Resilience and coping beyond the pandemic

ADPH | Registered Charity Number 1164513 August 2021
membership@adph.org.uk | www.adph.org.uk Page 1 of 13
Resilience and Coping Beyond the Pandemic
A Briefing for Public Health Teams
Prof. Jim McManus, Vice-President, ADPH1
Acknowledgements
We are very grateful to our ADPH Members and Andy Bell, Deputy Chief Executive of the Centre for Mental
Health, for their comments on and review of drafts of this paper.
1. About this Briefing
The purpose of this briefing is to provide Directors of Public Health (DsPH) and Public Health teams with
some rapid and concise orientation on the issues of population and workforce trauma, resilience and
coping during and beyond the pandemic, so that they can consider strategies both for the public and for
their workforces.
This briefing seeks to provide some frameworks for response to the needs of:
• Populations; because there will be multiple and differential impacts on various sub-populations
both by life course stage and by identity as well as socioeconomic status.
• Workforces, teams and systems; as the pandemic goes on, the risk of compassion fatigue, burnout
and traumatic stress in workforces increase. Psychological injury to staff (and by definition to
ourselves as public health professionals) may be worse than in other parts of the population
because the combination of enduring stress and their own motivation to keep serving their
populations, may result in people feeling unwilling or unable to seek help. If we can’t keep our
workforces resilient, we can’t continue to manage outbreaks.
This briefing is set within the context of public mental health. It seeks to provide pointers with links to
further resources and reading for DsPH to respond at system level and support themselves and their teams.
This briefing is really about after-effects as opposed to immediate effects.
2. Background: The Impact of Covid at Population and Workforce Levels
Following Singer2, Horton3 and others have pointed out that Covid-19 is not a pandemic but a syndemic:
a number of impacts (physical, social, financial or emotional) which combine together to have an effect
which is worse than any one individually. Some people may describe this as a “multiple whammy”. For
example, Covid has physical, psychological, economic, and social impacts on people. Seeing through a
syndemic lens is important for public health professionals to use in both understanding multiple waves
and dimensions of the impact of Covid, and in understanding the multiple issues to be faced in recovery.
There is growing and extensive literature on the syndemic impacts of HIV, mental health, disaster and
trauma.

‘Covid-19 is not a pandemic but a Syndemic : a coming together of multiple impacts (loss, fear,
isolation, financial impacts) which can combine and interact to create a “multiple whammy”.
People may be able to withstand one or two impacts, but not the multiple combined impacts.”
Directors of Public Health face two major sets of mental health challenges coming out of the pandemic:
• Responding to trauma at population level using a public mental health approach: There is an
accumulation of evidence that the pandemic has affected people not only individually but also
collectively. It has been a “major collective trauma” which affects most people psychologically or
emotionally in one way or another. The impact of this varies from person to person, and
community to community, and is dependent on a number of factors. And while some people will
recover and thrive, others will struggle at various degrees. This is a clear public mental health
challenge. Part of this challenge will be to ensure that clinical mental health services are able to
respond and are sufficiently resourced. But the demand and need will be some way beyond
capacity, and we must therefore identify a population wide approach to early intervention,
prevention and recovery.
• Ensuring you and your workforce are resilient and supported is part of a public mental health
approach: The sustained nature of the response to the pandemic, and the fact that we do not yet
have an endgame, means that DsPH, their teams, and the systems they lead, are under increasing
pressure and ongoing stress. This is an organisational wellbeing and resilience challenge. Not
addressing workforce need while addressing need for others, risks creating a strong sense of
unfairness among staff and creating further trauma.
3. Developing a Trauma Informed Population Recovery Plan: Population
as well as Clinical Focus
An individual clinical focus, while necessary and valuable to help people recover and cope individually, is
not sufficient in and of itself. The concepts of collective trauma, developed from disaster and conflict
psychology, offer a lens which is at population level, and should therefore be attractive to DsPH taking a
population approach.4
The work of Reimann and Konig (2017) can provide a useful lens for DsPH to use in
understanding collective trauma.5
Collective trauma refers to an event or a series of events that is psychologically or emotionally stressful
for a group of people which can be anything from a small group (e.g. a friendship group who experience a
sudden traffic accident) to a whole population.
Most people have experienced a change in their lives, beyond their control (e.g. lockdown) through Covid.
This can traumatise people. While everyone has experienced some trauma, some people have experienced
much more than others. The trauma of being locked down is different from the very serious trauma of
serious illness and bereavement. The evidence suggests that the effect is greater the closer you are to the
“storm”. Grief and trauma can express itself in a range of ways, including frustration, grievance, and
protest against public health measures. Some people have also become much more open to believing
conspiracy theories.6
Others may become anxious or depressed and be fearful of returning to normal social
life as restrictions ease7
.

Traumatic experiences and the variety of responses
• Traumatic experiences can lead to a variety of physiological, psychological, relational, spiritual,
and societal responses.
• Some people emerge from a traumatic experience relatively unscathed and adjust well. Recent
evidence from conflict and war psychology shows strong positive group identity accompanied by
mutual support within the group, can contribute to adjustment and coping and almost become a
“social cure”. Similarly, group identity can worsen or continue stigma and trauma.
• Other people may become changed for a short, medium, or very long period by a traumatic event.
• The exact degree of differential responses to traumatic experiences depends on a variety of
factors, including prior trauma history, current stressors, level of resilience, and the degree to
which there are meaningful relationships.
• People don’t need to have experienced an event first-hand in order to react to or be changed by
it. For example, some people have been traumatised by watching traumatic events on television.
At identity-group level (e.g. populations of identity, teams within organisations) trauma can be both a
galvanising factor for some people to seek or even to organise self-help (e.g. responses to hate crime)
while also being a source of further deep stigmatisation and difficulty. At identity-group level, trauma can
lead people to seek/organise self-help (e.g. responses to hate crime) or become a source of further deep
stigmatisation and difficulty. In some people, experiences of trauma will lead to clinical level mental health
conditions including PTSD and complex grief. This isn’t just about short-term behavioural effects but risk
factors for serious and enduring illness which can be modified if DsPH take steps now to reduce risk and
prevent re-traumatising people. Steps you can take are included in the briefing below.
Collective trauma, when aligned to public health concepts of i) looking at populations and sub-populations
and ii) the concept of syndemics, is an extremely valuable concept to use. Together these three concepts
can provide a “tri-focal” lens ideally suited to consider the impact of the pandemic. The pandemic impacts
at population, sub-population, and individual levels. We also know that the impacts of Covid have not been
equal. Those who are most deprived, Black, Asian and Minority Ethnic (BAME) communities, and those
who were unable to work from home have experienced the worst impacts. Caregivers (paid and unpaid)
have also experienced significant impacts.
When developing a population recovery plan, there is a need to both understand where, and in which
populations, differential impacts of Covid might occur. Some of the steps include:
• Developing a model or framework for understanding impacts and mapping them. This might be as
part of a very Rapid Needs Assessment, for example, undertaking some quantitative needs
modelling on trauma and impact both for now and for future
• Developing a multifactorial plan which is not just about clinical service capacity but is about
population levels as well as early intervention
• Building a coalition or partnership to run and deliver this
A very short “starter” section on more longer-term planning can be found at the end of this briefing.
Tools to support planning
As a more rapid tool to look specifically at Covid, ADPH, the Local Government Association (LGA), and
Hertfordshire County Council have developed a rapid ready reckoner model across the life course for

understanding this, with a matrix and an infographic.8
West Berkshire also developed a pictorial model
across the life course of multiple Covid impacts, not just mental health. These images can be found in
Appendix 1 and a number of public health teams have found these graphics easy to use in informing and
influencing action across local systems and partners.
In addition to these, there are three further useful tools:
1. The ADPH Major Incidents Checklist of Directors of Public Health
2. The Real World Public Mental Health Podcast Series
3. The Centre for Mental Health Briefing 56 on Trauma has a reckoner of the types of interventions
which could be put in place for different issues and needs
4. Workforce Resilience, Workforce Care and Self-Care
Workforces are important to consider in terms of resilience and impact in their own right for three reasons.
First, the enduring and multiple exposure to stressors of people responding to Covid puts them at
heightened risk of trauma and long-term problems. Second, a workforce affected by trauma presents a
significant threat to business continuity and pandemic response. Third, evidence is clear that workforces
can both promote resilience and mental wellbeing and be a significant challenge to it.
It is therefore crucial to see workforce resilience as a public health priority in its own right during and
beyond the pandemic. There are multiple challenges for workforces during the pandemic which will not
only have significant impacts on their health but create a substantial risk to sustainability of services.
Workforces are therefore important to include in their own right.
It is possible for people to experience more than one challenge in the workplace at different times, or even
the same time. These can be categorised as:
• Stress – the reaction we have when the demands we perceive on us in a situation, or our workload,
are greater than our perceived resources to meet them. This can be short or long term.
• Traumatic stress – a specific, more intense, and more complex type of stress that reflects exposure
to terrible events that are emotionally painful, intense, or distressing. This can be accompanied by
multiple challenges.
• Compassion fatigue – emotional and physical exhaustion compounded by “caring without
ceasing”, leading to a diminished ability to empathise or feel compassion for others.
• Moral injury - there is a risk of ‘moral injury’ where people either witness or carry out acts that go
against their moral code (e.g. having to deny someone a service or promote interventions which
conflict with their values). While this is better understood in relation to the armed service, it has
some resonance during Covid and is a risk factor for later mental illness (Williamson, et al 20219
).
• Burnout – a syndrome resulting from chronic workplace stress that has not been successfully
managed. It is characterised by three dimensions: feelings of energy depletion or exhaustion;
increased mental distance from one's job, or feelings of negativism or cynicism related to one's
job; and reduced professional and personal outside work efficiency. This can rapidly become a
serious problem for individuals inside and outside of work.
However, there are a range of approaches that can be taken to support workforces. In non-Covid crisis
times, developing a whole organisation approach using the Thriving at Work model is recommended. But
for now, as we continue to tackle Covid, there is a menu of rapid and easy interventions that can be used

to provide support at an individual and team level. These are outlined below.
A framework to protect and promote the mental health of workforces during
Covid
Level Actions Resources
Individual Level
(Self)
Any of the below approaches can be used and
will work differently for different people.
• Developing a self-care plan
• Developing a personal resilience plan
• Self-acceptance
• Self-compassion
• Identifying self-care buddies
• Healthline (2020) How
to Make a Self-Care
Checklist
• Derek Mowbray’s
guides on managing
personal resilience have
been used by many
DsPH
Individual Level
There are several important dimensions to
supporting individual employees.
Encouraging self-care is important but the
manager also needs to support people as much
as possible, lead by example, and show
compassionate leadership to encourage a
culture of this. The resources opposite are
designed to help busy public health teams.
Identifying signs of when people are not coping,
identifying sources of help in the organisation,
and signposting people to support are all crucial.
• The British
Psychological Society
(2021) Thriving when
work is tough: in Covid
and non-Covid times.
• Chartered Institute of
Personnel and
Development (2015)
Promoting Good Mental
Health (Podcast).
guides on managing
personal resilience
• CIPD (2021) Coronavirus
(COVID-19)- Mental
health support for
employees
• Resources by Mental
Health at Work
Team or Unit
Level
Good team working is positively associated with
better resilience. This can be promoted through
the following:
• Encouraging peer to peer support
• Creating a favourable social and teamwork
climate
• Facilitating team gatherings or clusters
• Connecting and getting together, actively
and openly listen
• Providing team support – i.e. ensuring there
• Covid and wellbeing
resources by the LGA
guides on managing
personal resilience
• Resources by Mental
Health at Work

is the physical environment to have breaks,
social connection when people are virtual et
• Ensuring people get some downtime.
• Establishing team rules and norms on work
patterns
Organisational
Level
The following actions should be considered:
• Implementing the Thriving at Work
framework
• Ensuring leaders signal and model that
mental health is taken seriously
• Encouraging people to talk about what can
be done
• Practicing compassionate and authentic
leadership – this requires having the
following four components:
• Attending – paying attention to others
and noticing when they are experiencing
difficulties and distress
• Understanding – making an appraisal of
the cause their distress
• Empathising – having an empathetic
response
• Helping – taking intelligent and
appropriate action to provide support
• Enabling greater manager and organisational
leader support which cares, values, and
appreciates the workforce – this includes:
• Signaling that staff wellbeing is a priority
• Recognising that compassion fatigue is
real
• Promoting regular honest and open
communications with the workforce
• Being visible and approachable
• Providing feedback
• Providing protected breaks
• Providing environments where staff can
talk openly and safely with one another
• Thinking about your own wellbeing
needs, creating a self-care plan and
seeking support if you need it
• Being open that you are doing this
• Mental Health at Work
(2018) How to
implement the Thriving
at Work mental health
standards in your
workplace.
• Other resources by
Mental Health at Work
guides on managing
personal resilience
• You may want to bring
in an organisation like
Noreen Tehrani
Associates to do some
psychological screening
of employees under
extreme stress and at
high risk. This can then
be used to inform the
development of a plan,
if your organisation
does not already have a
support programme in
place.

5. Key Skills for Tough Times: Self-Care and Self-Compassion
Self-care, self-compassion, and self-acceptance are powerful tools for maintaining resilience in tough
times. They are slightly different, and they are all needed. While there are many frameworks, it is sensible
to see self-compassion and self-acceptance as key dimensions within self-care.
There are multiple frameworks on self-care, but for now, here is a straightforward framework:
• Evaluate your coping skills and identify which ones are positive (e.g. down time) and which ones
are negative (drinking too much, eating the wrong foods).
• Reflect on which existing strategies work for you and which don’t.
• Examine whether there are barriers to self-care, what they are and what you can do about these.
• Do you need to ask for help or support of any kind?
• Each day, try to revisit and identify your daily self-care needs (and they can change day to day for
many).
• Write your plan down.
• Find a self-care buddy who may notice when you are using negative rather than positive coping
methods.
• Try to practice self-acceptance – recognise these are extraordinary and difficult times and be
honest to yourself and others. It is ok to feel overwhelmed at times and focus on some things and
not on others.
• Try to practice self-compassion. Some key components of self-compassion are:
• Self-kindness versus self-judgement – it’s ok to be imperfect.
• Common humanity versus isolation – recognising others feel the same. Everyone is
fighting a struggle we know little about. You are not alone.
• Perspective versus over-identification – try not to over-identify with things. Put the
situation into perspective and be mindful not to over-identify with negative feelings and
thoughts.
These tools will work differently for different people. Some may find it difficult to apply these without a
framework in which to put them. The resource section further explores the use of these tools and
frameworks such as the Thriving at work programme.
6. For the Longer Term
While this briefing is about Covid, and the medium to long term psychological impacts of Covid, it is also
important to be ready to consider longer term public mental health both for populations and workforces
beyond the pandemic and beyond recovery. This section very briefly provides some tools and pointers.
Beyond the immediacy of the pandemic, there is some good practice and frameworks that public health
teams and workplaces can and should go on to consider and which can help embed a commitment to
mental wellbeing into the organisational culture – building on some of the principles/practice noted above.
Longer term public mental health planning
This issue raises the importance of having a public mental health framework, plan, or strategy at local level.
While building such a framework is beyond the scope of this briefing, it is worth looking to see what aspects
of responding to Covid can be mainstreamed into core public mental health business. Or, if you do not

have such a plan, it can provide a useful basis to start a public mental health approach. It is, though,
important to have realistic ambitions and sustainable workloads. This may be more of a medium to longer
term consideration.
To help create such a framework, ADPH and Public Health England (PHE) have jointly produced a What
Good Looks Like tool on Public Mental Health. The Public Mental Health evidence and commissioning
guidance developed by Prof. Jonathan Campion provides a detailed menu of interventions, with evidence.
Thriving at work: looking to the long haul and beyond
There are multiple and often confusing and competing tools for workplace mental health. The menu of
interventions above is purposive and designed to point you to things you can do now and relatively quickly.
The Thriving at Work programme (which is distinct from, though analogous to, the West Midlands Thrive
at Work programme) is a framework for individual and organisational work that arose from the sustained
work of Porath et al.10 The Stevenson/Farmer Review was commissioned by the government to ascertain
how employers can better support individuals with mental health problems to remain and thrive in work.11
The thriving at work framework has a series of standards: six core standards and four enhanced
standards.12
These are set out in the table below.
The benefit of the framework is that it is thorough, however it requires clear, dedicated resource. While it
is difficult to fully implement in an organisation during a pandemic, many agencies have used these as a
series of principles to provide a rapid check and assess what can they do now. It can also be very helpful
as a framework to use in recovery. Another useful and brief tool for use during the pandemic, is the British
Psychological Society video Thriving when work is tough: in covid and non-covid times.
Thriving at work framework standards
Six core standards Four enhanced standards
• Produce, implement and communicate a
mental health plan at work
• Develop mental health awareness among
employees
• Encourage open conversations about
mental health and the support available
when employees are struggling
• Provide your employees with good working
conditions
• Promote effective people management
• Routinely monitor employee mental health
and wellbeing
• Increase transparency and accountability through
internal and external reporting
• Demonstrate accountability
• Improve the disclosure process to encourage
openness during recruitment
• Ensure provision of tailored in-house mental
health support and signpost to clinical help

7. Reading and Resources on Population Level Responses
The Covid Public Mental Health Knowledge Hub Collaboration is a group jointly moderated by the LGA and
ADPH. Anyone working on this topic can ask to join.
The Centre for Mental Health has a range of tools including briefings on trauma:
• Briefing 56: Trauma, mental health, and coronavirus
• Recovering at work : how businesses can support staff who may be facing trauma
Resource centres
• American Psychological Association – resources on trauma and shock
• British Psychological Society – Crisis, Disaster and Trauma Psychology Section
• British Psychological Society – Coronavirus Resources Centre for professionals and public
Useful books for population level responses
• Regel, S. and Joseph, S. (2017) Post-traumatic stress. 2nd ed. Oxford: Oxford University Press.
• Southwick, S., & Charney, D. (2012). Resilience: The Science of Mastering Life's Greatest Challenges.
Cambridge: Cambridge University Press.
More detailed reads and books for people leading on this topic
• Goldmann, E. and Galea, S., (2014) ‘Mental Health Consequences of Disasters’, Annual Review of
Public Health, 35(1), pp.169-183.
• Roudini, J. et al (2017) ‘Disaster mental health preparedness in the community: A systematic
review study’, Health Psychology Open.
• Schmidt, R.W., & Cohen, S.L. (2020) Disaster Mental Health Community Planning: A Manual for
Trauma-Informed Collaboration, New York: Routledge.
8. Reading and Resources on Workforce Resilience, Self-Resilience and
Self-Care
Video: Thriving when work is tough (British Psychological Society)
• Thriving when work is tough: in covid and non-covid times - YouTube
Thriving at work framework
• DWP & DHSC (2017) Thriving at Work: a review of mental health and employers
• Mind (2018) Thriving at Work: A guide to implementing the Thriving at Work standards
Blogs on resilience
• The LGA (2020) Resilience and leadership during Covid-19
• The Mental Health Challenge (2020) Keeping yourself and others safe: Leadership in the age of
COVID-19
Practically focused tools, training, and support
• Derek Mowbray offers managers personal guides to resilience, team guides and training. A

number of DsPH have used these because they are effective and affordable.
• Noreen Tehrani Associates provide a range of psychological screening and support including
consultancy and training
Self-care
• Markway, B. (2015) Your Ultimate Self-Care Assessment.
• Pearlman, L. and Saakvitne, K. (1996) Self Care Questionnaire.
• Mind (2017) Understanding Mental Health Problems: Self Care.
• Davis, T. (2018) Self Care: 12 Ways to Take Better Care of Yourself.

of 13
Appendix 1: Life Course Impact Ready Reckoner Graphics
Public mental health and wellbeing and Covid-19 | Local Government Association

of 13
Appendix 2: West Berkshire Council
Impacts of COVID-19 across the lifecourse: West Berkshire Council | Local Government Association

of 13
1
Jim McManus is Vice-President of ADPH, a Chartered Psychologist, Fellow of the British Psychological Society and of the Chartered Instituted of
Personnel and Development.
2 2
Singer, M. (2009) Introduction to syndemics: a critical systems approach to public and community health, San Francisco: Jossey-Bass.
3
Horton, R. (2020) Offline: COVID-19 is not a pandemic. The Lancet, 396(10255), p.874.
4
Centre for Mental Health (2020) Briefing 56: Trauma, mental health, and coronavirus.
5
Reimann, C. and König, U. (2017) Collective Trauma and Resilience. Key Concepts in Transforming War-related Identities. Comment on:
Transforming War-related Identities, Berghof Handbook Dialogue 11, Berlin: Berghof Foundation.
6
Joli, D. and McManus, J. (2020) Coronavirus Mini-Series #9 - Conspiracy Theories (podcast) Real World Behavioural Science.
7
Liu et al (2021) Public mental health problems during COVID-19 pandemic: a large-scale meta-analysis of the evidence | Translational Psychiatry
(nature.com)
8
LGA & ADPH (2021) Public mental health and wellbeing and COVID-19.
9 Williamson et al (2021) Moral injury: the effect on mental health and implications for treatment - The Lancet Psychiatry
10
Porath, C. et al. (2012) Thriving at work: Toward its measurement, construct validation, and theoretical refinement Journal of Organizational
Behavior, 33(2) pp.250-275.
11
Department for Work and Pensions (2017) Thriving at Work: a review of mental health and employers.
12
Mind (2018) Thriving at Work A guide to implementing the Thriving at Work standards in the sport and physical activity sector.

Resilience and coping beyond the pandemic

More Related Content

Similar to Resilience and coping beyond the pandemic

More from Professor Jim McManus AFBPsS,FFPH,CSci, FRSB, CPsychol

Recently uploaded

Resilience and coping beyond the pandemic