Communicating without doing harm: a scoping review on media coverage of traumatic events

Соломія Онуфрів

Львівський національний університет імені Івана Франка

Олів'є Абдельхамід, Сімона ван Дормолен Амстердамський вільний університет

У статті зібрано та систематизовано досвід ефективного висвітлення в медіа травматичних подій згідно з принципом «не нашкодь».Суть цієї ефективності полягає в тому, щоб журналісти, спілкуючись з респондентами, зокрема військовими і цивільними, не травмували психологічно героїв своїх журналістських матеріалів та аудиторію. Йдеться також про уникнення стигматизації та ретравматизації під час висвітлення в медіа цієї теми.Високий рівень поширення і глибокі наслідки травм, зокрема посттравматичного стресового розладу (ПТСР) як серед цивільного населення, так і серед журналістів у зонах конфлікту, підкреслюють необхідність усвідомленого підходу до висвітлення в медіа травматичних подій.

Особливу увагу приділено тригерам травми, уникненню стигматизації та ретрав- матизації, а також методам комунікації в традиційних і нових медіа.Дослідження показали, що рівень знань про психічне здоров'я відіграє вирішальну роль у його дестиг- матизації.Об'єкт аналізу - 22 академічні рецензовані наукові розвідки на зазначену тематику дослідження, які опубліковані в міжнародних електронних базах SCOPUS, Web of Science та PubMed.

У всьому світі перед журналістами, які висвітлюють збройні конфлікти, стоїть завдання не лише висвітлювати поточні події, але й робити це, пам'ятаючи про травми, які пережили (колишні) військові, цивільне населення і самі журналісти.Попри негативні наслідки впливу, медіа мають потенціал для того, щоб на основі досвіду висвітлення воєнних подій в Україні напрацювати відповідні професійні рекомендації для подолання травми війни.

Ключові слова: комунікація, травматичні події, ретравматизація, (де)стигматизація, посттравматичний стресовий розлад (ПТСР), висвітлення в медіа.

Introduction

Russia's invasion of Ukraine on February 24, 2022 brought up an important issue for the Ukrainian media: how to write in the media about trauma without re-traumatising and stigmatising. Military actions in Ukraine emphasize the urgency of adequate and timely (traditional and online) journalistic coverage. But how does one report on a situation that left so many traumatized?

In September 2022, for the first time since the beginning of the full-scale war, a study of the psychological state of the population was conducted in Ukraine. “Lessons learned from other emergency situations indicate that war will have direct and indirect effects on the mental health and well-being of Ukrainians. 40% of respondents experienced threats to their own lives and/or were direct witnesses of such threats in connection with being in the combat zone actions and/or under fire. More than 41% of citizens have relatives or loved ones who were or are in the war zone, including 16% who have lost someone close to them. 6% of respondents were under occupation, were directly threatened with violence or witnessed such threats. Every twentieth respondent (5%) experienced or witnessed all of the specified types of traumatic events (shelling, threats to the lives of loved ones, occupation or captivity). Only 9% of citizens said that they had not faced any such event during the period of full-scale war. The majority of respondents (more than 90%) had manifestations of at least one of the symptoms of post-traumatic stress disorder, and 57% of citizens are at risk of developing PTSD (Moz, 2022).

The research was conducted using an online survey on the Kantar Ukraine panel. It covered people aged 18-55 in Ukrainian cities with a population of over 50,000. Participation in the survey was voluntary and anonymous. The research methodology, its indicators and the questionnaire are based on scientific developments of the Institute of Social and Political Psychology of the National Academy of Pedagogical Sciences of Ukraine.

Estimates suggest that between 15.3% and 26% of all civilians enduring conflict experience Post Traumatic Stress Disorder (PTSD) (Johnson et al., 2021). Among journalists covering war and conflict, this amount is as high as 28.6% (Feinstein, Owen, & Blair, 2002). PTSD “is a disorder that occurs as a delayed or chronic response to stressful events or situations (either prolonged or limited in time) of an extremely dangerous or catastrophic nature” (Niewiadomska, Chwaszcz & Radon, 2017, p. 11). These events can be any traumatic experience, ranging from a natural disaster to rape, and from a car accident to war (Feinstein, Owen, & Blair, 2002). PTSD does not necessarily arise immediately after the traumatic experience, but generally occurs within several weeks to months after the event. In addition, the duration of the disorder varies considerably and has potential to become chronic (Niewiadomska, Chwaszcz & Radon, 2017). The psychosocial consequences related to PTSD are multifaceted, and may include: insomnia, anxiety, violence, and a difficulty with everyday work and caring for one's self (Tabarovsky, 2016). The high prevalence and profound effects of PTSD among civilians and journalists in conflict zones alike underscore the need for a conscious approach to the subject and trauma-related events by media.

This need is further enhanced by the possibility of re-traumatizing victims and civilians by such reporting. Re-traumatization is a reaction to a (traumatic) event influenced by previous traumatizing encounters, causing a more severe reaction. In itself, this new event does not have to be traumatizing, but may merely remind one of earlier experiences (Alexander, 2012). In addition, media outlets should be mindful of the stigma surrounding trauma and PTSD. The consequences of this stigmacome in many formes, including discrimination, (self-)exclusion and reduced help-seeking behavior (Krzemieniecki & Gabriel, 2021). As a result, many mental injuries go undiagnosed (Colborne, 2015). Research has shown, however, that increased and improved knowledge about mental health plays a crucial role in its de-stigmatization. Media outlets have the potential to make a positive contribution in this (Krzemieniecki & Gabriel, 2021). Complicating the fulfillment of this role, however, is the contradictory information throughout the field regarding the do's and don'ts of communication in relation to de-stigmatization and the avoidance of (re-)traumatization. This is, for instance, reflected in the discussion on trigger warnings: while trigger warnings intend to alert people to potentially trauma triggering content, recent studies suggest these warnings have no effect, place one's trauma at the core of their identity and may even have adverse results (Jones, Bellet &McNally, 2020).

Globally, journalists covering conflict have been tasked not only with reporting on the ongoing disputes, but also with doing this mindfully of the traumas experienced by civilians, (former) soldiers and themselves. The way this is to be done, however, remains ambiguous. The aim of this literature review is thus to assemble existing knowledge and experience concerning, the effective communication about traumatic events with people suffering from PTSD, guided by the principle of “do no harm”. Specific focus will be on trauma triggers, the avoidance of stigma and re-traumatization, and communication techniques throughout both traditional and new forms of media. Accordingly, the research question guiding this review is: what is known about the ways to write about psychologically traumatic events, PTSD, and trauma respectfully that would avoid re-traumatization of the victims and would contribute to alleviating stigma?

To address this question, a scoping literature review will be conducted. While the ongoing tensions along Ukraine's borders are the primary motivation for this review, for reasons of feasibility, literature covering a wide range of geographical areas, traumas and academic disciplines will be considered.

Methods. Study design

Knowledge and literature from a variety of disciplines are relevant to answering the research question. Therefore, more `framed' search tools, such as PICO and SPIDER, proved unsuitable for the literature search. Instead, as the research question guides all subsequent stages of a scoping review (Colquhoun et al., 2014), the key concepts embedded in the research question - as well as a variety of synonyms - have been used to create literature search strings. These key concepts are: “Communication” (i.e., for “write”), “Traumatic event”, “PTSD”, “Re-traumatization”, and “De-stigmatization” While the presence of the first three concepts was required in all hits (i.e., search string connection by “AND”), the presence of either one of the latter two concepts was sufficient (i.e., search string connection by “OR”). The literature search was performed in the electronic libraries SCOPUS(https://www.scopus.com/home.uri), Web of Science(https://www.webofscience. com) and PubMed(https://pubmed.ncbi.nlm.nih.gov/), on 5 December 2021. The first two libraries were chosen for their wide-ranging and varied literature collections, covering all academic disciplines. The latter library, in contrast, was chosen for its prominence in the (bio)medical field (VU, n.d.); a domain with crucial insights into trauma, PTSD and its consequences. All 595 search results were subsequently imported into Rayyan - Intelligent Systematic Review(https://www.rayyan.ai/). Using Rayyan enabled the reviewers to screen the results simultaneously, yet independently. Any conflicts that arose during the screening process were registered by Rayyan, whereupon the reviewers met to discuss and resolve them.

The first screening stage involved a title, abstract and keyword screening in Rayyan, to determine the relevance of the retrieved studies. A set of inclusion and exclusion criteria was established prior to screening. Included studies must address: traumatic events and communication approaches; the reporting of traumatic events/PTSD in the media; the effects of (inappropriate) communication on people with trauma/PTSD; and, the role of media and communication in (de-)stigmatizing trauma/PTSD. Conversely, studies were excluded when they focused on: dealing with trauma in healthcare facilities; unrelated consequences of PTSD; medical perspectives and definitions; and, stigma and trauma in combination with other medical aspects (e.g., HIV/AIDS). Due to the limited availability of studies, no criteria were set regarding geographical location, year of publication or methodology used. However, while acknowledging grey literature may possess relevant tools and tips, only academic, peer-reviewed articles were included.

After completion of the first screening stage, both reviewers conducted a full-text review to determine true significance and inclusion. Similar inclusion and exclusion criteria were used, which were now applied more strictly. However, this systemized search yielded only few articles. In addition, the reviewers identified several topics as missing from the dataset (e.g., trigger warnings). Hence, to obtain a complete overview of the available literature, and because time constraints did not allow for a more extensive systemized search, the dataset was expanded with handpicked literature. This handpicked literature was selected from the datasets of previous preliminary searches, which used broader search strings and, as a result, obtained more results than the used search string (which proved to be too narrow). Since the preliminary searches had already been through all stages of the screening process, additional literature could be handpicked directly from the datasets. In doing so, particular attention was devoted to topics missing from the systemized search, as to obtain a more complete overview of the available literature. Additionally, handpicked literature was retrieved through snowball techniques.

From the 595 results of the literature search, 126 duplicates were removed. After abstract-title and full-text screening, 7 eligible studies were selected, and 15 handpicked articles added. This resulted in 22 studies for literature review.

Figure 1. PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

The results have been divided into the four categories outlined above, following the baseline of the literature review. In this section, a selection of elements and findings from each of these categories will be discussed.

Table 1. Summary of Included Literature

PTSD and the media

The first category 12 studies had been included, discussing literature related to (the interlinkage of) Media and PTSD, consisted of a variety of different studies, highlighting both the positive and negative aspects of this interaction. Firstly, the literature showed that media outlets can play an important role in helping to explain PTSD, its effects and (successful possibilities for) treatment to the public. For instance, by emphasizing that symptoms and feelings related to PTSD are natural, especially after experiencing trauma (Otero, 2006). Additionally, it was found that media outlets play a crucial role in shaping the value or social importance assigned to PTSD, as well as in identifying potential areas for interventions to policymakers (Wu, 2017). In contrast, media exposure has also been identified as a trigger of PTSD. Hilton (1997) for instance showed how media portrayal of the Second World War likely triggered PTSD symptoms fifty years after the war had ended, in people who experienced the war. Similarly, in a study into the effect of news on Iraqi refugees, Kira et al. (2008) showed that seeing and reading war-related news has a traumatizing effect that is equivalent to that of direct or other secondary sources of trauma. In addition, Kira et al. showed a link between the aforementioned exposure and `poor general health', whereby people were found to be at greater risk of, among other things, cardiovascular and neurological problems.

Furthermore, in a relationship to this category for journalists, albeit taken from a different angle, studies showed journalists themselves are more likely to meet criteria associated with PTSD, [SK1] depression and excessive alcohol use as well, such as repeated exposure to trauma, feelings of powerlessness and broken world assumptions (Dadouch & Lilly, 2021). In relation to the role of journalists in the immediate aftermath of traumatic events, Barnes, Tupou and Harrison (2016) recommend incorporating the “emotional labor” framework into trauma-trainings. Emotional labor refers to “the process by which people are expected to manage their feelings in accordance with work-defined rules and guidelines” (p. 54) and helps journalists (in training) to process the traumas they themselves experience as well as to treat victims with respect.

In the second category of Communication and PTSD seven studies had been included, authors Acuna (2014) he argued that open communication is one of the factors that contributes most to preventing PTSD after traumatic events. As it was found that preventive communication in the form of trigger warnings increased individuals' feelings of enduring distress. Furthermore, for those who believe in the `power of words',

Additionally, another study Otero (2006), simple language, as well as local phraseology, should be used to discuss mental health.

Finally, when it comes to a slightly distressing exposure, trigger warnings seemed to have no effect (Bellet, Jones & McNally, 2018).

On the element of Communication & (Re-)Traumatization five studies provided a clear answer to the third sub research question What is known about the role and effects of communication on (re-)traumatization?) According to one of the studies, it has been suggested that individuals did not use trigger warnings to avoid trauma cues (Jones, Bellet & McNally, 2020).

One study confirmed their Re-traumatization hypothesis through analytical procedure between communicational media and re-traumatization as: population who had previously been traumatized including war, torture survivors, and PTSD patients, the more they watch, the more retraumatized they become (Kira, 2008).

As consequences of war, classic studies on traumatization of immigrants were conducted in Israel during the war on 1991, showing that older Holocaust survivors perceived higher levels of danger, had higher levels of anxiety, and experienced more emotional stress than participants without a Holocaust background. Thus, previous trauma such as the Holocaust appears to leave older adults vulnerable to psychological distress.

Finally, studies revealed that, friendly terminology of using the term migrant instead of refugee, exile, or immigrant removes from the set of associations the reasons why the affected people leave their country: war, violence, poverty (Stroinska, 2019). The politicians and the media who accept their language rob the traumatized war refugees of the main reason why people in potential accepting countries would want to show them the compassion that comes naturally when we see someone in need.

The fourth and final category involves six studies addressing the relations between communication and (de-)stigmatization. Stigma can be defined as “a mark or sign that disqualifies an individual from full social acceptance from the community” (Han, Cao and Anton, 2015, p.65). An example of war-related stigmatization is the large number of articles on criminality, trials and war crimes concerning war veterans, ten years after the war in Croatia (Franciskovic et al., 2011). In addition, in their study of hate speech in the era social media (directed at refugees), Stroinska and Cecchett (2019) found that, often, scientific, or medical metaphors are used to stigmatize others (e.g., portraying people as parasites or carrying (contagious) disease). This is similar to policies used in in Nazi propaganda. Furthermore, Bellet, Jones, and McNally (2018) found that the use of trigger warnings may, in fact, have a “soft stigmatizing” effect vis-a-vis trauma victims.

Contrastingly, however, Maercker and Mehr (2006) showed that, for crime victims, the degree of media exposure of the incident had no effect on an individual's experienced stigmatization as victim versus as survivor. And Han, Cao and Anton (2015) showed that media campaigns can also be used to promote knowledge, understanding and openness about mental health and thereby contribute to its de-stigmatisation. To achieve this allinformation provision, also on more general mental health topics, should be linked to the community and its situation. Additionally, Otero (2006) argues that, to destigmatize, it is important to stipulate that PTSD can be remedied through treatment and “represents a normal response to an abnormal situation” (p. 62).

Discussion

This review identified various recommendations for media and communication: i) use simple and locally accessible language (Otero, 2006); ii) use open communication (Acuna, 2014); and iii) link (general) information about PTSD to the targeted community (Han, Cao & Anton, 2015). While these recommendations are useful, they remain somewhat superficial, and, consequently, fail to meet the needs of the target group. Additionally, extensive guides on ethical trauma reporting and mind-full interviewing do exist within the grey literature. This covers topics such as: establishing contacts and conducting interviews, as well as both the journalist's and community's trauma (see for instance: Brayne, 2007).

This literature review had a number of limitations, with the most important being: time. The lack of time prevented the reviewers from searching more databases and including more literature, thereby potentially letting important results go unnoticed. Another limitation, was the exclusion of grey literature. This resulted in the exclusion of potentially important insights from, for instance, civil society organisations or journalistic associations. This exclusion is particularly pivotal as it concerns the knowledge and recommendations from this review's target audience. Future reviews should therefore focus on both academic and grey literature, and the interaction between them. In addition, this systemised literature review had a significant methodological limitation, namely: its search string. While the preliminary searches obtained sufficient and relevant results, the final systemised search yielded insufficient literature, thereby compromising the methodological validity of the review. The limited number of results obtained is likely due to the narrow search string used. However, while the search string was narrow, it generated a wide variety of irrelevant results (e.g., regarding HIV-related stigma). Due to time constraints, the reviewers were unable to conduct an additional and improved systemised search. Therefore, future research would benefit from a similar review, using a broader search string.

Nevertheless, this review had a number of strengths. The findings of the literature review provided a clear overview of both the positive and negative impacts media and communication can have on trauma and stigma. This underlines the importance of accurate and conscious communication, as well as the relevance of studies like the present. In addition, the results showed the scattered character of the field, with different types of (at times contradictory) information, spread across various disciplines. With this, the review can provide future researchers with insight into the themes, recommendations and disciplines that are relevant, and thereby - hopefully - contributes to resolving the debates and ambiguities embedded in them.

Conclusion

This scoping review presented an overview of the existing knowledge and literature on effective communication about traumatic experiences with people suffering from PTSD. The findings were not univocal, but rather demonstrated how media coverage can have both very positive and very negative implications. Whereby, via correct simple and community-oriented communication, media outlets can contribute to the normalisation and de-stigmatisation of PTSD. Future reviews are needed to expand and enhance the systemised search and to incorporate grey literature into the synthesis. Despite the negative consequences, the media have the potential to develop appropriate professional recommendations based on the experience of covering the war in Ukraine and become a therapeutic resource for overcoming the trauma of war, particularly in Ukrainian society.