COVID-19:

A pan-European study aiming at exploring relationships between different COVID-19 related stressors, coping strategies, and the wellbeing of affected populations has already been launched (see also https://estss.org/estss-pan-european-study-focused-on-exploring-the-impact-of-covid-19-related-crisis-on-the-wellbeing-of-the-general-population/ and https://www.global-psychotrauma.net/corona). In addition, ESTSS emphasizes the need for studies in the following directions: the impact of the COVID-19 outbreak on the mental health and psychosocial wellbeing of medical personnel involved in care of COVID-19 patients; the impact of COVID-19-related traumatic loss on family members of victims; the impact of COVID-19 on the wellbeing of forced migrants; the role of trauma-informed organizational culture in preventing professional burn-out. To collect evidence facilitating insight on the effects of COVID-19-related stressors and to analyse and define evidence-based methods of care, ESTSS welcomes inter-country, regional and international cooperation in research. This is in line with the role of ESTSS as part of the Global Collaboration on Traumatic Stress (https://ka.global-psychotrauma.net/).

4. To foster knowledge-exchange, the European Journal of Psychotraumatology (EJPT), the official journal of ESTSS, is focusing on the COVID-19 crisis:

The European Journal of Psychotraumatology is publishing a special issue on COVID-19 (see call for papers https://think.taylorandfrancis.com/special_issues/coronavirus-traumatic-stress/?utm_source=TFO&utm_medium=cms&utm_campaign=JPD14187&utm_source=CPB&utm_medium=cms&utm_campaign=JMY07281), with a rapid review process in place to recognize the urgency of the topic and to promote the dissemination of knowledge and experience on a larger scale.

Conclusion

Europe faces major challenges stemming from the COVID-19 pandemic, and protecting public mental health is one of these. Existing evidence suggests there may be an increase in mental health problems and psychotrauma-related reactions and conditions among affected populations. To minimize these grave consequences, it is crucial to put in place trauma-informed policies, strategies, and interventions as well as to promote evidence-based methods of trauma-specific care, tailored to the new circumstances. With the spectrum of activities outlined above, the European Society for Traumatic Stress Studies aims at contributing to this endeavour.