Trauma, mental health and the COVID-19 crisis: are we really all in it together?

As the world adapts to varying levels of social lockdown – and the lifting of restrictions – due to the COVID-19 pandemic, evidence is mounting that quarantine and other social restrictions negatively affect the mental health of the general population (Kumar & Nayar, 2020). This universal public health threat has impacted all communities, but there is a growing evidence base that different groups are more at risk from the virus. One group that we argue are at increased risk are survivors of childhood trauma; a population also disproportionately represented in mental health services (Sugaya et al., 2012). This editorial describes the triad of injuries impacting trauma survivors; and consider how these social, physical and psychological effects interact with the current COVID-19 pandemic. A careful balance is needed between recognising the life-changing impacts of traumatic injury whilst understanding the individual variation among survivors. Trauma aftermaths can be mitigated with access to meaningful support. We discuss evidence of increased risks to trauma survivors during the current pandemic, what specific support survivors might need, and how communities impacted by COVID-19 can learn from survivor activism.

We are trauma survivor academics, students, activists and clinicians writing from different life experiences and identities. As this article was being written the global movement of Black Lives Matter has been reignited following the death of George Floyd. This has resonated for us in recognising the collective trauma caused by systemic racism, and the ways in which structural prejudice can interact with individual trauma leaving some people at increased risk of poor mental health and negative treatment in mental health services (e.g. McKenzie & Bhui, 2007). We want to be transparent that we cannot represent the voices of all survivors.

COVID-19 and a triad of traumatic injuries

Survivors of trauma often experience a triad of social, physical and psychological injuries. While these injuries are typically studied separately, they are better understood as interlocking and interdependent, shaping subjective experience in complex ways across the lifespan (Rose, 2019). The result can be ‘harm building upon harm’, reducing the ‘shock absorbers’ available to cope at times of stress.

Social-What is it like to be a survivor in the world?

Population level evidence suggests childhood trauma survivors face social disadvantages. Trauma amplifies marginalisation and the impact of social inequalities such as racism, misogyny and poverty (Lantz et al., 2005), and these can interlock (Crenshaw, 2016). Experiences of racism have traumatic impacts themselves (Williams et al., 2018), and inequalities are showing themselves starkly for BAME communities who are at high risk of death from COVID-19 (Platt & Warwick, 2020). There is strong evidence that health inequalities arise from social inequalities (Campion et al., 2020) and “a clear need for healthcare organisations to take an equalities approach to redress further inequalities that are arising as an impact of the pandemic: to ensure fair access and targeted information for diverse groups and to address racism, disability and other forms of discrimination in healthcare services” (Ocloo, 2020).

The social impacts of childhood trauma can be lifelong, such as reduced educational and vocational opportunity (Metzler et al., 2017), leaving survivors at risk of hardship during the economic downturn caused by the pandemic. This is harmful at a time when people unable to work as a result of disability arising from traumatic experiences (Sansone et al., 2005) are at significant risk from punitive aspects of welfare reform (Mehta et al., 2020).

Physical- what does trauma do to our health?

At a population level, trauma survivors are at increased risk of chronic physical health conditions in adulthood, including COPD (Anda et al., 2008), respiratory conditions (Bellis et al., 2014), autoimmune disorders (Dube et al., 2009), diabetes (Huffhines et al., 2016) and premature death (Happell et al., 2017). Underlying health conditions are linked to elevated risk of the most serious forms of COVID-19 and we hypothesise that many trauma survivors will be at increased risk from infection.

Psychological- what does trauma do to our mind?

Survivors of childhood trauma are at increased risk of a range of mental health diagnoses (Sugaya et al., 2012) including depression (Salokangas et al., 2020), anxiety disorders (Heim & Nemeroff, 2001), psychosis (Shevlin et al., 2007) and bipolar (Aas et al., 2016), in addition to PTSD and C-PTSD. Given that mental health diagnoses can mask traumatic aetiology, clinicians often miss the importance of childhood abuse when assessing and supporting adults (Xiao et al., 2016). This is accentuated by a lack of consensus of the role of childhood trauma in adult mental health (Cromby et al., 2019), particularly within psychiatry (Isobel et al., 2020). This matters to trauma survivors, not least because of the risk of re-traumatization in psychiatric systems (Sweeney et al., 2016).

Viewing adult mental health through a trauma lens is important during the pandemic because lockdown creates environmental conditions that parallel features of childhood abuse. Trauma survivors report entrapment and a loss of control that have consequences for their mental health (Karatzsias, 2017). Social restrictions may recreate this entrapment, leading to a difference between the normative distress caused by feeling isolated and the specific mirroring of abuse that leads to re-traumatisation (Jennings, 2009).

Another feature of childhood abuse is loss of trust in people, often as a strategy to reduce further violence and abuse (Sweeney & Taggart, 2018). The relational problems that this creates are a feature of complex trauma (Cloitre et al., 2018). Currently, social distancing is a public health imperative; for some survivors, this could trigger a re-emergence of relational mistrust which may prove difficult to transition away from.

COVID-19, trauma survivors and mental health provision

For some survivors, this triad of social, physical and psychological injuries has created ‘a perfect storm’ during the current crisis. Given that trauma survivors with both physical and mental health problems are at risk of significant health inequalities, it is important that their health needs are treated holistically. This includes considering the possibility of underlying trauma which may manifest as ‘non-engagement’ due to anxiety about intrusive treatment. In addition, being in a ‘vulnerable group’ can mean that people are required to shield for long periods, increasing the negative impacts on mental health and social connectedness.

An aligned risk also comes from the reduction in relationship-based healthcare during the pandemic. The move away from embodied contact and the preventative PPE increases distance between service users and clinicians. This may have consequences for the quality of therapeutic relationships, a key issue for trauma survivors given the erosion of trust in institutions (Sweeney et al., 2018). While this relational distancing is necessary its impact should be acknowledged. The idea of socially distant clinical/therapeutic relationships becoming the ‘new normal’ runs counter to the importance of acknowledging the interpersonal context in which childhood abuse occurs, and the importance of therapeutic relationships founded on trust, mutuality and respect as core to the healing process.

Access to trauma-informed mental health care is critical. However, there are longstanding problems with the funding model of the UK mental health system (Mason et al., 2011) including ongoing underfunding of community-based organisations, leading to long waiting lists and time-limited support (Smith et al., 2015). This is despite strategic commitments to lifelong services for survivors of rape and abuse (see, NHS England Document 2018–2023), with services for BAME communities particularly vulnerable to cutbacks (Imkaan, 2020). Moreover, the core principles of trauma-informed approaches are vital in service planning (Sweeney & Taggart, 2018). These include prioritising relational, collaborative approaches to treatment, offering choice, and using a trauma lens to understand mental health presentation (Sweeney et al., 2018).

Service provision should be underpinned by an understanding of the heightened risks of violence in domestic settings, predominantly perpetrated against women and children (e.g. Abramson, 2020; World Health Organization [WHO] 2020), because revictimisation across the lifespan is a significant risk for many survivors of childhood trauma (Graham-Kevan et al., 2015). Once lockdown measures were enforced in the UK, calls to abuse charities increased: Refuge, the UK's largest domestic abuse charity, reported a 700% increase in contacts to their online abuse hotline (Refuge, 2020). Given that trauma survivors may be vulnerable to further exploitative relationships, they may be at heightened risk of IPV under lockdown (Peterman et al., 2020). Awareness of the increased risks currently, and in the aftermath of the pandemic, will be vital in developing trauma sensitive approaches to managing risks of violence and abuse. The LIVES (Listen, Inquire about needs and concerns, Validate, Enhance Safety and Support) principles from the World Health Organization are an instructive starting point for this work (WHO, 2013).

Learning from trauma survivors

Focusing on the potential vulnerabilities of trauma survivors risks reinforcing a fatalistic narrative, which aside from not presenting the whole picture, undermines hope in survivors and clinicians. As a counterpoint, we want to draw attention to aspects of survivor history that communities negatively impacted by COVID-19 can learn from: the use of peer support networks and activism to drive for systemic change and social justice. For instance, the women’s movement, often including survivor activism, had a central role in advocating for a broadening of the criteria for PTSD in DSM-III to include domestic sexual violence and child sexual abuse (Herman, 1992). Recognition that gender-based violence is a causal factor in poor mental health has paved the way for trauma based approaches today. What is instructive for the current context is that advances in medical treatment are often preceded by social activism.

A further lesson from the history of trauma activism is the importance of avoiding victim blaming in public health. This happens in gender-based violence and sexual assault where women’s behaviour is used to explain their victimisation (Gravelin et al., 2018) and has been critiqued by activists, most prominently through the MeToo movement. Some responses to the COVID-19 pandemic blame individuals and communities in a similar fashion, suggesting it is individual behavioural choices that are of paramount importance. While behaviour is of importance, whole groups are being blamed in politicized discourses; including Asian communities (Gover et al., 2020) and young people (Pelizza & Pupo, 2020). From a trauma perspective, the stigmatisation of young people breaking lock down rules is important as rarely is it asked, why are they not staying at home? In many cases, similar to women being entrapped in abusive relationships, these young people are trapped in homes at risk of violence and neglect (Chevous et al., 2020) and it is important that mental health services respond in a culturally competent way to these generational differences which might look like reckless behaviour.

A further point is that the expertise about what harms and heals lies primarily with trauma survivors, and that this holds true for each individual as well as for survivor-led groups and organisations. Survivors Voices, for instant, write that the collective experience of trauma survivors is one of:

denial, being shut down, turned away from, blamed, pathologised and disempowered – trauma piled upon trauma. We ALL have much work to do to foster survivor-safe-survivor-sensitive-survivor-empowering environments in our organisations and in our communities and to develop trauma-aware-trauma-competent practices within professional helping relationships. What is your part to play? (www.survivorsvoices.org).

Are we ‘all in it together’?

The triad of injuries survivors face suggests an increased risk during the pandemic. Whilst it is useful to normalise the impacts of COVID-19, it is neither clinically helpful nor empirically valid to make generalised statements that ‘we are all in it together’.

Survivors of childhood trauma are people, in all the multiplicity of identity and history that this brings. Some of us will face on-going violence and abuse as adults, and many of us will be disproportionately at risk during this pandemic and in its aftermath. It is vital that mental health services take the specific needs of trauma survivors into account, and that future, post-pandemic research pays attention to the needs of people for whom the current crisis is a continuation or re-emergence of the social isolation, injustice, powerlessness and sense of on-going threat that shaped their childhoods.

Disclosure statement

No potential conflict of interest was reported by the author(s).