By Lindsey Phillips
The uncertainty overwhelms us, exacerbating old anxieties and fears and creating many new ones.
If this reaction sounds familiar, you were likely alive when HIV, the virus that causes AIDS, elicited widespread fear and anxiety in the 1980s. In fact, the HIV/AIDS and new coronavirus/COVID-19 outbreaks share many similarities: an inadequate government response, the stigma attached to having the virus, the disproportional impact on underrepresented groups, and initial confusion over how the viruses are transmitted.
At the onset of the AIDS crisis, people incorrectly assumed that they could get HIV by kissing another person. Michael Soderstrom, a licensed professional counselor at Houston OCD Counseling in Texas, remembers his own anxiety when first hearing about HIV and AIDS. He says he didn’t want to sit on a public toilet for fear of contracting HIV.
There’s no doubt that the COVID-19 pandemic has changed us. The question is, in what ways will it continue to change us? Will we ever shake hands again? Will we wear masks each year during flu season? Will we learn from the lessons of previous health crises? One thing is clear already: The pandemic is reshaping not only people’s fears and anxieties but also how counselors are having to approach treatment.
Fear of contamination and harming others
What about people who wrestled with contamination fears before this pandemic? Have they experienced an increase in symptoms? Soderstrom, an American Counseling Association member who treats obsessive-compulsive disorder (OCD) and other anxiety disorders, has observed that his clients who fear contamination from blood, semen or bodily waste have not gotten worse, because quarantine largely takes them away from exposure to these “contaminants.” But he has noticed an increase in clients who worry about contracting diseases, getting sick or dying, as well as those with perfectionist tendencies who struggle with the fact that COVID-19 ultimately lies outside their control. The thought that they could contract the disease regardless of how carefully they follow safety precautions terrifies them, he says.
The pandemic has even given rise to a new phobia — coronaphobia, the fear of contracting COVID-19.
People with OCD are also at risk of backsliding right now because the isolation, heightened stress and uncertainty associated with the pandemic can lead to depression and generalized anxiety, which fuel OCD-related symptoms, says Soderstrom, a member of the International OCD Foundation and OCD Texas. He has seen several new clients who had previously dealt with OCD symptoms on their own, but their symptoms became unmanageable during the pandemic, causing them to seek professional help.
To some degree, everyone is concerned about cleaning and sanitizing right now, so when do these thoughts and behaviors cross over into becoming a problem? Soderstrom asks clients who struggle with contamination fears to establish a safety practice based on guidelines from a trusted health organization such as the Centers for Disease Control and Prevention (CDC). He also has clients record how often they are cleaning surfaces to help them recognize if their behavior is becoming problematic.
If clients realize they are going beyond the CDC guidelines and washing their hands obsessively, Soderstrom has them establish rules on when they should wash their hands, such as after using the bathroom or sneezing. He also encourages them to limit themselves to washing with soap and water for 20 seconds. At first, these clients may feel the need to also wash their hands every time they touch the front door because it could be contaminated. Over time, Soderstrom may ask them to simply “water wash” their hands after touching the front door. This fulfills their emotional need without the full brunt of soap and water. These ground rules serve to keep people anchored in reality because someone who wants certainty can always find a reason to wash or clean, he adds.
Soderstrom has also noticed an increase in clients who worry about infecting others with the coronavirus. These clients struggle with what is known as “harm OCD”; they are the same people who worry about hurting or killing someone with their actions, he explains. To illustrate, these clients might grab a doorknob and think to themselves, “I hope I have the COVID-19 virus and will give it to my mom.” But then they quickly reject this thought and obsessively clean the doorknob out of fear that they will actually give their mother the virus.
Over-responsibility is a substantial issue with OCD, Soderstrom continues. Some clients feel responsible for not protecting others from the coronavirus, so they are constantly cleaning commonly touched surface areas such as car-door handles before others use them.
With these clients, Soderstrom often uses a responsibility pie exercise. If a client is worried about giving their older parent the COVID-19 virus and killing them, then he would ask, “What are all the other ways they could get COVID-19? How many times have they been to the store? How many times have other people come over to their house?” This exercise helps clients realize that assuming full responsibility for the possibility that someone else could get COVID-19 is not realistic, he explains.
Soderstrom also finds this exercise personally helpful. Whenever he has intrusive thoughts about the possibility of getting COVID-19, he asks himself, “What ways could I get the virus? If I did get the virus, who would be responsible — me, the government or the people I’m around?” Thinking through these questions helps him realize that even if he did get COVID-19, it would not automatically mean that he had been irresponsible or was a failure. Because myriad factors are at play, he knows he can only do the best he can to stay safe; the rest, ultimately, is outside of his control.
Relationship and separation anxiety
In the coming months, Rocio Morris, a licensed mental health counselor and the assistant clinical director at the Bougainvilla House in Fort Lauderdale, Florida, believes counselors will see an increase in relationship issues. She has already noticed that more of her clients are coming to therapy because of attachment and communication issues within the family. For example, one of Morris’ clients is in a codependent relationship with her mother, and the mother’s anxiety over the pandemic is in turn affecting her. The mother constantly worries about the family contracting the virus, which only serves to increase the daughter’s anxiety.
In addition, a few of Morris’ clients are having identity crises because they are isolated and trying to figure out who they are in the absence of their normal support networks. One client in particular is actively grappling with her sexual orientation, but she is doing this alone in a home with a mother who is unsupportive and two young siblings. Before the pandemic, this client would have found support through school activities or by hanging out with friends who were having similar experiences. Now, she feels trapped and all alone in her house.
To complicate matters, the client has a history of self-harm. Morris, an ACA member who specializes in working with teens and adults struggling with anxiety, depression, behavioral issues and life transitions, is working to cultivate the client’s inner strengths to help her through this challenging time. For example, because the client is artistic, Morris has encouraged her to use expressive coping techniques. So, when the client feels the urge to harm herself, she opts to paint that part of her body instead.
Morris, owner of the private practice Reimagine Life Counseling Services, thinks these types of relationship issues are likely to increase. Once pandemic-related restrictions are lifted, some people will be anxious to leave home or to be apart from certain family members, whereas others will start dealing with the outcome of being stuck in a toxic environment for months on end, she says.
Soderstrom believes counselors may see an increase in clients who are panicked about leaving home and being away from family members because they have grown more attached during the pandemic. “It’s like a part of who we are didn’t get exercised [during the pandemic] and got out of shape,” he says. “We have to exercise that part of ourselves again to be our full selves. … We have to reexperience fear. We have to reexperience doubt. We have to reexperience … emotional isolation outside the house.”
Soderstrom knows how much isolation can affect someone’s social anxiety. A few years ago, he had an extroverted client who lived overseas with his father for an extended period of time. The client mostly stayed isolated inside his apartment because he didn’t speak the local language. When he returned to the United States, he came to see Soderstrom because he had developed social anxiety about reconnecting with his friends. The extended break from his social activities had affected his self-confidence, and he found it easier to avoid his friends, which only reinforced his anxiety, Soderstrom says.
With Soderstrom’s help, this client overcame his anxiety, but Soderstrom worries that once the need for physical distancing finally passes, more people will struggle with social anxiety and panic disorders because they too have been isolated for extended periods of time. He predicts that some people will find social situations such as going to the mall or being around large groups of people triggering at first.
“Because this [pandemic] is such an individual experience for everybody, people are going to come out of this or move forward from this with different [experiences], such as losing somebody or experiencing trauma in the home,” Morris observes. These differences will affect how people learn to interact with one another again, she adds.
Confronting, not avoiding, anxiety
Clients often come to see Andrea Batton, a licensed clinical professional counselor and the clinical director at Maryland Anxiety Center, and ask her to “get rid of their anxiety.” No one wants to feel anxious or afraid all the time, of course, but the treatment goal isn’t to completely eradicate these feelings, she says. Batton, an ACA member who specializes in treating anxiety and OCD-related disorders, explains to clients the adaptive nature of these emotions, which includes informing us about our environment and helping us to survive. The point of counseling is to learn how to respond to these emotions in more helpful ways, she says.
Similarly, Soderstrom advises his clients not to ignore these thoughts and feelings but rather to be curious about them. Too often, he says, clients try to run away from these thoughts. “We try to control thoughts by either getting rid of the trigger or avoiding the trigger,” he explains. His goal is to get clients to embrace their emotions by capturing the thought and refocusing their energy back into their body or on another thought they value more.
So, if an adult child is eating lunch with their father and they have an irrational fear that they have the COVID-19 virus and just gave it to their father by hugging him, they can pause and acknowledge this intrusive thought as one that may feel true but isn’t. They can ground themselves by shrugging their shoulders, remind themselves of the low likelihood they are giving their father the virus, and refocus their attention on what they will discuss during lunch.
“The art of refocusing gives us ultimate power,” Soderstrom says. “It’s the moving on or refocusing on something we value or something that’s important that teaches us to devalue whatever the [intrusive] thought was rather than avoiding it.”
Although this isn’t the intent, physical distancing guidelines are encouraging many people to avoid the stimuli that trigger their anxieties or fears, and this can have serious repercussions on their overall progress, says Batton, a member of the International OCD Foundation and a board member for OCD Mid-Atlantic. Some school-age children, for example, struggled to go to school before the pandemic because they wanted to avoid situations that might trigger worries about having a panic attack or a specific phobia such as a fear of vomiting. Virtual classes — which have become common during the pandemic — serve to reinforce avoidant behavior.
“Avoidance is a compulsive behavior that reinforces the notion that there is danger at school,” Batton says. So, she wants to see these students return to in-person instruction full time. The same goes for clients who want to avoid work or other settings that trigger anxiety, phobias, or OCD-related worries or fears.
Counselors will have to work with their clients to figure out plans to ease them back into these spaces once it has been deemed safe to do so, Batton continues. “We don’t want anxieties, worries and fears to limit your life,” she says. “We want you living in accordance with your values [and] life goals, not [with] what anxiety tells you to do or your fears tell you not to do.”
Reappraising negative thoughts
When people are triggered, their mind automatically goes to worst-case scenarios, says Batton, a member of the Anxiety and Depression Association of America. When clients struggle with worst-case-scenario or all-or-nothing thinking, also known as “thinking traps,” counselors can help by teaching them how to respond to their thoughts more rationally, she continues.
Cognitive reappraisal isn’t about “looking on the bright side” or trying to be positive, Batton notes. Instead, counselors should help clients consider other possible explanations and look at what else might be going on. For example, if a student is struggling in a virtual class, they may start to think, “I’m going to fail the class. Everyone else understands the material. I’m stupid.” These thoughts will only make the student feel more anxious about the class, so they will dread doing homework or even avoid going to the class again, thereby reinforcing these less rational thoughts, she explains.
Batton’s goal instead is to teach the student to take a step back and consider what else could be true about the situation. Maybe the other students are also confused. Maybe the class is difficult. Maybe the student won’t get an A in the class, but they will still pass. After challenging the negative belief, the student can engage in more adaptive and helpful behaviors such as starting a study group or speaking with the teacher about how to improve in the class.
This cognitive reappraisal technique helps clients change the way they respond to intrusive thoughts over time. “When you’re having more rational thoughts, you’re going to feel more neutral. You’re not going to feel as anxious. You’re not going to feel discouraged … or afraid,” Batton explains. These neutral emotions and rational thoughts lead to more productive behaviors, which in turn fuel more rational thoughts.
Morris says many of her clients are falling into thinking traps when it comes to the pandemic. She often relies on thought-stopping exercises to help them get unstuck and move forward. If a client is afraid to leave their house because they may get the COVID-19 virus, she helps them identify the trigger and stop the negative thought before it snowballs into a physical reaction. She asks the client, “What is one small thing you can do to feel more in control?” Maybe they could put on a mask and go for a careful walk around their neighborhood rather than locking themselves inside their house.
Morris also shows clients a few common thinking errors such as negative labeling (e.g., “I’m stupid.”), blowing things up (e.g., “This pandemic will never end. I’m going to live alone forever.”) and self-blaming (e.g., “My neighbor has COVID-19. I probably gave it to them.”). She then asks them to identify which ones they are experiencing. This helps initiate the conversation and individualize the coping skills the client needs to respond to these thoughts, she adds.
Soderstrom helps his clients engage in logical, rather than emotional, thinking by asking Socratic questions. For a client who worries that they didn’t clean the doorknob well enough and may be responsible for giving their family the COVID-19 virus, Soderstrom would simply ask, “Would you bet $10,000 that if a scientist came and swabbed the doorknob, they would find the virus? What’s the evidence for this thought? What would you tell your friend if they were in a similar situation?”
He also asks clients to complete a thought record that consists of seven columns: the situation/trigger, feelings, unhelpful thoughts/images, facts that support this thought, facts that challenge this thought, an alternative (more balanced) perspective and the outcome. This activity anchors clients and pulls them away from black-and-white thinking, he says.
Rethinking exposure therapy
As Batton points out, exposure therapy is the backbone of clinical treatment for anxiety and obsessive-compulsive and related disorders. But not all exposures are possible during a pandemic. Asking a client with social anxiety to go to a large party is bad therapy right now, Batton jokes.
For that reason, counselors have to get creative with their exposure ideas. For example, Batton is using a HIPAA-compliant version of Zoom and Bluetooth to “ride along” with her clients who have driving phobias. This allows her to still see clients’ facial expressions, such as a clenched jaw, while she coaches them during the exposure. When she has a client with compulsive bathroom rituals, she sets a timer and virtually watches them brush their teeth to limit how long they engage in this behavior. Batton also helps clients with emetophobia (a fear of vomiting) by making fake vomiting noises together during the virtual session, sharing her screen to look at photos of vomit and watching video clips of other people vomiting.
Regardless of how the exposure occurs, the goal is to initiate those intrusive thoughts and anxieties to help clients realize that their worst fear is unlikely to occur. Through this experience, they don’t “unlearn” the fear. Instead, they gain “new safety learning” or inhibitory learning (i.e., learning that the feared stimuli and their emotional response to it are safe) and habituate to the thoughts and uncomfortable feelings, Batton explains. The fearful thoughts lose their power and diminish over time, she adds.
Before the pandemic, Soderstrom rarely went into clients’ homes to do exposure therapy. Now, with the transition to telebehavioral health spurred by the pandemic, he regularly enters clients’ homes virtually and works on their phobias and anxieties in real time. For example, one client fears losing control and accidentally stabbing her grandmother. Previously, as part of treatment, he would ask the client to take a plastic knife and sit beside her grandmother or hug her as a homework assignment. Now, he can observe her while she actually performs this exposure exercise.
Soderstrom is also finding inventive ways to help clients focus on their core fears. For example, he’s asked clients with social anxiety to call someone on the phone and post new videos on TikTok.
Virtual exposures have actually expanded Soderstrom’s options for treatments because, as he points out, “so many obsessions/compulsions are done inside the house.” So, he plans to continue virtual exposure sessions even after he returns to having in-person sessions. He likes that the virtual exposure sessions provide him with visual, not just written, evidence of clients’ progress.
Batton finds that virtual exposures have provided cost-effective treatment options for her clients. Before the pandemic, she had to charge a travel fee every time that she conducted an in-home visit to do exposure work. Because of the pandemic, and thanks to telebehavioral health, in-home visits have been eliminated, and because exposure therapy is typically as effective virtually as it is in person, she plans to continue this practice on occasion after the pandemic-related restrictions end.
Counselors’ own fears (and hopes)
At the beginning of the pandemic, Soderstrom worried he would lose his connection with his clients. He thought he wouldn’t be as effective as a therapist because of the physical distancing restrictions. But Soderstrom was happy to learn his fears were unsubstantiated. He just had to adjust his technique and become more vulnerable with his clients.
With telebehavioral health, clients may not be able to pick up on the counselor’s body language, or they may not feel comfortable being vulnerable themselves, Soderstrom says. He finds that being open and honest about the way he is feeling often elicits clients to be more open with him. For example, he recently told a client, “Sometimes, I feel like it’s hard to do treatment right now.” This prompted the client to share that they also found therapy difficult. The client hadn’t been able to finish their therapeutic homework assignments that week and had even considered quitting therapy. Soderstrom reassured the client that they weren’t alone in this feeling.
Morris believes that counselors need to keep suicidality on their radars in the coming months and years. The suicide rate among teenagers has already been rising, and one must assume that the job losses, isolation and loss of life resulting from the coronavirus pandemic will only push that rate even higher, along with suicidal ideation among both teenagers and adults, she says.
Morris emphasizes the importance of counselors doing more outreach during these times. She recently hosted a webinar for a local high school on how COVID-19 is affecting teenagers and discussed the warning signs of suicide as a preventive measure. By providing psychoeducation, she hopes to normalize conversations about suicidal ideation and prevent future suicides.
Batton’s biggest fear for the profession itself is that many counselors will choose to engage with clients exclusively through telebehavioral health even after the pandemic danger has passed. She acknowledges that returning to in-person sessions may not be easy or straightforward for many clinicians, especially if they had to break the lease on their office spaces. But she hopes most counselors will find a way to return to an office in some capacity. Batton longs to see clients and counselors interacting in person again, in part because in-person sessions are beneficial for clients who struggle with certain fears and anxieties such as social phobias, she says.
Morris shares Batton’s concerns about the possibility of counselors not returning to their offices. She’s currently hiring counselors for her clinical office and has found many of them are still fearful of providing in-person sessions, even after taking the appropriate precautions of wearing masks and sanitizing between sessions. Morris acknowledges that the whole process has been unsettling for many clinicians. First, they had to quickly adapt to moving their practices online; now they are being told they can go back into the office with safety precautions. She wonders, “How long is it going to be before counselors feel comfortable again with face-to-face sessions?”
Soderstrom says some of his clients are worried about the potential consequences of the prolonged suffering experienced over the past year because of the pandemic. Others with anxiety disorders and OCD fear that if their situation gets too tough, they might implode or incapacitate themselves with worry. He reassures them that humans are strong and can adjust to even the worst circumstances — just as they have done before.