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Dr. April Naturale on COVID-19 Trauma, Grief, and Growth

Dr. April Naturale on COVID-19 disaster recovery and community resilience

On December 31st, a cluster of people with pneumonia of unknown etiology were identified in Wuhan, China. By January 7th, the nation’s health authorities confirmed that the cause was a novel coronavirus, 2019-nCoV. To date, we know the virus has made its way to at least 185 countries and territories, overwhelming healthcare systems and causing governments to implement physical distancing to combat it. What’s likely next in mental health, as the unrelenting virus continues moving quickly across the globe, is increases in traumatic grief, PTSD, and posttraumatic growth.

April Naturale, Ph.D., a leading traumatic stress specialist on disaster recovery and community resilience, says disaster experts have primarily centered their response and study on the immediate and intermediate phases after an event. As a result, they know, for instance, that crisis intervention programs, psychoeducational information, and social support—as well as the crisis intervention contacts themselves—help to decrease people’s anxiety. She says these measures reduce the stigma associated with a community’s typical responses to disasters, helping survivors to feel less like “something is wrong with them.” There has also been some momentum looking ahead: experts turning their lens to include the long-term impact of disasters. They’ve discovered rises in domestic violence, substance abuse, divorce, and traumatic grief. “This is different from the type of grief where a person is missing a loved one and remembering them. Instead, traumatic grief doesn’t change. It stays with people and stops them from functioning, which makes it diagnosable.” 

Trauma

Many communities that experience a disaster hold firm to the concept that it’s vital to never forget. For example, after 9/11, the Department of Justice offered funding to numerous communities in the New York area so that they could have a local memorial. “We did a survey to see if people wanted it and, overwhelmingly, they said, “No way—we don’t ever want to stop remembering because people can learn from this.’” She notes that this is a theme she’s seen time and time again after a disaster. “These events become reference points in our lives.” 

Some people, though, says Dr. Naturale, are unable to adapt to the loss. What’s unique is that a person can start to have traumatic stress symptoms, years, even decades, after the disaster. “It might be that something sets them off or activates their distress, and it can happen at any time.” She points out that mental health workers need to keep traumatic stress and grief on their radar because even if somebody appears at a community mental health center having experienced a horrific trauma or disaster 15 years ago, “they could have symptoms that look like it has happened more recently.” Traumatic stress and grief are not the same as PTSD. While the trauma of an event is awoken, the person may still not experience intrusive imaging, avoidance, or denial. Instead, they might have anxiety, obsessiveness, or sadness and grief. “It may not be to the point that it’s pathological, but rather an ordinary response, years later, to an event somehow activated in their memory.” 

The COVID-19 pandemic is already resulting in an uptick of traumatic stress and grief, resulting in a significant increase in calls—from about 50 a day to 600—to the Disaster Distress Helpline, the nation’s crisis call and texting service. Also possible, perhaps even more likely, says Dr. Naturale, is that the reaction will be similar to what we see in our veteran population who experience chronic PTSD symptoms. “People’s symptoms remain at a constant, heightened level, and for some, may become so severe that they become engrained, stuck.” Unlike other disasters we are more familiar with, like a tornado, hurricane, or mass shooting, COVID-19 has yet to stop. “We don’t see an endpoint.” This sustained, continuous state, Dr. Naturale says, can harm people’s wellbeing, physically and mentally. 

Continuous, Heightened Sense of Fear

A continued state of fear—fear of death or serious injury to ourselves or to our loved ones—is exhausting. Dr. Naturale says that the constant threat makes it “challenging for the body to maintain good health.” “It’s tiring to have heightened anxiety, worry about and check in with family all the time, being afraid to go out, and having a rapid heartbeat.” These symptoms can tire us out and can quickly become chronic because our fear response continues to be active. “It doesn’t get to settle down.” 

The result, she says, is that people begin to lose their ability to function well and start to have anxiety symptoms such as sleep problems, agitation, poor decision-making capabilities, and poor judgment, which are just a few of the longer-term effects of chronic distress. Dr. Naturale says that, after Hurricane Katrina and 9/11, people’s symptoms began to decrease after a few months. Conversely, during COVID-19, she and her colleagues are seeing more aggravated, chronic complaints. “It’s serious, and why we are trying to help people use good coping skills and get into a routine, so they aren’t in a constant state of distress.”

The Unseen

What compounds ongoing heightened stress is that we can’t see the virus, causing widespread fear. “We don’t know who is a threat. Is it the stranger sneezing without covering their mouth or the asymptomatic person?” Either way, she notes, close proximity makes people worried about droplet exposure. Dr. Naturale says this is reminiscent of the terrorist sarin gas attack on Tokyo’s subway on March 20, 1995. The Aum Shinrikyo cult set off several packages of the deadly gas in the subway system, killing 12 or 13 people (reports are inconsistent) and injuring thousands. Secondary exposure also injured essential personnel, including healthcare workers and firefighters. In fact, 135 (9.9%) of the 1,364 fire department first responders experienced exposure while transporting victims to emergency facilities. 

Unpredictable

COVID-19 has presented another challenge that further exacerbates people’s fear: it’s unpredictable. “It’s a tricky virus that has varied symptoms, thus making it difficult for the best academics and scientists in the field to determine best practices. We don’t know what it will do next or what antiviral will sufficiently combat it.” Dr. Naturale says that’s why mental health and medical experts from around the world must collaborate. She says that, otherwise, the result is a sense, especially in those affected, including front line healthcare workers and other responders, that they are alone. Instead, they could be speaking to and reading the after-action reports to access the lessons learned in nations where the virus hit earlier. 

“It hasn’t been our habit in the United States to look back at what other people did in a situation because we seem to have the sense that it’s our emergency: no one else has experienced anything like what we are going through. To a certain extent, each event is unique, but the human responses are the same globally in people: sadness is sadness, and happiness is happiness. There are important and helpful lessons to be learned so that we don’t keep trying to reinvent the wheel.”

Connection to Combat Isolation

Over time, we are discovering the unintended consequences of physical distancing, separating people from the supports on which they rely. Dr. Naturale says isolation will continue to be a problem, particularly in nursing homes, hospitals, and residential facilities where procedures, as a result of an infected person at the facility, may require people to be isolated in their rooms. It’s not just adults who are at risk. Among adolescents, because it gives more emotional closeness, face-to-face social interaction is more protective against loneliness than electronic communication. 

Physical distancing is our greatest defense against COVID-19, but Dr. Naturale points out that isolation can halt the recovery process, putting vulnerable people at further risk of a mental health crisis. “We know from suicide prevention literature that isolation is one of the biggest red flags.” 

During COVID-19, we have to work even harder to connect if we can’t physically be with one another. “In a disaster, social support helps us more than anything else.” Face-to-face interaction allows people to feel each other’s projections, picking up on one another’s mood. “Humans have a herd mentality when it comes to wanting to be with our people and wanting to give hugs; we thrive on the energy of friends and loved ones.” Dr. Naturale says lack of connection and isolation will be an ongoing problem during distancing orders if we don’t figure out how to sufficiently protect ourselves from the virus and still be in the presence of loved ones. “We need to feel the stability, calm, and love that we share for each other.” She says that emails, writing notes, and phone calls offer connections. Virtually meeting with one another allows people to see one another’s facial cues and even make eye contact to some degree. When it comes to handwritten notes, Dr. Naturale suggests people “write their authentic and truthful thoughts.” “Sharing what you care about and like in that person allows for that essential projection of emotion, which we thrive on.”

Shifting into the Unknown 

What will likely be distressing for many people, perhaps even more so than the current situation, is the uncertainty of transitioning back to a world without physical distancing. Dr. Naturale says communities and individuals need to be careful. “We will be so eager to go back to what we did before, and turn to those comforts, when, really, we need to continue taking precautions.” Experts believe that, like with the 1918 flu, there will be waves of COVID-19, with the second wave hitting in the fall. Coinciding with the flu season, this would result in an increased demand on our healthcare system, making the second wave potentially worse than what we are experiencing now. What we know from history is that the second wave of the 1918 flu was more deadly, and those communities that ignored physical distancing had more cases of influenza. “We talk about this when we train our staff. When they go out into communities, they need to remind each other that we will continue to need to take precautions.” 

As regulations are lifted, people will individually decide which safeguards they buy into and which ones they don’t, creating a great deal of variability. Dr. Naturale notes that people should do what makes them feel most comfortable and safe because “being afraid all the time is going to have a negative effect, both physically and emotionally.” While it’s not possible to control what others do, she says that people do have choices, such as deciding not to spend time with those who aren’t following the recommendations or regulations. “It’s going to come to a personal decision as to who we engage with, how much protection we feel comfortable with, and what we do to make sure that we can get away from situations that make us feel unsafe. That’s a lot of what we are going to be talking to community members about.” 

People are tired of sheltering in place. As a result, some will continue to buck against precautions. Dr. Naturale says compliance is most likely to occur when people are employed and have their basic needs met—home, shelter, and food. Also, she notes, it requires a sense of community—that we are all in this together.

Posttraumatic Growth

While COVID-19 and sheltering in place has created enormous stress on many Americans, including illness, separation from ill or dying family members, unemployment, days that don’t seem to have an end, simultaneously working and caring for children or aging parents, there are also positives. Dr. Naturale says it’s been a time out—a reset of sorts that highlights the absurdity of work schedules in the United States that have resulted in long hours where “we haven’t been able to spend enough time with loved ones or do activities that have more meaning in our lives.” She says the outcome may be a cultural shift, altering the American work-life balance. Whenever there’s a disaster, there’s trauma, but there is also posttraumatic growth that allows people to rethink their priorities. That can result, says Dr. Naturale, in people having more gratitude for and spending time reconnecting with their parents or children, getting to know their neighbors, and being helpful in their communities. People have reported feeling that they have been able to recenter themselves. She believes we will take that with us, perhaps even more than the fear and trauma.

“As a race, we have survived by helping each other—it’s something innate in our makeup that tells us if we don’t help each other, we’re not going to survive as a species. COVID-19 is helping us pay more attention to this, and being more connected with folks on a deeper level is a good thing. Hopefully, we will take that away from this first intense, shocking initiation of now having the virus in our lives. Disasters will happen, but we can protect ourselves and be kind at the same time.”