COVID-19, Fear and What Counsellors Can Do To Help
In this article we look at some of the ways mental health professionals can support clients during the COVID-19 global crisis.
A member of our writing team related the following experience during these times of near-lockdown. She had gone out to do some essentials such as grocery shopping and getting prescriptions filled for her healthy but self-isolating husband. Returning home, she threw down her things, wailed, “It’s just awful”, and burst into tears. Her astonished husband enquired, “What happened?”
“I’ve never had errand-running and shopping be such a dismal experience,” she lamented. “After four pharmacies, I could still only get one of your items filled, because everyone has panic-bought huge supplies of the others. Pharmacists still don’t know when they’ll get more stock. The grocery store had rows of empty shelves, so your request for bread and milk is not fulfilled. There is nary a frozen veggie to be had, and you had better pace yourself on the toilet paper we managed to score last month; I’ve been out six times without spotting a single roll. Does it even exist? The look on shoppers’ faces is nothing short of glum. And when I went to check out, the girl at the checkout counter gave me a frozen smile, told me to pack my own bags, and conspicuously stepped back, sanitising her hands as I was trying to stuff food into bags and get away. She acted like I was a walking virus!”
After a mood-restoring cup of tea, our colleague was able to disidentify from the frustration, but her experience – which resonates with many of us trying to do “normal” life in these abnormal times – gave her the insight that the world is actually fighting two pandemics now: COVID-19 and the parallel virus of fear and panic which is generating over-reactive, anti-social behaviour, stigma, and other psycho-social problems. It is that “virus” which we address in today’s article.
The Symptoms and Stressors
Soon after the coronavirus was identified in that now-famous market in China, myriad articles began appearing about the physical symptoms that infected people may have. More recently, pieces have popped up identifying the psychological stressors and the symptoms we can expect to see as we collectively deal with both the prospect of physical infection and also the need to isolate ourselves in our homes or elsewhere, forsaking the regular, normal human interactions that we are accustomed to, and which provide the rich texture and framework for daily life.
The obvious symptoms and stressors
In late February, The Lancet published a “rapid review” of the psychological impact of quarantine and how to reduce it (Brooks, Webster, Smith, et al, 2020). Using three electronic data bases, they found 3166 papers on the topic, of which they reviewed 24. The stressors during quarantine were found to be:
Fears of infection: Both fears about their own health and fears of infecting others were reported, with psychological outcomes evident from these fears three months later.
Frustration and boredom: The confinement, loss of usual routine, and reduced social and physical contact with others often caused frustration, boredom, and a sense of isolation from the world.
Inadequate supplies: When basic supplies, such as food, water, clothes, or accommodation were unavailable during quarantine, it was a source of anxiety and anger that continued to be felt four to six months after the quarantine. Study participants reported receiving their masks and thermometers late or not at all. In some cases, food, water, and other items were only intermittently distributed.
Inadequate information: Many participants cited poor information from public health authorities as a stressor, reporting unclear guidelines about actions to take and confusion about why they needed to quarantine. Differences in the style, approach, and content of various public health messages because of poor coordination between the various levels of government and jurisdictions meant that, in Toronto at least, those in the middle of the SARS epidemic experienced huge confusion. The lack of clarity led to participants fearing the worst. Participants also perceived a lack of transparency from government officials about the severity of the pandemic (Brooks, Webster, Smith, et al, 2020).
In late March, The Telegraph reported that, during the outbreak in China, “generalised fear and fear-induced overreactive behaviour were common among the public” while fear, anxiety, and post-traumatic stress disorder were commonly on display (Farmer, 2020). The U.S. Centers for Disease Control and Prevention (CDC) observed recently that the public mental health crisis first spawned by the COVID-19 Pandemic in China had several unique factors that authorities in other countries need to integrate into their considerations as they manage the outbreaks in their own countries.
First, noted the CDC, there are many people on the planet (and there were many in China) who remember the 2003 outbreak of SARS; that epidemic has left psychological scars on social and economic life as a result of the disease. COVID-19 is more easily transmitted than the SARS virus was, and the case fatality rate is substantially or even hugely higher than that for seasonal influenza (Worldometers, 2020). Second, fear and anxiety are widely generated from the epidemiological realities that not only does the virus have a long incubation period, but also its victims are frequently asymptomatic in the early stages when they are highly contagious.
Third, while China has been globally acknowledged as having handled the crisis well once the outbreak was recognised as serious, it has been criticised for its initial downplaying of the severity; this eroded trust in public authorities and led to widespread cynicism about the government’s transparency and competency. Naturally the large-scale forced quarantine measures were stressful, causing a negative psychosocial impact on those under lockdown. Finally, repeated reports of shortages in medical protective supplies, staff, and beds in hospitals caused massive concern around the nation (Dong & Bouey, 2020). Sadly, the leaders and health authorities of other countries have seemed not to learn from China’s experience, as these circumstances have been repeated multiple times in other countries caught off guard by the virus’ rapid, stealthy spread.
The less obvious signs of trouble
Hopelessness: There is a saying that in a disaster, hope is the first casualty. The World Health Organization has just one week ago called attention to several less obvious psychosocial considerations during the outbreak; one of them is hope (WHO, 2020). At this writing, news reports have stated that this past week in the United States, 6.65 million people applied for unemployment benefits (The Guardian, 3 April 2020). In Australia, the job losses due directly to the pandemic have now topped 100,000 (for a country of 25 million!) (SBS News, 28 March, 2020). It is difficult to maintain an unwavering stance of hopefulness when a person is confined to their home for an indefinite future and is likely to be unemployed upon being released. As a mental health practitioner, restoring hope may be a major, early therapeutic task you must do, regardless of the presenting issue.
Stigma: The WHO also reports that there has come to be significant stigma in regard to this virus. Those who have had it but recovered are on the receiving end of stigma from friends, relatives, and co-workers who fear that they may be infected from the person, despite the person being tested and declared “virus-negative”. Similarly, many healthcare workers, who jeopardise their own health and life to serve unwell others, are finding that family and friends avoid them as if they had contracted the virus, a finding also noted by The Lancet “rapid review” (WHO, 2020; Brooks, Webster, Smith, et al, 2020).
Individuals feeling under pressure and children needing more attention/attachment due to uncertainty: As the economic catastrophes mount with businesses large and small standing down thousands and closing their doors, individuals feel the pressure, which means that tensions in those individuals’ families are ratcheted up. Moreover, many are the partnerships which have rubbed along fairly well in the past because the people in them have gone their separate ways to work during the day, only coming together in the evenings. For those same people now housebound together 24/7 (often in a rather confined space, such as a small unit), the result is accelerating tension in the relationship. Those who work with domestic violence have warned that the incidence of this will inevitably rise. We can add to that the pressure parents are under to respond in healthy ways to children who – also feeling the fear and uncertainty – have greater attachment and attention needs. They are needs which parents, through their own pressures, are decreasingly comfortable to offer. All of this is totally in addition to the massive strain on our healthcare professionals as they struggle with overwhelming numbers of patients and often inadequate personal protective equipment.
Loss and grief: As the death toll increases, we are all more likely than before to know someone who dies from COVID-19. But even if we and our loved ones escape that fate, there is no denying that we all have experienced loss, which we must grieve. Katrina Grace Kelly’s column in the Weekend Australian (Kelly, 2020) reflects that the obvious losses of job, superannuation balance, and share values are bad enough, as markets tumble and personal wealth is wiped out “in the blink of an eye” (p 20). But Kelly exhorts us to also recognise the losses from our sudden inability to rely on those things which ordinarily comforted and held us: personal interactions with family and friends in social gatherings, sports meets, concerts, cultural events, and of course meals and drinks at our favourite pubs/restaurants/cafes. This is all denied us now, and we must not deny the loss of preferred lifestyle that the closures entail.
There is individual grief, our collective grief, and sadly, anticipatory grief, as we steel ourselves for more losses to come – and to last for an unknown period. Various models for dealing with loss and grief (such as Kubler-Ross’ well-known model) posit the steps we must go through after initial denial: steps such as shock/disbelief, anger, bargaining, depression, and finally acceptance (Kubler-Ross, 1969). The point for us here is that we must be alert to the numerous losses our clients will need to grieve even when parts of their lives remain intact. As the losses mount, we are also talking about cumulative grief (experiencing second or more losses while still grieving the first).
Who is most at risk in this environment?
We have been advised repeatedly by health authorities that elderly individuals, particularly those over 80, are most at risk from COVID-19. While this is borne out by mortality statistics, there are additional high-risk groups when we consider mental unwellness. Numerous reports identify the frontline healthcare workers (doctors, nurses, ambulance workers, and others) as among those most likely to experience the depression, anxiety, and PTSD that are emerging with this virus; they are also at risk from secondary traumatic stress through being exposed to so many traumatised patients fighting for their lives (Dong & Bouey, 2020; Brooks, Webster, Smith, et al, 2020; WHO, 2020).
The CDC cites the notification by the National Health Commission of China, back in January, 2020, that a special intervention workforce convened to deal specifically with mental health issues identified five additional groups as key intervention targets: confirmed patients, individuals suspected of having COVID-19 and awaiting test results, individuals who have been in contact with COVID-19 patients, unwell people who refuse to seek care, and susceptible members of the general public (Dong & Bouey, 2020).
A separate article in The Lancet has just identified a major group, whom we as mental health professionals must take note of: those who had pre-existing mental health disorders when the pandemic began to spread. Concern was raised that, for those in psychiatric hospitals, the risk of transmission is greater because of cognitive impairment, little awareness of risk, and diminished efforts regarding personal protection.
Moreover, those with mental health issues may have more barriers in accessing timely health services due to discrimination against them. Even when they do receive treatment, however, such individuals’ COVID-19 treatment may be less effective due to the mental health co-morbidities. Finally, as such patients take in the general emotional responses to the pandemic, they may relapse or experience a worsening of condition due to high susceptibility to stress compared to the general population (Yao, Chen, & Xu, 2020).
Our response: Interventions that can help
We can choose interventions from a range of therapies, depending on the symptoms most prominent or troubling to the client. Here are a few samples to illustrate the basic (really, not rocket science!) responses on our part that will go a long way toward relieving angst. Note how many of them can be in the category of merely getting some perspective.
From positive psychology
Beyond Blue (2020) reminds people to remind themselves that this is a temporary period. The isolation, the restrictions on freedom, the health threats, and also the massive unemployment, will not last forever. Beyond Blue is taking a leaf from the positive psychology playbook here. Martin Seligman, the “father” of positive psychology, noted that an optimistic explanatory style contributes greatly to one’s happiness. It consists of noticing that – even as bad as any particular event is, a person can reflect that the event will not be all of the following: permanent (that is, most things will pass), pervasive (e.g., even if you lose your job, you may still have sustaining relationships), and personal (i.e., you may hate being under lockdown, but it’s nothing personal; we’re all in this together) (Seligman, 1992). In other words, we can get a sense of perspective.
Psychosynthesis and mindfulness
One of the first skills Psychosynthesis practitioners teach distressed clients is often that of disidentification. A two-step process consisting of first identifying with the stressor and then disidentifying from it, the skill is paralleled by the mindfulness process called defusion, in which the person practicing the skill first fuses (identifies) with the feared thought (e.g., “I could get sick and die from this”) and then distances him/herself from it (disidentifying or defusing) by creating an Observer Self. This Self watches the client be consumed with fear or worry, but from some distance, where the worrisome thought is not as potent. Disidentification and defusion create a more spacious psyche, which affords clients the ability to see their problems from further away than before; the threat level decreases (Assagioli, 1973/1984; Harris, 2009).
CBT and the reframe
In CBT-based psychologies, the practitioner works to help the client reframe limiting, unhelpful, and/or irrational thoughts, replacing them with more adaptive, realistic ones. Thus, thoughts such as, “I’m sure I’ll lose my job in this pandemic, and I’ll never work again” are reviewed and evidence is sought for them. Even if the person is/has been working in an industry which is closing up during the pandemic (for example: the aviation and hospitality industries), there is no evidence to suggest that these industries will not roar into life again when lockdowns are lifted and we are on the other side of the pandemic. Beyond that, the client can be probed to examine if s/he has ever lost a job before, for whatever reason. If so and the person has been working recently, there is clear counter-evidence to the assertion, “I’ll never work again” (Beck & Weishaar, 1995).
In this therapy – as stated in its name — the practitioner helps the client to focus on solutions to the current problems (Ackerman, 2017). No, the client may not be able to go to the gym, but what at-home exercising options might there be? Online yoga workouts, fit balls, and dumbbells may offer heretofore ignored possibilities for keeping fit. Beyond that, the practitioner can probe for how the client may have coped with situations that were similar (in whatever way) in the past. How might these solutions be re-formed to work for the current situation? What coping skills can be identified to be recruited now?
Mindfulness and other stillness practices
Does the client have a spiritual holding to call on in this crisis? Can those practices come more to the forefront of the client’s life? Mindfulness and other stillness practices, such as the Buddhist loving-kindness meditations or progressive relaxations can help the client to relax, centre, and find peace in an agitated world.
Finding meaning, purpose, and values (MPV)
Whatever school of psychology we employ to recruit useful interventions, the bottom line is that those who are able to find meaning and purpose in the events happening to them during the pandemic – or anytime – are able to reduce suffering, enhance their resilience, and become beacons of light to others in our collective dark times of pandemic spread. A primary Psychosynthesis tool but widely adopted in many other schools of psychology as well, “MPV” identification establishes what has ultimate meaning, clarifies what then is one’s purpose, and enables choosing which values are then enacted (Assagioli, 1973/1984). It is a powerful antidote to the virus of fear and panic sweeping the globe.
In this article we have outlined how, in addition to the obvious stressors of restriction, inadequate supplies, and unclear information (which induce symptoms such as fear, frustration and boredom), there are many less obvious threats to tend to in the current environment. These include the wildfire-like spread of hopelessness, stigma, a sense of pressure, and the individual and collective need to mourn our many losses, not least of which has been the loss of our affluent society’s free and easy lifestyle. We identified who is at higher risk during these times, and outlined samples of the kinds of interventions that, as practitioners, we can offer clients whose lives have been turned upside down.
And what of our stressed colleague after her routine errand run? She ultimately came to realise that, as irritating as the current times are globally, the contrast with how we are normally able to live, work, and play gives rise to an immense gratitude for what we have had (another resilience skill!), and the will to engage on all fronts, that our collective rebound to a new normal may be permeated with genuine peace, cooperation, and empathy as we stamp out the other virus. We all have a role to play in that, but as mental health practitioners we may have a starring role.
- Ackerman, C. (2017). What is solution-focused therapy: 3 essential techniques. Positive Psychology Program. Retrieved on 24 January, 2018, from: Website.
- Assagioli, R. (1973/1984). The act of will: A guide to self-actualization and self-realization. Wellingborough: Turnstone Press.
- Beck, A.T. & Weishaar, M.E. (1995). Cognitive Therapy. In Current Psychotherapies, 5th Ed., Corsini, & Wedding, Eds. Itasca, Illinois: F.E. Peacock Publishers, Inc.
- Beyond Blue. (2020). Looking after your mental health during the coronavirus outbreak. Beyond Blue. Retrieved on 29 March, 2020, from: Website.
- Brooks, S.K., Webster, R.K., Smith, L.E., et al. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet: Volume 395 (10227), pp 912-920, March 14, 2020.
- Dong, L., & Bouey, J. (2020). Public mental health crisis during COVID-19 pandemic, China. Centers for Disease Control and Prevention (CDC) Research Letter. Volume 26 (7) (July, 2020).
- Farmer, B. (2020). The COVID-19 mental health crisis: expect depression, anxiety and stress disorders, researchers warn. The Telegraph. Retrieved on 28 March, 2020, from: Website.
- Harris, R. (2009). Mindfulness without meditation. In HCPJ (Healthcare Counselling and Psychology Journal), October, 2009, pp 21 – 24.
- Kelly, K.G. (2020). In the mourning after, we will come to terms with loss. The Weekend Australian, 28-29 March, 2020.
- Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.
- Seligman, M. (1992). Learned optimism. Australia: Random House.
- World Health Organization. (2020). Mental health and psychosocial considerations during the COVID-19 outbreak. WHO. Retrieved on 29 March, 2020, from: Website.
- Worldometer. (2020). Worldometer. Retrieved on 29 March, 2020, from: Website.
- Yao, H., Chen, J.H., & Xu, Y.F. (2020). Patients with mental health disorders in the COVID-19 epidemic. The Lancet. Volume 7 (4), PE21, April 01, 2020.