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Earlier this year, none of us could have imagined that our day-to-day lives, or the lives of the individuals and families we serve, would change so dramatically and swiftly come March. I certainly did not. Here it is, October, and I can count on my hands the number of times I stepped into my now-rather-lonesome office. Masks have become as ordinary as socks. Six-foot distance markers dot the floors. Grocery stores have traffic signals. For some, that payroll check has stopped coming in or has been drastically reduced. Families have been separated. Certain services have stopped or become less effective. Family violence has intensified. Health disparities have increased. Racial/ethnic discrimination has worsened. Mental health problems have become more frequent and severe. Children are falling through the cracks in education. Families have lost loved ones. I could go on, but you all have already experienced or witnessed these changes. Indeed, COVID-19 has spurred a paradigmatic shift across every life domain, upsetting social norms, pushing us out of our comfort zones, and worse, putting some individuals and families at significant risk.

Early in April, my research team, in concert with many others, became interested in studying the impact of the pandemic on families and mental health. With experience developing trauma-specific assessment tools, we set out to create the Epidemic-Pandemic Impacts Inventory (Grasso, Briggs-Gowan, Ford, et al., 2020), a comprehensive assessment of pandemic-related experiences that span several domains including changes in work/employment, home life, social activities and isolation, emotional and physical health, positive experiences, and an addendum of experiences that pertain to racial/ethnic discrimination (Yang et al., 2020). The EPII differs from other measures developed during this time, which tend to focus on perceived level of stress. We also developed supplemental modules for special populations including health care providers and perinatal populations (see bit.ly/UCONN-EPII). We have begun to use the EPII in our research, and more than 100 research teams nationally and internationally are currently using the EPII to study various populations of interest. The EPII, together with alternative or complementary measures of pandemic-related experiences and perceptions, such as the Stoddard-Kaufman Coronavirus Impact Scale (Stoddard & Kaufman, 2020) and the COVID-19 Exposure and Family Impact Survey (Kazak et al., 2020), may yield critical insight into patterns of experiences that convey risk for different types of adverse outcomes, including mental health impairment. This knowledge will be essential for mental health providers, especially those serving trauma-exposed populations, which we know are especially impacted by new experiences of stress and resource loss.  

Preliminary findings underscore the scope and severity of what families are currently experiencing and suggest a dose-response relationship between number of types of experiences and adverse outcomes, similar to what we know about trauma and childhood adversity (Grasso, 2020a). For example, in a small sample of trauma-exposed, primarily Hispanic/Latina mothers who previously participated in a prenatal study, cumulative pandemic adversities predicted increased negative affect from pregnancy to early motherhood, which in turn was associated with child behavior problems (Grasso, 2020b). Increased household conflict during COVID-19 was specifically associated with maternal negative affect and less perceived competency. We also found a link between unfavorable changes in mental health treatment and increased mental health problems, including posttraumatic stress. In another example, adults (ages 18-90) with high-risk profiles of pandemic adversities across EPII domains were more likely to have a history of interpersonal trauma and more severe symptoms of posttraumatic stress, depression and anxiety (Grasso, Briggs-Gowan, Carter, et al., 2020). A different research group administered the EPII to New York City-residing college students and found associations between cumulative pandemic adversities and mental health difficulties, including posttraumatic stress, with students reporting traumatic loss most impacted (Lopez-Castro et al., 2020). Finally, in a sample of staff employed at an urban children’s hospital, direct care providers reported a greater number of pandemic adversities, especially in the workplace, and reported higher symptoms of depression and anxiety relative to their non-providing co-workers (Grasso et al., in preparation). 

These findings align with what we may have observed in our psychotherapy clinics. I personally have noticed an increase in anxiety, depression, traumatic stress and developmentally regressive behaviors among the children and adolescents I see, as well as increased stress and parenting difficulties among parents. When I conceptualize the reasons for the increase in stress and symptoms, they vary by family. Consider the following hypothetical cases.

Jess is a 10-year-old girl receiving Trauma-Focused Cognitive Behavioral Therapy (Cohen et al., 2018) to treat symptoms associated with witnessing domestic violence between her mother and father before they separated. Her course of treatment was near complete prior to the pandemic. During the pandemic, Jess’ stepfather is furloughed and the family experiences increased financial strain, which leads to an increase in verbal discord between caregivers. Caring for a 9-month-old infant also adds to her caregivers’ burden. During this time, Jess experiences a resurgence of trauma-related symptoms, which had mostly resolved leading up to the start of the pandemic. Part of the work I do with Jess and her family involves identifying and acknowledging how changes in the family environment are influencing symptoms associated with her previous exposure to domestic violence. In session, I help Jess to differentiate the violence she witnessed in the past from the verbal arguments she is witnessing now. I help Jess to understand how hearing these verbal exchanges may be triggering her trauma memory. I also process this with Jess’ caregivers and help them to become aware of how the verbal arguments are affecting Jess and discuss whether there are alternative ways to negotiate the family’s new financial burden. At this time, Jess’ mother acknowledges that she also has been experiencing an increase in depression and that this may also be a contributing factor.

In a different family, Rasheeb is a 12-year-old boy with a history of traumatic loss and in treatment for dysregulated mood and complicated grief. His father died from cancer when he was 10. Rasheeb’s mother is an emergency room physician and has had to reduce contact with Rasheeb and his grandmother, who lives with them, due to increased risk of infection at the hospital. She is temporarily staying at a friend’s house. Rasheeb has always been close to his mother, especially after his father’s death, and relies heavily on her for “calming him down” and “making him feel better.” During this time, Rasheeb becomes increasingly dysregulated, spending a lot of time in his room, not eating or sleeping regularly, showing outbursts of anger towards his grandmother, and, according to his grandmother, is distant and depressed. In session, Rasheeb acknowledges feeling constant worry about his mother’s safety. I explore with Rasheeb his understanding of his mother’s risk of infection and it turns out that he has misguided beliefs that exacerbate his worry. In a virtual conjoint session with his mother, we discuss all that she is doing to reduce her risk at the hospital and that the extra precaution of staying with a friend is to minimize his grandmother’s potential exposure given her pre-existing health conditions. We also discuss strategies for Rasheeb to feel close to his mother even though she is spending more time at work and residing with a friend, including arranging frequent and predictable virtual calls and check-ins. With Rasheeb’s grandmother, I help her to understand the increase in Rasheeb’s emotional distress and strategize ways for her to provide increased support during this stressful time.

Finally, Marc is a 17-year-old adolescent who had just begun Prolonged Exposure (PE; Foa et al., 2009) prior to the pandemic due to symptoms associated with an extensive trauma history that includes childhood sexual abuse, several types of violence exposure, and other forms of adversity. Marc was in therapy for a few months before he agreed to focus on the sexual abuse and begin PE. Up until then, the focus of therapy was on improving emotion regulation capacity and establishing rapport. Marc’s PTSD and depressive symptoms at intake were severe; however, there was notable progress over his initial sessions. When a shelter-in-place order was put into effect, several weeks of therapy were disrupted because the clinic did not have telehealth functionality in place. When sessions resumed, it was clear that Marc’s symptoms had worsened to the point at which he acknowledged having thoughts that life was not worth living. Because of the gap in sessions and the change in modality, as well as Marc’s chaotic home environment, I decide to put PE on hold. In reviewing what had changed for Marc, it becomes clear that many of the activities that Marc relied on to structure his day and channel his focus had stopped—school, his part-time job, basketball. Marc describes days when he has no outlet to escape his thoughts, which increasingly include intrusive images of the sexual abuse and thoughts that he is unlikeable, worthless and permanently changed by the abuse. To add to this, Marc’s mother, also caring for two younger siblings, had lost her job as a waitress. With the four of them at home and under significant stress, they find themselves at their wits’ end. Over a series of virtual sessions, I re-establish rapport with Marc and revisit several of the emotion regulation strategies that we had worked on prior to the pandemic. We brainstorm new strategies for structuring his time and managing his increase in trauma-related cognitions, including exercises to help process and challenge these thoughts. Although Marc’s mother is not an active participant in his therapy, Marc and I speak of ways he can help his mother to cope with the increased family stress without resorting to arguments.

Is it clinically valuable to assess pandemic-related experiences? I would argue that it is. In the same way that trauma clinicians gather information about trauma exposure and co-occurring adversities in order to establish a working conceptualization of a patient and her or his symptoms, it behooves us to facilitate ways of exploring how this unprecedented pandemic is influencing a patient and a patient’s symptoms. What are the implications for therapy? Is it helpful for the patient or the patient’s family to be aware of these changes so as to modify the home environment or adjust strategies? A tool like the EPII may be useful in thinking through all of the ways in which the pandemic has facilitated change, good and bad. Part of the EPII explores positive changes that have occurred because of the pandemic, such as increased time with loved ones, greater appreciation for things, and newfound talents or social connections. Identifying these strengths and resources are as important as identifying burdens because it provides the therapist a foundation to build on and a potential avenue for improved coping. Even without the use of a structured tool like the EPII, therapists are encouraged to start a dialogue with their patients about how life has changed since the pandemic—as we would do when assessing trauma exposure. This should be an ongoing dialogue given that our situation is evolving and circumstances surrounding the pandemic are in flux. The following are general suggestions for how trauma therapists might approach this.

  • Facilitate a discussion, which may involve use of a structured assessment tool, to explore how the pandemic has influenced the many aspects of a patient’s life
  • Consider both adverse and positive changes and experiences
  • Help patients (and caregivers when applicable) draw connections between pandemic-related impacts and change in symptoms or functional impairments
  • Conceptualize how a patient’s trauma history may influence her or his experiences during the pandemic
  • Consider whether these experiences or changes have implications for therapy modality or approach
  • Explore whether there are aspects of a patient’s environment that can be modified to reduce strain or trauma triggers
  • Explore whether there are aspects of positive change that can serve as a foundation for resource enhancement
  • Keep the dialogue open, as the circumstances of the pandemic are not static and have potential to change  

About the Author

Damion J. Grasso, PhD, is a licensed clinical psychologist and associate professor of psychiatry and pediatrics at the University of Connecticut School of Medicine. His research and clinical work broadly focus on trauma-related psychopathology across development, with a research emphasis on methods for quantifying characteristics of trauma exposure and identifying intermediate phenotypes that link exposure to adverse outcomes.

Email: dgrasso@uchc.edu.
Twitter: @damiongrasso


Cohen, J. A., Deblinger, E., & Mannarino, A. P. (2018). Trauma-focused cognitive behavioral therapy for children and families. Psychotherapy Research, 28(1), 47–57. https://doi.org/10.1080/10503307.2016.1208375

Foa, E. B., Chrestman, K. R., & Gilboa-Schechtman, E. (2009). Prolonged exposure therapy for adolescents with PTSD: Emotional processing of traumatic experiences: Therapist guide. In Programs that work. https://doi.org/10.1093/med:psych/9780195308501.001.0001

Grasso, D. J. (2020a). Adverse Childhood Experiences and Traumatic Stress Disorders. In J. G. Beck & D. M. Sloan (Eds.), Handbook of Traumatic Stress Disorders (2nd Edition) (2nd ed.). Oxford University Press.

Grasso, D. J. (2020b). Cumulative Pandemic-Related Adversity Moderates Change in Affective Symptoms from Pregnancy to Early Motherhood in a Primarily Hispanic, Low-Income Sample. Submitted for publication.

Grasso, D. J., Briggs-Gowan, M. J., Carter, A., Goldstein, B. L., & Ford, J. D. J. D. (2020). A Person-Centered Approach to Profiling COVID-Related Experiences in the United States: Preliminary Findings from the Epidemic-Pandemic Impacts Inventory (EPII). Submitted for publication.

Grasso, D. J., Briggs-Gowan, M. J., Ford, J. D., & Carter, A. S. (2020). Epidemic-Pandemic Impacts Inventory. Unpublished.

Kazak, A., Canter, K., Phan-Vo, T.-L., McDonnell, G., Hildenbrand, A., Alderfer, M., Schultz, C., Barakat, L., Kassam-Adams, N., Pai, A., & Deatrick, J. (2020). COVID-19 Exposure and Family Impact Survey (CEFIS). Unpublished.

Lopez-Castro, T., Brandt, L., Anthonipillai, N. J., Espinosa, A., & Melara, R. (2020). Experiences, impacts and mental health functioning during a COVID-19 outbreak and lockdown: Data from a diverse New York City sample of college students. Preprint.

Stoddard, J., & Kaufman, J. (2020). Stoddard-Kaufman Coronavirus Impact Scale.

Yang, A., Ablorh, T., Hall, A., Roemer, L., Carter, A. S., Ford, J. D., Briggs-Gowan, M. J., & Grasso, D. J. (2020). The Epidemic-Pandemic Impacts Inventory (EPII) Racial/Ethnic Discrimination Addendum. University of Connecticut School of Medicine. Unpublished.