Odd Bird Out
How the Covid-19 Pandemic Has Changed the Landscape of Mental Health
How the Covid-19 Pandemic Has Changed the Landscape of Mental Health: The Importance of Intergenerational Trauma Focused Therapies
At the end of 2021 I wrote a research paper for one of the classes that I was taking. My genetics as well as my research writing class helped to ignite a curiosity and passion for the kind of work I hope to do one day. And now, for something completely different (than you expect from me):
Generations of people have experienced trauma in various ways. However, our understanding of its effects on the human brain, body, behavior, and even the biology of subsequent generations has expanded greatly within just the last century. The first noted works on the study of transmission of trauma to subsequent generations was done in 1966, by Canadian psychiatrist Vivian M. Rakoff, MD. In her groundbreaking studies, she concentrated on analyzing and documenting the mental health and effects of trauma on the children of Holocaust survivors. According to the American Psychological Association (2021):
“Trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives” (American Psychological Association [APA], 2021).
Given the state of the world since the current pandemic began in 2020, access to trauma informed care and therapy services should be a priority for state and federal governments. Ideally, this would be implemented in an effort to mitigate the intergenerational effects of trauma due to the severity of this global event, for current, as well as future generations. In offering access to quality, free or affordable mental healthcare, promoting its benefits, and erasing stigma, communities could begin to heal current intergenerational trauma. An effective form of prevention would be to require and standardize mental health assessments, similar to the current ACE (Adverse Childhood Experiences) assessment, but more specifically focused on trauma related to the pandemic, within the school system. This would allow mental health professionals to coordinate and deliver the appropriate services that should be offered to various age groups, based upon exposure and severity. This data would also give useful metrics needed for funding to give front line workers desperately needed support, schools to hire more counselors, businesses to offer mental healthcare services, and communities to assist at risk members.
Early Research on Intergenerational Trauma
Children of Holocaust Survivors
Within the study of intergenerational trauma, children and grandchildren of Holocaust survivors have been some of the most studied samples. Even though the Holocaust ended with the conclusion of World War II on May 8, 1945, the effects have permeated generations since. Canadian psychiatrist Vivian M. Rakoff was of the first to conduct and document such a study. In their research, Rakoff et al. (1966), noted that of the children studied of Holocaust survivors “it would almost be easier to believe that they, rather than their parents, had suffered the corrupting, searing hell”, due to the severe psychological distress they displayed (p.755).
Many years later, Yehuda et al. (2007), conducted a study in which they found that the “offspring of trauma survivors with PTSD have a greater prevalence of PTSD after their own life events than offspring of trauma survivors without PTSD”. Sigal, J. et al. (1988), also noted that grandchildren of Holocaust survivors were at a 300% more likely to be referred for psychiatric care. This is important because it supports the claim made in a study by Schulte and Hall (2018), in which they state:
“These results suggest that the effects of biological memory may be context dependent. Across many species, similar multigenerational effects of early life experiences have been documented, clearly showing that biological memory is a real and heritable phenomenon that occurs among many (if not all) animals. This biological memory is a record of past experiences and, potentially, those of our parents and grandparents” (p. 60).
Another study on the subsequent generations of trauma survivors was also done on children and grandchildren of those who survived the Dutch Hongerwinter. The Dutch Hongerwinter was an extreme famine in the Netherlands from 1944-1945 toward the end of World War II, in which over 20,000 people died of starvation. According to Zimmer (2018), “The Dutch Hunger Winter has proved unique in unexpected ways. Because it started and ended so abruptly, it has served as an unplanned experiment in human health”. He goes on to state that pregnant women “were uniquely vulnerable, and the children they gave birth to have been influenced by famine throughout their lives” (para. 3).
Tobi et al. (2018), conducted an extensive study that suggested certain genes were mediated or silenced in subsequent generations due to regulation within a methyl group after trauma, a concept known as epigenetics. The Centers for Disease Control and Prevention (CDC), defines epigenetics as, “the study of how your behaviors and environment can cause changes that affect the way your genes work. Unlike genetic changes, epigenetic changes are reversible and do not change your DNA sequence, but they can change how your body reads a DNA sequence” (para. 1). According to research compiled by Wirth (2018):
“The Hongerwinter demonstrated that there can be a critical window, such as the first trimester of gestation, that impacts one’s entire life and sometimes the lives of one’s children. Beyond heart disease, folic acid deficiency during gestation in the Hongerwinter has been associated with a higher level of schizophrenia. But malnutrition is just one factor affecting the epigenome - in mice, maternal care in the first months of life has been demonstrated to epigenetically effect stress response in later life. Plus, pollution, drug addiction, family dysfunction and stress may all play a part in our individual epigenetic code” (para. 6).
Among studies on generations of Holocaust and Dutch Hongerwinter survivors, there have also been studies on generations of other disasters, including the Famine-Genocide in Ukraine from 1932-33 (Bezo B., & Maggi S., 2015), the Armenian Genocide of 1915 (Haladjian, L., 2020), as well as studies on the offspring of refugees, military veterans, and more.
The Spanish Flu
In 1918, the world experienced its most recent pandemic since Covid-19, which we are currently struggling through. The Spanish Flu, also known as the “1918 Pandemic” and the “Great Influenza”, was attributed to killing fifty million people in only two years. Mamelund (2003) states, “Spanish Influenza survivors were reported to have problems with sleeping, depressions, mental distractions, low blood pressure, dizziness and to cope at work and with everyday life for weeks, months or even years after 1918-19” (p. 5). In addition, Wasserman (1992) explains that with the increase in Spanish Flu related deaths also came an increase in suicide. He postulates this was due to a lack of social interaction, including the closing of schools, churches, theatres, banning of large public meetings, as well as fear induced by the pandemic.
As with any crisis, there are lessons to be learned, and systems that can and should be put into place for prevention and mitigation of lasting effects. Since the Spanish Flu of 1918 is the most comparable example of a worldwide disaster type event, we should be looking to its research for answers. Eghigian (2020), emphasizes this belief by stating:
“If history teaches us anything, it is that we should always be measured in how we glean lessons from the past. That said, the example of the influenza of 1918-1920 gives us reason to expect that the present pandemic will carry in tow its own set of mental health challenges” (p. 26).
Trauma Informed Care & Covid-19
Symptoms of Trauma
The current pandemic, much like global disaster events before it, has it’s own unique set of challenges and permeating effects. At its root however, trauma can be broken down even further into a wide variety of emotional, mental and even physical effects. These can include, but are not limited to, anxiety, depression, insomnia, suicidal thoughts, and more. Tucker and Czapla (2021), note that already, many “groups have met the qualifying criteria for post-traumatic stress disorder (PTSD) according to DSM-5 as a result of the pandemic. (p. 9). It is with this fact in mind that a plan needs to be formulated and executed to help navigate the intricacies and heaviness of our collective burden.
Covid-19 has been labeled as many things; a national emergency, global disaster, natural hazard, and more, but what holds true regardless of label is the core effect of mass trauma. According to the American Institutes of Research (2020), common responses to trauma could include emotional responses such as irritability, guilt, grief, anxiety, depression, anger; behavioral responses such as aggression, withdrawal, trouble managing emotions, loss of interest; and physical responses such as headaches, stomach aches, fatigue, muscle pain and more (as cited in Ontario Agency for Health Protection and Promotion, 2020, Table 2). This could be as a result of front line work, illness, loss of a loved one, loss of a job or housing, isolation, increased exposure to domestic violence, and more.
Dias and Ressler (2014), used the process of fear conditioning in mice to prove that traumatic memory can be inherited in up to two descendant generations of the original test subject. This along with research of other catastrophic world events, solidifies the necessity for trauma informed care as an intergenerational trauma solution.
Trauma Informed Care and Therapy Options
For a person seeking care for trauma, there are many options. Depending on the trauma, the therapy that would suit that person could vary greatly. Traditional talk therapy, art therapy, EMDR, and psychodynamic therapy, among other types can all be effective. For those experiencing post-traumatic stress disorder due to disasters or global hazards such as the pandemic, trauma focused cognitive behavioral therapy (CBT) has shown to be effective. The APA (2017), defines cognitive behavioral therapy as:
“Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications” (para. 1).
State and Federal Government Aid & Community Resources
The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a comprehensive framework for local, state and federal governments and policymakers to replicate. Ortiz and Sinko (2020), insist that with the urgency at hand there would be no “need to start from scratch”. They go on to state that acts of kindness and compassion, prioritizing routines and wellness activities, encouraging and helping neighbors, and contacting our policymakers can help to garner community healing and resilience (Federal and State Policymakers Need to Take Action section).
Trauma Informed Care & Education
According to The National Child Traumatic Stress Network (NCTSN) and Halladay Goldman et al. (2020), “creating a trauma-informed environment …is essential to help school communities feel safe and supported during times of danger and adversity” (p. 1). The NCTSN also offers a framework for how to best approach this task, with suggestions such as, encouraging students and parents to connect with teachers and counselors, maintaining a regular routine as much as possible, as well as teach about other historic crises and how communities overcame them (p. 6).
Currently, most pediatricians and mental healthcare professionals utilize some form of the ACE assessment. This assessment is ten questions geared towards evaluating evidence and severity of trauma related to physical, mental or sexual abuse, household challenges such as domestic abuse, divorce, incarceration of a household member, as well as emotion or physical neglect. (CDC, 2021). Due to the current events and increasing the mental health crisis, this assessment warrants expansion to include questions related more specifically to the emotional, mental, behavioral and physical effects of the pandemic. In addition, it should be standardized within this school system, allowing early and regular childhood mental health screenings as an initial measure of preventative care.
In conclusion, the solution for intergeneration may be complex, but if we use history and science as a guide, we can begin to heal and change the narrative and stigma surrounding mental health and break the cycle of intergeneration trauma.
American Psychological Association (APA). (2021). Retrieved 31 October 2021, from https://www.apa.org/topics/trauma
American Psychological Association (APA). (2017). Retrieved 30 October 2021, from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
Bezo B., & Maggi S. (2015). The intergenerational impact of the Holodomor genocide on gender roles, expectations and performance: The Ukrainian experience. Ann Psychiatry Ment Health 3(3): 1030.
Centers for Disease Control and Prevention, Kaiser Permanente (CDC). (2016). The ACE study survey data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Fabout.html
Centers for Disease Control and Prevention (CDC). (2020). What is epigenetics?. Genomics & Precision Health. https://www.cdc.gov/genomics/disease/epigenetics.htm
Dias, B., & Ressler, K. (2014). Parental olfactory experience influences behavior and neural structure in subsequent generations. Nature Neuroscience, 17(1), 89–96. https://doi.org/10.1038/nn.3594
Eghigian, G. (2020, May). The Spanish flu pandemic and mental health: A historical perspective. Psychiatric Times, 37(5), 26.
Haladjian, L. (2020). Intergenerational trauma among second, third, and fourth generation Armenian genocide survivors [Doctoral dissertation, Fielding Graduate University]. ProQuest Dissertations Publishing.
Halladay Goldman, J., Danna, L., Maze, J., Pickens, I., and Ake III, G. (2020). Trauma informed school strategies during Covid-19. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress.
Mamelund, Svenn-Erik (2003). Effects of the Spanish influenza pandemic of 1918 - 19 on later life mortality of Norwegian cohorts born about 1900, Memorandum, No. 2003,29, University of Oslo, Department of Economics, Oslo
Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2020). Focus on: Trauma-informed practices for children and families during the Covid-19 pandemic. Toronto, ON: Queen's Printer for Ontario.
Ortiz, R., & Sinko, L. (2020). Responding to the trauma of Covid-19. Retrieved 10 October 2021, from https://ldi.upenn.edu/our-work/research-updates/responding-to-the-trauma-of-covid-19/
Rakoff, V, Sigal, J., & Epstein, N. (1966). Children and families of concentration camp survivors. Canada’s Mental Health, 14, 24–26.
Schulte, P., & Hall, J. (2018). Echoes across generations. In P. Tortelli, M. Turin, & M. Young (Eds.), Memory (pp. 57–64). Peter Wall Institute for Advanced Studies. https://doi.org/10.2307/j.ctvbtzpfm.9
Sigal, J., Dinicola, V., & Buonvino, M. (1988). Grandchildren of survivors: Can negative effects of prolonged exposure to excessive stress be observed two generations later? The Canadian Journal of Psychiatry, 33(3), 207-212. https://doi.org/10.1177/070674378803300309
Tobi, E., Slieker, R., Luijk, R., Dekkers, K., Stein, A., Xu, K., Biobank-based Integrative Omics Studies Consortium, Slagboom, P., van Zwet, E., Lumey, L., & Heijmans, B.(2018). DNA methylation as a mediator of the association between prenatal adversity and risk factors for metabolic disease in adulthood. Science Advances, American Association for the Advancement of Science, 4(1). https://doi.org/10.1126/sciadv.aao4364
Tucker, P. & Czapla, C. (2021, January). Post-Covid stress disorder: Another emerging consequence of the global pandemic. Psychiatric Times, 38(1), 1-11.
Wasserman, I. (1992). The impact of epidemic, war, prohibition and media on suicide: United States, 1910-1920. Suicide and Life-threatening Behavior, 22(2): 240-254.
Wirth, M. (2018, November 7). A lasting legacy. The Analytical Scientist. https://theanalyticalscientist.com/fields-applications/a-lasting-legacy
Yehuda, R., Teicher, M., Seckl, J., Grossman, R., Morris, A., & Bierer, L. (2007). Parental posttraumatic stress disorder as a vulnerability factor for low cortisol trait in offspring of Holocaust survivors. Archives of General Psychiatry, 64(9), 1040–1048. https://doi.org/10.1001/archpsyc.64.9.1040
Zimmer, C. (2018, February 6). Dutch genes still bear scars of a famine. The New York Times, D5.