By Katherine Buck, PhD, LMFT
This article is an edited version of a continuing medical education lecture Dr. Buck presented during the 2020 Annual Session and Primary Care Summit.
What is happening to our population?
In June 2020, a CDC study showed that a staggering 40% of adults are struggling with mental health issues. Considering we are many months into this pandemic and probably have many more to go, this likely can only get worse over time. Additionally, we are likely to see lasting mental health effects after the pandemic has “concluded.”
Who is at highest risk?
Racial and ethnic minorities, essential workers, and unpaid caregivers are having the worst mental health outcomes, and younger adults are at a higher risk that normal. Many patients are reporting anxiety or depression, increased substance abuse risk, and have considered suicide. This is occurring across many walks of life and socioeconomic strata.
Individuals with pre-existing mental health problems like schizophrenia or bipolar disorder may be hurting even worse from the social isolation of the pandemic, and since there is less access to mental health facilities, and telehealth is not always the best option, they may not be getting the care they need.
How about recovering COVID patients?
Delirium is one thing we are seeing in hospitalized COVID patients. Those that weren’t even sick enough to need to be in the hospital still describe a COVID fog. We don’t really know the long-term effects, but we’re thinking a third to half could have some kind of lasting neurological psychological effects. Additionally, we are seeing long term effects on anxiety, sleep, and general mood.
So how can we help our patients right now?
First and foremost, being anxious is normal right now — both for patients and clinicians. It’s about as close to whatever we have for normal. If we all went and did a GAD-7, almost all people could be positive in some manner on that. So it is also important to not over pathologize some of the “normal” levels of anxiety.
One of the things you can do with your patients in the exam room is just talk about it, help to name the feeling. You might say something like: “This is really hard. It sounds like you’re worried. This situation feels overwhelming.” Then they feel understood in that moment. That alone can be its own intervention.
Generally, when we think about treating patients with anxiety, we think about motivating social support and we think about helping them avoid avoidance. We want them to not avoid a situation that could provide positive reinforcement.
What are things I should look out for in my patients?
One thing I would recommend as a resource is the coronavirus workbook from The Wellness Society in the UK — it is really well done and has great patient-friendly resources. Some key ideas that they discuss are below.
Threat scanning is something that a lot of people who are anxious do naturally. For instance, worrying that if they coughed it may be coronavirus. If I ask my patients, “How many times do you cough a normal day?” most of us don’t know. It’s pretty normal to cough a few times throughout the day, but because of the increased stimulus value of a cough right now, that immediately becomes scary.
Catastrophizing is a similar cognitive distortion where we jump to the absolute worst-case scenarios and those two kind of go hand-in-hand. We’re scanning for something that feels weird as opposed to, “oh, I just slept wrong and that’s why I’m having this pain.”
Hypothetical worry is where we get on that “what if” train. One of the things that can sometimes be helpful with patients who are really engaged in this what-if game is the idea of thought challenging, which I’ll discuss later.
Emotional reasoning is hard not to do right now. It’s a real challenge when an emotional experience becomes your reality. “I feel scared, so I must be in danger” could be applied to just about everything happening in our country right now.
Another thing to watch out for is the idea of fortune telling. We don’t know what’s going to happen with a lot of things. We have educated guesses, but nobody can predict what’s going to happen tomorrow and if we take scary things that we hear on the news as absolute fact, it’s setting us up for a disappointment as well as this running anxiety. So things I often do with patients when they are involved in this thinking is rather than ask if a thought is wrong, ask is this helpful or unhelpful as a way to think? I will teach patients about the idea of putting a thought on trial. I will ask this patient, “What’s this thought that is scaring you? What is the thought that you keep having?” Then I’ll ask patients to come up with as much evidence as they can for it and as much evidence as they can against it. Sometimes I’ll literally just pull the exam paper down on the table and write it out on the exam paper. I ask them to present this evidence as if they were both the prosecutor and the defense attorney. So who wins? Is there some reasonable doubt?
How can I help my patients to have a healthy information diet during these uncertain times?
Just like we talk to our patients about having healthy food diet, we should encourage a healthy information diet. Media stories feel really heightened right now, so good questions to ask yourself about a story that you’re reading is “Has the story been covered by multiple outlets or just one?” If it’s only been covered by one media outlet, that’s a pretty good tip off that the story may not be trustworthy. I don’t get into whether something is true or not, but I’m trying to take 100% thoughts down to 50%, because then there’s room for wiggle and there’s less room for the certain anxiety.
My general recommendation for keeping a healthy news diet is to be intentional. Instead of losing hours to the television or getting sucked into a doom scroll on Facebook, maybe set aside 30 minutes a day.
Be sure to check stories with somebody who’s trusted. This is especially important for some of our elderly patients who may not have the internet literacy that some of our younger folks have. This is also important for health care workers who may be immersed in COVID at work and then going home and watching more news. If you’re working in health care, you will probably get appropriate safety information in your place of business and can potentially back it down in the evenings. I also recommend the concept of a digital detox day during times of heightened anxiety.
How can I talk to my patients about the concept of control?
What do we have in our control? What do we have outside of our control? There are a lot of different metaphors that I use with patients about this. A popular one I have used lately is the idea of “pulling the shades.” If you pull the shades, what’s inside your house and what’s outside your house? Right now very few of us have the bandwidth to deal with something that’s outside our house emotionally. The things that are inside our house can be addressed with action-focused coping. I work with patients to make a plan for one or two things they will do about the things that are inside their house before our next session.
The things outside of our control really lend themselves well to emotion-focused coping. How can you foster positive emotions within yourself? We get really caught up in trying to control other people, trying to make decisions for other people. That’s just not going to happen, and almost all families in America right now have some level of disagreement. It is important to remember what is inside your house and outside your house.
Another activity that I will recommend for managing anxiety is the idea of distraction. It sounds very simple, but there are certainly barriers right now that make it a little more challenging. I typically advise patients to make a list as big as they can on things they like to do and then we figure out a way to make them happen.
I remind patients about the importance of planning, the importance of routine and a sense of control. I advise people working from home to get up and make their bed and go into a different room to do all the things that they would normally do at work. There’s something of value to keeping that routine. I also encourage people to come up with daily and weekly plans when feeling sort of lost. The coronavirus workbook has great monthly and daily plans. And these plans don’t have to be huge. You can commit to doing five minutes of a thing. Five minutes of exercise are better than no minutes of exercise. Then slowly over time you can shape that behavior.
Another topic I talk about all the time is the importance of gratitude. This works anytime to lift your mood. The Duke Patient Safety Center in North Carolina has done a number of studies looking at the impact of gratitude and researchers have found it to have a larger and longer effect than using an SSRI. It’s also got a great effect on workplace safety as well as workplace culture. I cannot recommend gratitude enough; it tends to retrain our focus. We often see what we’re looking for. If we’re spending all of our time right now looking for danger, the world is an even more dangerous place.
A gratitude practice I recommend is “three good things.” I tell patients to write down three good things that happened during the day before they go to bed. There’s also benefit to sharing gratitude. You could get a big roll of paper, put it on your break room wall and have people write down things they are grateful for that day. The more you train yourself to do it, the more you will have a positive outcome with it.
I also recommend to my patients that they keep good social connections. I often talk to patients about how to make friends, because there are many ways to make friends. I ask patients to determine if they have someone they could call at 4 a.m. if there was an emergency, and if that answer is yes, that person meets that requirement for needed social support.
One thing I always recommend for mood management is exercise. Almost any exercise will enhance your mood. We’re looking for 30 minutes three to five times a week, but it’s fine to break it into bits and to make a small start to work up from.
I also talk to patients who are anxious about diaphragmatic breathing. Most people will tell you, “I tried taking a deep breath and it didn’t work.” Well, there are two keys points that are important to evidence-based diaphragmatic breathing. The first is the rate. I want patients to breathe in for half as long as they breathe out, or out for twice as long as they breathe in. Second is the mechanics, and that’s breathing out and down from the diaphragm. It helps you create a better oxygen exchange It helps send triggers to your body to be calm. Often times when patients tell me, “I did breathing and it didn’t help,” I ask them to show me what they did and usually, it’s all up in the chest. I ask patients to lie down and try belly breathing, so that a deep breath in makes the belly stick out.
How do I deal with frustrated colleagues?
I think for most people the stress of this waxes and wanes. I know in our practice at any time we usually have a few people having a good day, a few people having a bad day, and then people in the middle, always giving one another some grace. I think that’s pretty valuable when people snap, when people are feeling frustrated. I usually ask, “Hey, what else is going on?” rather than taking the bait of the frustration or the snap.
One thing you can encourage folks to do is find ways to take some time to take care of themselves. We’ve talked about the information diet and we’ve talked about all the things that we do for patients, so we can both encourage ourselves and our colleagues to engage in those behaviors.
So find a way to incorporate exercise into your life, take up a gratitude practice, and just give yourself and everybody else a little bit of grace.
Katherine Buck, PhD, LMFT, is the Director of Behavioral Medicine at John Peter Smith Hospital Family Medicine Residency, Fort Worth, Texas