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Complications of Trauma and the Impact of COVID-19

On the morning of March 11, 2020, the World Health Organization (WHO) declared the coronavirus (COVID-19) outbreak a pandemic.

There has never been a time more important than today, in terms of understanding the complexities of trauma and the lifelong impact on survivors of homicide victims.  All the while, we are learning some ominous new phrases, like social distancing, self-quarantining, lockdown, nonessential businesses, and flatten the curve.  And the thing was, it all happened so fast. Every time we refresh our news feed, we get more bad stats, more to scare us, limit us, and isolate us. Millions are facing enormous losses such as jobs, food security, and those who live alone, talk of suffering a kind of loneliness beyond anything they’ve ever experienced. And, we’ve all seen untold images of overwhelmed doctors and nurses, gowned, masked and gloved, heroically attending to the ill and dying. Anxiety producing images are everywhere.

We are living in a time of pervasive uncertainty and imminent crisis. We face a worldwide pandemic, threatening climate catastrophes, deepening political instability, overt inequality, and regular eruptions of mass violence, plenty of fuel for depression and anxiety. The psychological, emotional, behavioural, financial and cultural diversity of our communities create even greater challenges and contribute to the complexities of treating trauma.

Even for those who are far removed from the crime of homicide, the complications associated with the fears surrounding COVID-19 have interrupted peoples’ lives.  Loss in many cases are the feelings of safety, security and balance. These losses trigger all sorts of reactions to previous experiences of other types of violence, including but not limited to, partner abuse, gender-based violence, child abuse, human trafficking, addictions and bullying, thereby creating the need for additional support in processing a previous trauma.

In the case of trauma experienced by parents of murdered children often times they continue through life in a state of near-constant fear that it will happen again.  Under these extreme circumstances, it’s not only the brain that goes into a vigilant state of bracing for danger – it’s the body and nervous system as well.

An interesting study funded by the National Institute of Justice in the U.S. found that survivors of homicide victims, who experienced the homicide, whether during their childhood, adolescence, or adulthood showed an equal likelihood of post-traumatic stress disorder (PTSD).

Homicide-related psychopathology among the bereaved assessed in this study includes the prevalence of lifetime homicide-related PTSD, depression, complicated grief, and substance abuse.

In the treatment of family members and other survivors of homicide victims, victim serving agencies have expressed concern that there is very little evidence-based research into the nature and prevalence of emotional, psychological, behavioral and financial impacts.

In going forward, developing best practices for victim serving organizations to address crime victim trauma, is an important part of any future planning on the part of all levels of government.  Meanwhile, mental health systems around the world are underfunded, inadequately staffed, and strangled by bureaucratic red tape. This erosion of resources at the macro level has taken its toll on individual mental health practitioners. Research reveals rising levels of burnout, sick leave, and involuntary and voluntary attrition. A vicious cycle has set in. Dwindling funding and a decrease in the number of practicing clinicians leaves fewer and fewer available to meet demand, resulting in increased pressure on the remaining resources.

The current crises have amplified the existing cracks in the foundation of our mental health system, and threaten the welfare of those in need.

There are no statistics available in Canada at this time, however, in the United Kingdom, for example, a recent report found 2,000 mental health nurses, therapists, and psychiatrists quit every month, since the Covid-19 pandemic began.  Canada needs to get ahead of this curve.  It is now critical that governments invest in resources to address the demands for mental health services that victim serving organizations have historically and continue to encounter daily.

When we think about traumatic events, it’s not just what the event is; it’s what the event causes for you.  The Covid-19 pandemic has dramatically altered everyone’s daily lives, including how people grieve the loss of a loved one. It has created a new context for people to comprehend death and grief, because so many people are dying in quite “disturbing” ways.  As with the death of a loved one due to homicide, it is sudden, unexpected and traumatic.

PTSD and the Effects of COVID-19

The most important thing to remember is that post-traumatic stress disorder is not about what is wrong with you, it’s about what happened to you. A single moment can last forever in the memory.  Remembering a traumatic experience can trigger a painful cycle of fear, anger, helplessness, depression, loneliness and shame.  Reliving the experience can feel almost like the actual moment of the event.

A diagnosis of PTSD requires exposure to an upsetting traumatic event. The exposure could be indirect rather than first hand. For example, PTSD could occur in an individual learning about the violent death of a close family member or friend. It can also occur as a result of repeated exposure to horrible details of trauma or violence.  Interestingly, after the SARS outbreak in 2003, both healthcare workers and people who were self-quarantined exhibited symptoms of PTSD.

According to experts, the COVID-19 pandemic could have a similar effect.  Healthcare workers providing frontline services, as well as people who have suddenly lost jobs or loved ones due to COVID-19 may be at greater risk for developing long-term difficulties, as well as those who already struggle with other mental health conditions, such as anxiety or depression are at an increased risk of more ongoing distress. Fear has overwhelmed the globe for months. It is therefore, understandable that the need for additional resources, comprised of enhanced and better funded victim support programs, as well as specific trauma treatments, which include both traditional and alternate modalities is now urgent.  This segment of our population, survivors of homicide victims, has historically been hugely underserviced.

As a population, survivors of homicide victims experience “a shattered assumption” of what life should have been.  They are a hugely underserviced, lacking the appropriate treatment options. The lack of emotional and financial support programs is self-evident. Given how many aspects of life are changing as a result of COVID-19, at such a rapid pace, survivors dealing with this type of complicated grief and trauma feel a “tsunami of loss”.

Social Isolation and Loneliness and the Impact of COVID-19

Many victims of crime were already living through an epidemic of loneliness, even before the Coronavirus pandemic started. Those who are lonely, as a result of a crime, do not choose to be isolated. Loneliness can be defined as the subjective feeling of being alone and not connected to others. Those who experience loneliness tend to have higher levels of cortisol, which is an indicator of stress. An accumulation of this stress hormone can suppress your immune system when exposed to pathogens. Being told to stay away from one another physically is the opposite of our innate response as humans to seek out and support one another during stress to maximize survival. Humans have lived in groups for thousands of years for this reason.

The new term “social distancing” was intended to stop or slow the spread of COVID-19 by limiting the number of people you come in contact with, while keeping a physical distance from one another. But more recently, the WHO says efforts taken to slow the spread of COVID-19 should instead encourage strengthening social ties, while maintaining that physical distancing. The new term “physical distancing” emphasizes the need to be physically apart, but socially we still need to work together. There are decades of research that support the importance of social connection and belonging. According to Abraham Maslow, humans possess an innate desire for a sense of belonging and acceptance. These needs are met through pleasing and fulfilling relationships with others. From the beginning of our lives, we are wired to connect. Conversely, isolation and disconnectedness are a common response experienced by victims of crime, and survivors of homicide victims. As a result, encouragement to promote social connection, by victim support organizations in a safe manner and in keeping with the WHO recommendations, is critically important today.

There are some ways to engage in positive social interactions while halting the spread of COVID-19 and turn social distancing into distant socializing.

Nature cultivates interconnectedness of others and reminds us that we are just a small part of the greater whole.  Hiking, taking a bike ride or a walk as often as time permits, and smiling and greeting people you pass along the way keep us connected to others and the outside world.

Thanks to the advancements and use of technology, we can interact in socially healthy ways.  Using Facetime, Zoom, or any other mode of streaming, as a chat function, can keep us connected with loved ones.  There are, also, virtual exercise classes, yoga and music and choir options offered. There are also party mode streaming capabilities that allow friends and family to join together in watching programs on television that, also, allows for a chat function.

Especially important is the ability to use various technology applications and conveyance-based platforms by victim service organizations and health professionals to deliver counselling and treatment sessions through these types of media.

Safe and socially distancing need not increase feelings of loneliness. Talk about your feelings of loneliness with others. It may not rid you of your loneliness entirely, but it lets you know you are not alone in that feeling.

The Media and the Impact of COVID-19

Staying informed also gives a sense of control over one’s life in a time when we are feeling not in control.  However, it is important to be cognizant of limiting our exposure to media related to COVID-19 reports, by using consistent and credible news sources for your information. Limit how often you check for updates. Constant monitoring of news and social media feeds can quickly turn compulsive and counterproductive—fueling anxiety rather than easing it. The limit is different for everyone; therefore, it is recommended to pay attention to how you’re feeling and adjust accordingly. If you’d feel better avoiding media entirely, ask someone you trust to pass along any major updates you need to know about. We’re in a time of massive upheaval. There are so many things outside of our control, including how long the pandemic lasts, how other people behave, and what’s going to happen in our communities. As long as we’re focusing on questions with unknowable answers and circumstances outside of our personal control, this strategy will get us nowhere—aside from feeling drained, anxious, and overwhelmed. Stick to trustworthy sources such as the WHO, Health Canada and your local public health authorities.

Fear – Victims of Crime and the Impact of COVID-19

Those who have been victims of crime have significantly greater fear of becoming future victims of crime. Three commonly used indicators are:

  1. feeling unsafe alone at home after dark
  2. feeling unsafe walking alone after dark
  3. worrying about becoming a victim of crime

Whether real or imagined fear, persistent hyper-vigilance and heightened anxiety raise stress hormone levels.  Fear can take an emotional toll, especially if you’re already living with an anxiety disorder or PTSD. Now, with COVID-19, fear has become pervasive in the general population. For many people, the uncertainty surrounding COVID-19 is the hardest thing to handle. We still don’t know exactly how we’ll be impacted, how long this will last, or how bad things might get. And that makes it all too easy to catastrophize and spiral out into overwhelming dread and panic. Even in the face of this unique crisis, there are many things you can do to manage your anxiety and fears. Staying appropriately informed is important, particularly about what’s happening in your community, so you can follow advised safety precautions. Unfortunately, there is a lot of misinformation going around, as well as sensationalistic coverage that only feeds into fear. Therefore, it’s important to be discerning about what you read and watch.

Most of us, who have been victims of crime, need reassurance, advice, or a sympathetic ear during this difficult time. As a word of caution, be careful who you choose as a sounding board. The coronavirus is not the only thing that’s contagious. So are emotions! Avoid talking about the virus with people who tend to be negative or who reinforce and ramp up your fears. Turn to the people in your life who are thoughtful, level-headed, and good listeners.

Domestic/Partner Violence and the Impact of COVID-19

The United Nations has said that violence against women is as serious a cause of death and incapacity among women of reproductive age as cancer, and a greater cause of poor health than traffic accidents and malaria combined. And, according to the United Nations data, a third of women worldwide suffer some form of violence in their lives.

The WHO has stated that the COVID-19 pandemic is causing a mental health crisis due to heightened stress and use of drugs and alcohol during months of lockdowns and stay-at-home measures.   Ongoing stay-at-home measures, coupled with the social and economic impacts of this virus, are increasing the risks of domestic violence.  Home is not a safe space for many. The mental health crisis is reaching a level that we’ve never seen before, and it is now urgent that mental health support is considered a critical component in the pandemic response.  We must reiterate here that governments at all levels need to expand mental health services and prioritize mental health as a part of their response to the pandemic.  Helpline calls have risen greatly, but the real extent of domestic violence during the COVID-19 pandemic is likely under-estimated as victims of abuse and violence are stuck at home, and outreach services are interrupted or unavailable.  With reduced contact to friends and family, or barriers in access to services and shelter, we are leaving the most vulnerable with nowhere to go.  The response to the rise in domestic violence has been complicated by the fact that police and health services are already under huge strain from the demands of dealing with the pandemic. Many domestic abuse shelters are already full, while others are barring new victims for fear of spreading the virus.

In developing best practices, to address this national, as well as global threat, measures must create safe ways for women to seek support without alerting their abusers.  Setting up emergency warning systems in pharmacies and grocery stores is one option that has been put forward, since these are among the few places people are still allowed to visit.  Shelters for abuse victims should be declared essential services and investment boosted in online services, and funding for nonprofit organizations, who supports victims of crime.

As a community, our focus should be to maintain high standards and to improve the health and wellbeing of our society as much as possible. As organizations that support victims of crime, it is our responsibility to educate and promote advancements in treatment options and inform policy makers, governments and our public health professionals thereby assisting them to make informed decisions that provide for the best outcomes possible.

Gun Violence and the Impact of COVID-19

Unlike some countries, Canada is not a country that promotes gun ownership.  Although gun ownership is legal and possible in Canada, there are various levels one must go through to obtain a license, including proof of gun safety etcetera.  Although checks and balances are in place to ensure those who should not be in possession of a gun exist, it still doesn’t prevent the illegal acquisition of firearms.  Gun violence has been on the rise since COVID-19 was declared.

The country’s worst mass shooting in history occurred in the midst of widespread shutdowns and took a grim prominence over COVID-19.  The mass shooting in Nova Scotia, with 23 dead, occurred in April.  Death related to gun violence has been escalating throughout many cities in Canada in 2020, and police agencies are constantly in the news expressing concerns that the lack of law and order is alarming and becoming widespread.

A possible explanation for the spike in gun violence recently may be related to the surging unemployment during the pandemic. It’s also possible that rising alcohol sales documented during the pandemic contributed to increases in gun violence. In many provinces across Canada where the economy ground to a halt to slow the spread of COVID-19, liquor stores remained open as essential businesses. Previous research has found that alcohol consumption can make people more likely to get into disputes that turn violent and involve firearms.  Although any type of violence can result in death, in cases involving firearms, most often the result is death.   Because we are only mid-way through 2020, it has been hard to know yet whether we are seeing a true, statistically significant increase in gun violence on the national level, as a result of   the pandemic. In addition to the concerns of rising gun violence this year, money and attention have been diverted to the fight against COVID-19, thereby leaving less funding for violence-prevention programs, especially in large urban areas.  Statistics have shown that social and community programs in large urban centres have been successful in reducing the crime rates.

If financial uncertainties, decline in social programs and substance abuse are contributing to a rise of gun violence in Canada, the best way to prevent this escalation is going to be by shoring up the social safety net, so that people have fewer economic stressors and more access to programs and services.

Various modalities such as music or pet therapy, forest and nature therapy applications, artistic expression, visualization reframing with meditative applications, as well as the traditional treatments such as cognitive behavioural therapy are available to explore.

Cognitive Behavioural Therapy

In treating victims of crime, a large amount of research has accumulated on the efficacy and effectiveness of Cognitive Behavioural Therapy (CBT) for anxiety disorders including PTSD.  However, as with the numerous types of trauma and the wide spectrum of individuals who experience trauma, extensive studies are still needed to determine which specific treatment components lead to beneficial outcomes, as well as which patients are most likely to benefit from these treatment components.

Since its introduction in the 1950’s behavioral therapy has evolved to include cognitive psychotherapy. Cognitive therapy focuses on changing perceptions, which is proposed to change emotions and behaviors. Subsequently, the terms cognitive therapy, behavioural therapy, and cognitive behavioural therapy have emerged. Over the years a large number of diverse protocols have been created for providing CBT to patients with PTSD, or an anxiety disorder. However, despite the large number of diverse CBT protocols for treating anxiety disorders, important similarities exist between these various treatments.  As with any type of treatment for PTSD or anxiety disorder used to treat victims of crime, the appropriateness must be evaluated by an accredited therapist specializing in the field of cognitive therapies. One size does not fit all; therefore, every treatment plan must be designed to address a particular type of circumstance and the corresponding individual need.

Nature Therapy

As defined by the Canadian Wildlife Federation, nature therapy, sometimes referred to as ecotherapy, describes a broad group of techniques or treatments with the intention of improving an individual’s mental or physical health, specifically with an individual’s presence within nature or outdoor surroundings.

Forest Bathing

Forest bathing, in its essence, means taking in the forest atmosphere. It’s to bathe one’s mind and soul with the forest. Shinrin-yoku, its formal title, is a concept that Japan adopted in 1982 which has shown to significantly improve people’s health. According to scientific studies, forest bathing (walking and spending time in the forest) can lower your blood pressure and lower your pulse rate.  Other studies have compared the cortisol levels in people after walking in a forest with those in an urban setting. They found that those who walked among the trees and nature had significantly lower cortisol levels, felt less depression and experienced a boost in energy levels.

Leaving your phone at home, so you won’t be distracted by notifications or calls, will provide the opportunity of being more focused so you can soak in the beauty, and pay more attention to sounds, sights and smells all around you.

Forest settings are much richer in oxygen levels.  For that reason, the air feels different in the forest leading to high levels of energy and mental focus. Taking slow deep breaths and focusing on meditative thoughts calms the body and reduces anxiety despite changes in the world around us.

Imagery Rehearsal Therapy

Imagery rehearsal therapy (IRT) is a cognitive-behavioral treatment for reducing the number and intensity of nightmares, such as those experienced by people with PTSD. Nightmares or terrifying dreams are among the most common PTSD symptoms. IRT focuses directly on helping to make nightmares less intense for people with PTSD. The intensity of a nightmare usually builds until the sleeper is too terrified to continue–and wakes up. In IRT treatment, you’re helped with the guidance of a qualified medical professional, who specializes in this treatment modality to reimagine your nightmares with different, less frightening outcomes. The goal is not to trigger emotional responses; instead, it’s to help you to “reprogram” your nightmares with as little emotion as possible, and to be less terrifying, if and when they occur again.

Pet Therapy

The inclusion of animals in psychological treatment is not new, nor is it uncommon. The first reported occurrence is estimated to be the late eighteenth century.  Animal-assisted therapy has been proposed as a treatment adjunct for traumatized patients and in the treatment of PTSD. In animal-assisted crisis response, dogs are used directly after a traumatic event to reduce stress and anxiety.

Evidence suggests that animals may provide unique elements to address several PTSD symptoms. With respect to intrusion, the presence of an animal is purported to act as a comforting reminder that danger is no longer present. Individuals with PTSD often experience emotional numbing, yet the presence of an animal has been reported to elicit positive emotions and warmth. Animals have also been demonstrated as social facilitators that can connect people and reduce loneliness, which may assist individuals with PTSD to break out of isolation and connect to the humans around them.

Music Therapy

Music holds a ubiquitous role in our society and the creation and consumption of music represents a universal human activity. There is a long and rich tradition of using music to cultivate resilience and facilitate healing in the wake of violence and oppression. Music has increasingly become internationally recognized as an intervention to be employed with clinical populations. Heath professionals and music therapists are working together to incorporate music therapy into treatment. The music therapist formulates a treatment plan that can involve musical improvisation, listening exercises, singing, music making, or the playing of an instrument, leading to a discussion of the emotions conveyed through a piece of music.  Or a music therapist can offer a tailored structure to shape and develop the course of therapy. For instance, the patient can create his/her own music with the therapist’s guidance as a way of expressing emotions.  The possibilities are limitless.

It is interesting to note here that the strength and power of music to motivate the human spirit has been demonstrated throughout history.  Songs and chanted hymns often accompanied physical labour that was endured by peoples enslaved; to coordinate movement and boost resolve to complete arduous tasks.  The introduction of communal music-making activities to reduce anxiety, stress, and fear in the wake of community violence, as result of racism and discrimination has been long practiced.