Winning the mental warfare with COVID-19 (CBT Self-Help for COVID-19 Anxiety)

Recent reports indicate that the level of mental health symptoms amongst the general population are on the increase. A Young Minds study published in The Guardian on March 31st 2020 asked 2,111 under 25s with a history of mental health needs, how the pandemic had affected them. 83% said the pandemic had made their mental health worse.

More recent clinical experience also indicates that the overall numbers of mental health disorders, in particular anxiety and depression  are on a steady increase and will eventually cover many different segments of the population.

There is currently a justified, growing concern for the mental health of all frontline workers from NHS and the police forces across the country; but also for delivery drivers, various transport workers, engineers, cleaners and supermarket workers. No doubt, these truly are the heroes of the day.

On the other hand there seems to be less focus on other clinicians from the second tier of exposure who may not necessarily be on the frontline, directly tackling COVID-19 patients, for instance GPs, mental health nurses, psychotherapists, psychiatrists, physiotherapists in smaller hospitals or private clinics. Even less thought is given to the general population who cannot it seems, cope psychologically and emotionally in self-isolation.

The potential consequences of self-isolation

We know from various psychopathology,  biology and behaviour studies  that in spite of displaying incredible resilience in the face of various diseases, humans are not well equipped to deal with social isolation and ‘psychological  uncertainty’ for prolonged periods of time –  this would inevitably be a catalyst for a range of mental health pathologies including depressive and anxiety disorders. For those that are already suffering from a mental health problem, it could symptomatically be even worse, as the recent Young Minds study clearly outlined only a few days ago. Social isolation, catastrophical thinking, long episodes of negative rumination, lack of purpose, increased drinking and less physical exercise are risk factors for major depressive disorders and anxiety disorders.

Self-isolation therefore may be both a blessing and a curse, since it will clearly help us manage COVID-19 but at the same it might bring with it a series of challenges including, how to spend time at home in a way that improves our mood and does not increase feelings of fear, sadness, anger, isolation and lack of purpose.

There are several self-help tools originating in the family of Cognitive Behavioural Therapies that are likely to help. To offer some context, Cognitive Behavioural Therapy or CBT is an umbrella term for a range of evidence-based psychotherapies that successfully combine behaviourism with philosophy, learning theories, cognitive psychology and more recently neuroscience and neuroaffective research. Unlike other therapies, CBT is structured, symptoms focused, goal-oriented and aims to enhance self-efficacy by introducing a range of self-help technology. These techniques could  be very helpful in the current climate.

 CBT strategies for social isolation

A number of evidence-based strategies are recommended by CBT therapists. It might be best to organise those in 3 categories: mind, body and regulation of emotions; or in CBT terms, cognitive interventions, behavioural interventions and regulation of affect (or emotional regulation).

Mind or Cognitive Interventions

When it comes to the ‘mind’ everyone is different but individuals’ reactions to threats are very similar.  The current ‘threat’ is obviously that of being infected with a dangerous virus which leads to fear, intense preoccupation, hypervigilance and a range of other symptoms associated with an anxiety disorder and stress.

A good place to start is by understanding and truly accepting that ‘fear’ is an essential emotion, much like sadness, anger or joy; all these emotions are very well embedded and encoded in our genes, in our neurological circuits. Such complex connections essentially enabled our species to survive over tens of thousands of years. And as such, this is not an emotion we would want to get rid of. For example, if we would not experience a higher degree of fear in relation to COVID-19 we would be too laid back and less inclined to protect ourselves and other members of our community. 

Nonetheless, there is a very fine line between the emotion of fear and an anxiety disorder, best explained perhaps by some of the cognitive psychology research which stipulates that people tend to get anxious when they overestimate the probability and possibility of the threat and underestimate their coping skills or other (external) rescue factors, resources and so on, they might have at their disposal (when or if faced with the predicted threat).

Following up from that, a very useful self-help strategy evolves from this formula which focuses on ‘de-catastrophising‘ the impact of the threat. In this case obviously, it translates into decatastrophising the threat that COVID-19 would pose to our health and our community in the long run.

Decatastrophising COVID-19

The process of decatastrophising might feel a little slow involving several daily practices, it is best to be patient and thorough.

Mindfulness & acceptance of your distressed thinking

To begin with, we could attempt a very simple mindfulness and acceptance technique.  My advice for everyone at home is to practice regularly and gradually learn to increase their awareness of unhelpful ‘trains of negative and catastrophical thoughts’ in order to learn to distance themselves from them.

Just allow your thoughts to come and go as they please and do not engage with the content, with the message these thoughts are trying to deliver…  just accept them…

You will soon learn to view your thoughts exactly for what they are – just normal mental activities – you do not have to believe every thought that pops into your mind AND feel the need to immediately act on it… learn to indentify Gaps of Silence in-between these ‘trains of thoughts’…  gaps where you feel safe and not urged to do anything… it might be helpful to imagine [whilst engaging your slow abdominal breathing] that there is always a gap in-between these long, sometimes connected trains.. Aim for the Gap.. Aim for the Silence. 

Mindfulness-based techniques can feel difficult when you try them for the first time, be patient with yourself, allow for mistakes, you do not have to get it perfect. It is a bit like going to the gym for your first time, your muscles will hurt, however you will get stronger if you persist.

Facts Finding, Installing Hope and Positive Self-Talk

A completely different way of dealing with catastrophic or negative thoughts, would be to practice generating a much more optimistic and hopeful ‘Self-Talk’ or ‘Self-to-Self dialogue’ between your ‘Anxious-Self’ and ‘Strong-Self’.

This optimistic and positive dialogue could be extended to someone in your household or to your social media community and consists of research and careful examination of all the evidence surrounding the threat (i.e. CORONA-19), keeping a focus mostly on positive facts:

Fact number 1: in regards to the level of threat, the virus is indeed dangerous but the majority of people will recover and most will build immunity against it.

Fact number 2: NHS, universities and research labs across the world are working tirelessly to develop testing tools and treatments which would more than likely build our immunity against COVID-19.

Fact number 3: there are a lot of specific examples of successful treatments, perhaps people that we know (i.e. Matt Hancock, Health Secretary) and have now recovered and are well. It may be important to write down these specific cases in bullet points and describe in detail a situation that impressed you and gave you hope.

Fact number 4: in regards to available resources and coping skills, much can be said about external resources which are literally improving every day (i.e. the new Nightingale Hospital in East London). But in regards to coping, ask yourself the following questions:

– Given all the above facts and the real threat this virus poses to me, how could I cope and what resources are currently at my disposal?

– What else lingers from my recent findings… perhaps more optimism… more coping strategies… or more hopeful facts…?

– In light of all my research and recent evidence, how true are all these statements?

“The human race is fighting back in a variety of ways!”  (0-100%)

“We are not giving up!”   (0-100%)

“We have seen much worse! We refuse to fall victims!”  (0-100%)  

* Rate the level of your belief in those statements from 0-100% and if the scoring is below ‘50%’ ask yourself, what could you do in order to improve the rating? How about backing these statements up with some more research and even more examples of resilience and recovery or other recent achievements and posting those on social media or write it in your personal journal (as opposed to focusing mostly on negative and sad stories).

Positive Data Logs

Another useful cognitive-behavioural intervention, would be compiling a Positive Data Log (PDL) on social media or indeed in your personal journal (or both, if you prefer it).

It is important to use these questions as guidance for your new PDL, though one could get very creative and add to it, there are no limits put on your exploration.

– What am I learning from this experience about myself, about significant others (i.e. family & friends) and about the world around me?  

– In how many positive ways has my life changed as a result of this situation?

I could of course think of a few things including, having more time with my wife and child, the desire to help the most vulnerable in the community, writing this article, being less focused on material things and more focused on the health needs of the family, on the needs of community in general, a renewed focus on hobbies long forgotten, on my true values, religion or spirituality or indeed the positive impact the virus has on pollution and nature.

All such mental strength or resilience building exercises could be viewed as ‘personal training’ for the mind; is it not curious that we find it absolutely normal and natural to go to a gym, invest time and money in strengthening our bodies and yet when it comes to our minds we hesitate… Why don’t we start right now infusing and enriching our minds with a positive attitude, more optimism and hope… What would that feel like?

The one thing that most people in social-isolation would have right now is time, this makes us a lot wealthier than we were this time last year.

Time can be used to catch up on your hobbies or unfinished projects, it provides space for creative and positive thinking, an opportunity to reconnect and talk to your partners or old friends (… I probably spoke more with my wife this last week then the whole of 2019 – we had a lot of catching up to do…)

Time provides us with an opportunity to repaint the spare bedroom, make bad music, practice our weird dance moves or read more. So what if you have not read a book in years – right now might be a good time to start by choosing the one you missed as kid.

All of the above strategies are very effective mind techniques or cognitive interventions against negative and catastrophical thinking and in favour of installing hope and a more optimistic outlook on life. Such positive mental focus and creative thinking would eventually lead to a variety of self-discoveries, interesting experiments and more valued actions.

….. For example only a few days ago I discovered for the first time how much I enjoy gardening with my family. It is something I would have never considered Pre-COVID19… I might decide now, to show off by posting online this gardener-version of myself; I may briefly describe my newly found talent and in doing so, perhaps I will inspire another friend….

Behavioural interventions

I already mentioned earlier how my own positive data log and research lead to the discovery that I like gardening and enjoy longer talks with my family. Of course, not acting on these self-discoveries would have not provided me with the evidence that I actually enjoy new activities and therefore I could incorporate them in my daily or weekly routine. 

It is therefore important that we put into practice all new valued actions through routine and structure. In CBT we propose a self-management tool called Behavioural Activation this intervention is based on a simple idea – we feel much better when we engage with activities that we Enjoy, Feel a Sense of Achievement or Feel Connected with Others.

Enjoyment, Achievement and Connection!

Research into treating depression indicates that a day that includes a good balance of those three types of activities leads to significant improvements in our mood. Getting stuck in a vicious cycle of not doing things would make us feel unsatisfied, low in mood, less productive and less likely to want to do anything in the future.

Another important Behavioural Activation principle (briefly mentioned earlier) includes having clear routines and a daily structure. It might be tempting, even enjoyable in the short-term to have a flexible daily schedule however, once again the evidence clearly suggests that having a clear sleep routine, specific mealtimes and a strict exercise routine is much more helpful. Of course, there is no harm in having some unstructured or ‘down’ time during the day however, a general lack of achievable goals and structure may lead to helplessness and hopelessness (which could predispose an individual to more symptoms of depression).

SMART Planning at this stage becomes very important. For those that are not familiar with the concept, having SMART goals refers to goals which are Specific, Measurable, Achievable, Realistic and Timed – SMART ! If your goals do not meet the criteria, they need further tweaking or even changing.

For example, the goal ‘I want to be happy’– is not specific enough and cannot be measured whereas… ‘I would like to spend 20 minutes every day doing yoga with my partner’ is clearly a SMART goal, more likely to lead to feelings of joy and relaxation.  

When planning your day or even your week ahead, we must remember to carefully examine what we actually planned for. Look out for a combination of activities that include enjoyment, achievement and connection. If you are missing one element in the day try to build that in, later in the week – it is important that you do not abandon your plans and you do not procrastinate if it seems at times too challenging.

Give your Behavioural Activation diary an interesting name like Katie’s journal, Journal of my Achievements, Mr Big’s Diary, etc., own it and design it, in any way you want to.

You could create your own list/s for the day or a timetable for the week. You could use digital diaries with reminders, smart mobile phones or tablets, you could use Alexa or Google Home or simply use post-it notes which you could move around if need be.

Avoidance and Safety-Seeking

When you are analysing your catastrophical thoughts or even when you are compiling your PDL’s you might, from time to time, notice a tendecy to avoid situations that are likely (in your perception) to cause you harm through contamination. Such ‘safety-seeking behaviours’ can be excessive and would maintain anxiety or the feeling of being under threat. For instance, wearing a face masks in a shop is a necessary measure, whereas wearing a mask in your own home where you live alone or in your garden or even in your car may be an exagerrated behaviour that maintains a sense of threat. Carefully examine your tendancy to avoid and safety-seek and ask a trusted friend or a trusted family member for their opinion if it helps – it may be important to modify such behaviours.

Refocusing on Personal Values & Interests

One other behavioural self-help tool is Refocusing on Personal Values, Hobbies & Interests. You can ask yourself:

Is the way I am spending my time in line with my own personal values and interests?

At this stage, it might be a useful to study your PDL and compile a list of all your values and interests. If you are someone that likes to help others, it is important to make sure that some of your time is dedicated to activities that do that… you might consider donating or even volunteering for a day or two every week.

If learning new things is important for you, make sure that there is time for that. You could make time for creative activities for relaxation or lots of other things that could be done from a distance, like writing, painting, or sending letters to loved ones.

Emotional checking-in

Another important technique is creating a routine of ‘Emotional Checking-ins’ (or emotional sharing) on a weekly basis. This is like calling a regular team meeting at work with all your colleagues for the regular feedback and follow-ups, only in this case the focus on the agenda is our emotional state and what we do.

Take a little bit of time for yourself when you are with your family or your housemates at the end of the week on each Friday evening, to review how things have gone for you during the week and work out if there are things you want to improve for the following week.

Try to answer these questions:

–Did any activities noticeably affect your mood in a positive way?

–What are you grateful for?

–Who do you want to acknowledge this week?

–Was there a day when you felt not so great?

–What was going on then and what could you do in order to improve next week?

Checking-in with ourselves and each other about how we feel and what we have done, can improve the mood and quality of the communication between different members of the household. As a weekly exercise this could lead to many insights, though some families prefer to do it daily – for example, every dinner time or before bedtime.

Remember – this is a checking-in exercise it is not a forum for resolving outstanding problems, everyone gets a turn for a 3 to 5 minutes to talk about themselves, and everybody else listens, acknowledges and thanks the speaker.

Assuming that you plan to have these feedback sessions on every Friday evening, it may be important not forget to plan something special,  more relaxing and even more fun for the weekend, at the end of the each session, something to look forward to. This might involve a family movie or 60 minutes of ‘disco night’ whatever works for you, your family or your housemates.

Let’s also remember that for now, we are allowed to use the outdoors for 30 minutes of training or walks, we can use our gardens but also our balconies.

Emotional Regulation

When we are dealing with any kind of mental health problems we cannot ignore how the body reacts to all external negative feedback and internal catastrophical thinking. Our system is very complex, it relies on the body to communicate to our mind that something is up or something is going on and vice-versa. 

We know in other words, that stress and anxiety have an immediate impact on our physiological state and mood through a variety of, what could be perceived as, unpleasant symptoms.

Anxiety and stress in particular are characterised by symptoms of hyperarousal such as heart palpitations, sweats, laboured breathing, chronic muscular tensions and so on. Such symptoms maintain the illusion of severe anxiety and over time could even trigger a fear of actual symptoms of anxiety.

Therefore it becomes vital for us to learn to down regulate when we are in a state of hyperarousal to a normal state, so that our physiological system does not weaken the immunity further and in the long term it does not develop stress related chronic illnesses (such as chronic pains for example or a worse).  

Research shows that regular physical training, attention training exercises, abdominal breathing and progressive muscle relaxation can help with the process of down regulation.

8-Emotional Regulation Exercises for Mind, Body and Soul

1. The 3 – 4 – 5 Breathing Method

… Breathe in up to 3 (counting in your mind)… hold your breath up to 4 (counting in your mind).. and finally, very-very slowly breathe out, counting in your mind to 5 or more…  This breathing pattern is very important! It is preferred that you breathe in through your nose opening your diaphragm widely and relaxing your abdomen and slowly breathe out through your mouth. 

2. The Breathing Square (also known as the Breathing Box)

The Breathing Square is similar, though in this case you also visualize drawing a square with your minds-eye while synchroning your breathing patters with the drawing of an imaginal square. You could also use your hand (or finger) to ‘air draw’ the square…   

Breathe in as you start drawing a lateral of the imagined square (starting with the right low corner), hold your breath on another lateral and exhale slowly through your mouth on the other two laterals, thus closing the square…

3. Progressive Muscle Relaxation

4. Body Scanning

5. Mindfulness training: Exploring Difficulties

6. Mindfulness training: The 3 minute Breathing Space

7. Body Appreciation

‘Body Appreciation’ might sound a little unusual for a mindfulness training exercise but experience shows that we can easily forget how to love, care and appreciate our bodies…

… Have a long bath instead of a shower in the evening… use scents and your favourite bath cream… take your time to notice the pleasant smells… to feel the warmth of the water touching your body… imagine right now how this feels… give yourself permission to relax.. dont look back at your day.. dont look ahead at the rest of your night.. just allow your sense to come alive and feel… notice how the cream feels on your body as you gently apply it… do not rush this will only take a few more minutes.. minutes that you will soon learn to enjoy and appreciate..

8. Physical Strengthening

Physical Strengthening exercises are not any more difficult if you’re stuck indoors, but the motivation is usually low since training is naturally associated with going to a gym or a even park. Seek inspiration from tens of YouTube personal trainers, yoga teachers and other online classes. At the moment we still have the option to go out for 30 minutes of training but be realistic regarding your ability and plan a set of exercises which are tailored to your body and current ability. A walk with the dog is excellent exercise for some people whereas for others, complex martial arts or yoga exercises might be more appropriate.  

The basic principles of Emotional Regulation:

It is important to learn NOT to be afraid of our emotions, try to understand their role and allow them to alert you without immediately feeling the need to ACT – unless you are indeed in an imminent danger.

Learn to use your abdominal breathing and creative imagination to down regulate and calm yourself down… there is a lot of help, a lot of websites, apps and YouTube channels that provide excellent training in Mindfulness, Progressive Muscle Relaxation or Hypno-CBT.

Summary

1. Write down a daily routine (your BA Diary should help with that) for Monday to Friday and a separate one for Saturday & Sunday – more relaxing and fun activities at the weekend and more time for hobbies and interests. Just like an ordinary week. Mon to Fri could be allocated to working from home but do not be tempted to work for more that 7 hours a day plus your regular breaks. Learn to switch off from work – working from home it’s not as straight forward as it sounds, it can be a mental health trap !
2. Review your week every Friday (see Emotional Check-ins chapter) and make changes for the following week if necessary.
3. Make sure your weekly plans include a combination of activities, the key words are: Achievement, Enjoyment with Connection.
4. Check with your PDL, or personal journal and make sure that your values and interests are covered and leave some room for new ones that you will soon discover.
5. Exercise – daily and schedule it in your diary, reserve 30 mins for physical training – outdoors (if safe and possible) and 30 mins more indoors if you can cope (i.e. jogging plus aerobic routines).
6. Mindfulness – daily ! Aim to gradually increase your times over the following few weeks from 10 – 15 – 30 to 45 minutes of regular minfulness practice; no limits on this, as much as you can cope with – be patient you will not get it at first !
7. If you are tired Sleep ! Do not fight it by trying to stay awake. Also train yourself to have power naps during the day or use a Mindfulness exercise to unwind.
8. Nutrition and hydration: be sensible.. the temptation is to snack more and drink more alcohol, stay focused on healthy options, creative cooking (including smoothies) could be one of your new Values! Eat Well But Sensibly and Reduce the Alchool Intake ! Drink 1-2L of Water Every Day !
9. Read and Write as much as possible… Start with the CBT exercises proposed above. Also do not forget to check out all the interesting links I have attached here for you, just click on the highlighted sections.

After all of that, do you still feel you are on a ‘holiday lockdown’?

A Free Podcast and more Free Links will be added to this article over the next few days, please feel free to come back and ‘check-in’ from time to time.

Whatever type of exercise or self-help tool you feel is appropriate for you and those you live with, it remains vital that you include this in your daily structure, you enjoy it, you feel a sense of achievement and even a sense of being connected with others while doing it.

As a final note, I would like to share a surprising poem of hope with you by O’Meara, C.

And the people stayed home. And read books, and listened, and rested, and exercised, and made art, and played games, and learned new ways of being, and were still. And listened more deeply. Some meditated, some prayed, some danced. Some met their shadows. And the people began to think differently.

And the people healed. And, in the absence of people living in ignorant, dangerous, mindless, and heartless ways, the earth began to heal.

And when the danger passed, and the people joined together again, they grieved their losses, and made new choices, and dreamed new images, and created new ways to live and heal the earth fully, as they had been healed.

Stay Healthy and Hopeful!

by  Daniel Mirea (4.04.2020)

*Acknowledgement to Mark Williams & Danny Penman for some of the mindfulness materials used fairly and for non-profit purposes. Their complete training programme can be purchased via the link provided, currently there are free offers on on Amazon Prime through the Audible app.

*Training in Evidence-based Hypnosis ( Hypno-CBT ), Relaxation and Stress Management offered on-line during the lockdown here.