Journal of Contemporary Psychotherapy

https://doi.org/10.1007/s10879-020-09463-7

ORIGINAL PAPER

The Nature and Treatment of Pandemic‑Related Psychological Distress

William C. Sanderson1 · Vinushini Arunagiri1 · Allison P. Funk1 · Karen L. Ginsburg1 · Jacqueline K. Krychiw1 ·
Anne R. Limowski1 · Olenka S. Olesnycky1 · Zoe Stout1

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
The COVID-19 crisis has created a “mental health pandemic” throughout the world. Scientific data are not available to
fully understand the nature of the resulting mental health impact given the very recent onset of the pandemic, nevertheless,
there is a need to act immediately to develop psychotherapeutic strategies that may alleviate pandemic-related distress. The
psychological distress, in particular fear and sadness, is a function of the pandemic’s negative impact upon people’s ability
to meet their most basic needs (e.g., physical safety, financial security, social connection, participation in meaningful activi-
ties). This paper presents evidence-based cognitive behavioral strategies that should prove useful in reducing the emotional
suffering associated with the COVID crisis.

Keywords COVID-related psychological distress · Pandemic · Psychological intervention

Mental health issues such as anxiety, depression, substance Brooks et al. 2020). Much of the population is worried about
abuse, and suicide were increasing in the U.S. well before meeting their most basic needs (e.g., paying rent, buying
the pandemic (Substance Abuse and Mental Health Services food) as a result of economic hardship (e.g., unemployment)
Administration 2019). Thus, it is no surprise that the very as well as an increasing scarcity of resources (e.g., food,
recent “mental health pandemic” as a result of COVID-19 cleaning products, personal protective equipment such as
(COVID) will further accelerate the increasing prevalence of masks). People are living in a chronic state of fear of con-
these disorders (Marques et al. 2020; Strakowski et al. 2020) tracting the virus. Socially distancing and disconnecting
as a result of its impact upon people’s day-to-day functioning rather than affiliating has increased loneliness and decreased
(Brooks et al. 2020). Indeed, a recent survey by the Kaiser social support, particularly in elderly and disabled popula-
Family Foundation found that 56 percent of people reported tions and those with underlying health conditions. The arti-
that the worry or stress tied to COVID had a negative effect ficial substitutes for social connection such as online video
on their emotional well-being (Panchal et al. 2020). Moreo- events often exacerbate, rather than relieve, the feeling of
ver, many individuals may attempt to cope with these nega- disconnection. People have been removed from the sources
tive psychological effects in unhelpful ways (e.g., alcohol/ of activity that allow them to feel esteem, status, and pleas-
substance use) that can actually result in an increased sus- ure (e.g., work, graduation ceremonies, weddings, engaging
ceptibility to COVID-19 (Da et al. 2020; Volkow 2020). in sporting activities). The impact upon dating and finding a
Clearly, the COVID crisis is likely to have an enormous mate is profound in an era of remaining six feet from others
negative impact upon mental health if left ignored. and fearing any close contact may lead to transmission of
The pandemic has disrupted the ability to satisfy core the virus. Finally, for those who are parents, the stress of this
human needs in almost all areas to an alarming extent (e.g., role is enormous (e.g., home schooling, explaining the pan-
demic to young children), and certainly the idea that children
Co-authors (all authors other than the primary author) listed in will flourish in the present environment seems implausible.
alphabetical order to demonstrate equal contribution. Given the sudden onset and impact of the pandemic, sci-
entific data are not available to fully understand the nature
* William C. Sanderson of the resulting psychological distress, but existing research
[email protected]
suggests anxiety, depression, and worsening stress are com-
1
Department of Psychology, Hofstra University, Hempstead, mon reactions (Rajkumar 2020). People are suffering and
NY 11549, USA

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 Journal of Contemporary Psychotherapy

reaching out for assistance—there was a need to act imme- treatments for individuals with anxiety disorders, depres-
diately in order to develop strategies that may alleviate psy- sion, and related emotional distress (Table 1). The approach
chological distress. Typically, when we produce a paper or we used is identical to that which led to the development of a
treatment manual we spend months planning, writing, and variety of evidence-based treatment manuals for psychologi-
reviewing it before making it available to others. Given the cal disorders (e.g., panic disorder, depression) where basic
rapidly evolving mental health crisis that occurred, we pro- cognitive behavioral strategies were tailored to address the
duced an initial product after only 3 weeks of the first coro- specific psychopathology of the disorder. We expected that
navirus cases in New York, which we continued to revise as these strategies would prove useful for those suffering from
we learned more about Covid-related problems (cf. Sander- similar emotional states secondary to the challenges associ-
son et al. 2020). ated with the COVID crisis. In fact, since so many individu-
To develop this guide, we brainstormed using our clini- als are struggling as a direct result of the COVID crisis, we
cal observation skills to identify pandemic-related triggers have started to conceptualize these symptom clusters as a
and resultant psychological problems we were seeing in our Pandemic-Related Stress Disorder (PRSD).
patients, family, friends—and our own lives. Thus, we are While there has been progress, as outlined above, in
confident that the areas identified in the original document understanding the nature and interventions for COVID
(Sanderson et al. 2020) represent the spectrum of COVID related psychological distress, an additional problem has
related psychological distress. Once we created this list emerged as a result: the already overburdened mental
we developed strategies that would allow people to man- health system must now provide treatment for a substantial
age these negative emotional states using a self-help for- wave of persons in need. Similar to the concern of flatten-
mat (this guide can be accessed at www.psych​rescu​e-covid​ ing the curve for medical disorders to avoid overburdening
19.com or at the permanent DOI address provided in the the healthcare system, mental healthcare may find itself in
reference section). This self-help guide can be used in con- the position of having more patients than can be reasonably
junction with the current paper, which more concisely out- accommodated (Marques et al. 2020). In fact, it is prob-
lines therapeutic strategies, to maximize the effectiveness able that this substantial increase in patients will last well
of one’s intervention. Nearly all of the strategies that we beyond the pandemic itself (Fiorillo and Gorwood 2020).
included were taken from evidence-based psychological Many individuals, particularly younger generations, are

Table 1  Summary of commonly encountered distress provoking triggers and recommended evidence based therapeutic strategies

Fear
Increased media consumption Stimulus control
Perception of increased risk Cognitive reappraisal
Existential concerns Acceptance, tolerance of uncertainty, problem-solving
Sadness and depression
Hopelessness Stimulus control, cognitive reappraisal, behavioral activation
Helplessness Cognitive reappraisal, behavioral activation
Non-bereavement related loss Acceptance, increase social support, expressive writing
Loneliness Self-validation, cognitive reappraisal, problem-solving
Loss of reinforcement and meaning Activity scheduling (pleasure, mastery), contributing, social connection
Rumination and Depressive Thinking Self-monitoring, gratitude
Other negative psychological experiences
Guilt and Shame Determine justification, forgiveness, reparations, cognitive reframing
Frustration and Unrealistic expectations Cognitive reappraisal, managing expectations, goal-setting
Claustrophobia Cognitive reappraisal
Chronic Stress Stress management, meditation, physical exercise
Irritability and conflict Relaxation, assertiveness, anger management
Lifestyle factors
Lack of sunlight Activity scheduling, light therapy
Poor sleep Stimulus control, relaxation, cognitive reappraisal, psychoeducation
Sedentary behavior Activity scheduling
Changes in eating habits Cognitive reappraisal, behavior management, stimulus control
Changes in technology use Behavior management, assertiveness

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Journal of Contemporary Psychotherapy

experiencing significant consequences of the economic non-essential activities. Individuals with obsessive–com-
crisis (e.g., financial uncertainty) that will take consider- pulsive disorder (OCD), many of whom hold contamina-
able time to resolve. A national survey conducted by The tion fears independent from COVID, may be particularly
National Center for Health Statistics indicated that approxi- impacted by widespread concern over the coronavirus and
mately 35% of Americans reported experiencing symptoms may require specific adjustments to treatments (Fontenelle
of an anxiety or depressive disorder during the end of May and Miguel 2020).
into June 2020, when several states had already started to However, that being said, what can be modified is one’s
reopen (CDC 2020). Furthermore, the process of reopen- level of fear. Many are at a panic level of fear, meanwhile,
ing in itself may result in increased feelings of anxiety. As the overwhelming majority of people are in fact not overly
individuals have become accustomed to staying at home for vulnerable to COVID. For those individuals, the following
safety, beginning to reintegrate into society is nerve-wrack- should become their guiding principle: COVID-19 will pass,
ing for many; psychologists have started to refer to these humankind will survive, almost everyone will still be alive
fears as “re-entry anxiety” (Dusharme 2020). Moreover, the in its aftermath. The scientific evidence clearly supports this
Centers for Disease Control and Prevention alerted that the statement.
second wave of COVID-19 is likely to be far more devastat-
ing than the first (Sun 2020). Increased Media Consumption
As a result, in line with the suggestions of Marques et al.
(2020), we have been examining scalable psychotherapeutic To varying degrees media (television, newspapers, social
intervention models to increase our proactivity, reach out media, websites) coverage of events such as the COVID cri-
to those with distress, and attempt to decrease the likeli- sis increases one’s perception of risk (Ropiek 2010). There
hood of more severe responses later on. Schleider (2020) has is an old saying in the media: If it bleeds, it leads. The idea
developed and tested brief, accessible interventions deliv- is the more horrific the story (e.g., the more frightening), the
ered in non-traditional settings (i.e., telepsychology). She more likely it will be the headline and receive a lot of time
found that a single session of a solution-focused consultation or space in the way the media source covers it. Thus, media
was associated with a reduction in psychological distress in outlets are biased towards presenting the most threatening
adults seeking psychotherapy (Schleider et al. 2020). Thus, scenarios (people dying on ventilators, overfilled morgues,
we adopted her approach and have developed and are in the stories of the sickest patients, etc.) and not focused on alter-
process of field-testing a consultation-oriented intervention native information which may present a more balanced or
(rather than a more traditional “psychotherapy” model) con- nuanced view (e.g., interviewing tens of thousands of people
sisting of two 60-min telepsychology online video sessions who had no or mild symptoms—overwhelmingly the typical
(cf. Limowski et al. 2020). The focus of the first session is course of COVID—or even people that were fairly sick who
to identify factors that appear to be causing the most distress recovered). Consequently, these messages shape the general
and providing evidence-based strategies for the client to uti- public’s reality of the COVID crisis as overall more threat-
lize. The focus of the second session, held approximately ening than it is because of the biased information. It is also
one week later, is to assess the success of the initial recom- worth noting that it is not uncommon for false information
mendations and to provide additional strategies if necessary. to be spread by social media.
Based upon the results of our field-testing we may ultimately The news media can be viewed as a stimulus that triggers
increase the number of sessions in this intervention. a certain response (immediate fear, skewed beliefs). Since
this stimulus is something that everyone does in fact have
control over the recommended strategy is stimulus control
Fear (Borkovec et al. 1983; McGowan and Behar 2013): reduce
or eliminate exposure to the stimulus to prevent the undesir-
Fear is an emotion provoked by the perception of danger or able response. While one needs to be informed, watching
threat that evolved to protect us and enhance our ability to or reading the news for approximately 30–60 min per day
survive. Given that the core concerns of this pandemic are should be sufficient to keep up with the necessary informa-
about illness and death, fear is an expected emotion. The tion. Accurate, non sensationally-oriented, print media is
first step in working with pandemic-related fear is to vali- recommended. The Johns Hopkins Coronavirus Resource
date the person’s emotional experience, within reason. It is Center (https:​ //corona​ virus​ .jhu.edu/) meets these criteria and
also important to help the person understand that fear can thus, is a highly recommended source to avoid unrealistic
become one’s ally rather than something to get rid of. When risk perception. News from local and state health depart-
channelled appropriately, fear protects the individual as well ments which present factual and locally-oriented information
as others by leading to protective behaviors such as hand are other reputable sources through which individuals can
washing, mask wearing, social distancing, and minimizing stay informed.

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Perception of Increased Risk your anxiety further even though proportionally these are
relatively low numbers compared to the entire population.
The topic of media information provides an excellent
segue to perception of risk (danger). As discussed above, Existential Concerns
the media impacts beliefs about coronavirus in that it
increases the perception of danger by presenting somewhat Central to human behavior is the motivation to stay alive—
skewed information. even before the COVID crisis. If evolution designed the
With regard to the experience of fear, for the most mind for anything it is to guide human survival. As men-
part, the more dangerous one perceives something, the tioned above, fear is the invariable reaction that occurs when
greater the amount of fear that is experienced. Thus, the a threat is perceived and it guides our behavior towards max-
therapeutic goal is to help an individual develop accurate imizing survival (e.g., avoiding and escaping from danger,
risk perception so that his or her fear is in proportion to reducing the threat).
the threat. The primary strategy to use is cognitive reap- Some individuals seem to want certainty about their risk
praisal (Lazarus and Alfert 1964; Gross and John 2003) and likelihood that nothing bad will happen. Unfortunately,
to identify, examine, and when appropriate reappraise the the fact is, there is no certainty that one will live beyond this
situation. moment. The probability for most everyone is that they will
Clearly, coronavirus is a threat. But like most threats, it be here tomorrow—that is almost 100% certain. But since
is not the same for everyone. It is essential to keep in mind it is possible that something can happen at any moment, it
that fortunately most everyone will survive coronavirus. The is not a full 100%. That is a point that must be accepted.
following are several examples of how media consumption Otherwise, attempting to gain certainty when it does not
distorts a person’s risk perception because of the way infor- exist will exacerbate fear.
mation is presented: The following three points are important to keep in mind
as we try to help individuals to accept the existential real-
ity of our existence and consequently decrease fear driven
Black and White Thinking by the attempt of obtaining certainty: (1) One can never be
100% certain that nothing will happen at any point in the
You see COVID in extremes: either you do not get it, or you future starting with now, (2) We take risks every day living
end up on a ventilator. There is no middle ground or shades our lives, and there is no alternative; very few of us would
of grey. want to live in a bubble to maximize our safety and give up
our lifestyle, (3) The best one can do is manage risks, not
Selective Attention eliminate them fully.
In the COVID environment, one must ultimately con-
You only focus on the worst cases. If a celebrity announces front death to move forward with some level of comfort. It
they are COVID positive but only have mild or no symp- is important to work towards accepting that we risk our sur-
toms, you forget about him or her. But if a celebrity is very vival every day so that we can live the life we want to live.
ill, that is the example that sticks in your brain. The best one can do to manage their fear in the coronavi-
rus landscape is to: (1) acknowledge this reality, (2) control
whatever is reasonably possible (e.g., wear a mask while
Catastrophizing shopping, wash hands regularly, socially distance), and (3)
move forward and live life. We attempt to get people not to
You only focus on the worst outcome and personalize it: you deny the possibility of death, but to do their best to attend to
are going to end up hospitalized with COVID just because managing risk and focus on realistic probabilities.
that is a possibility. You lose the distinction between pos-
sibility (anything is possible) and probability (what is likely
to happen based upon knowledge of base rates). Sadness and Depression

Sadness (depression) is an emotional response that is pri-

Emotional Reasoning marily triggered by the occurrence of personal losses that
are important to an individual and cannot easily be restored
Because you feel anxious about this highly contagious virus (e.g., loss of a job, failing a test) or in some instances are not
that everyone else is anxious about, you assume it is danger- able to be restored (irrevocable losses). These can be tangi-
ous– just because you feel it is. Watching media that displays ble losses, such as the death of a loved one or the breakup
cases and deaths like a scoreboard continues to exaggerate of a relationship, and they can be more abstract losses, such

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as failing to live up to one’s expectations, or failing to have and are urged to use accurate, non-sensationalized sources
the marriage that one expected. The most severe form of (Borkovec et al. 1983; McGowan and Behar 2013). Reap-
sadness occurs when a person experiences, or perceives an praisal of hopeless attitudes towards our current situation is
experience, where the loss cannot be undone. The classic also recommended as it is important to keep the reality in
example is the death of a loved one (i.e., bereavement) where mind that for the most part these pandemic-related stressors
the loss is clearly irrevocable. However, it can also apply to are not permanent, although they may feel this way when
a situation where a person believes (perceives) the loss is one is in the midst of them. Focusing on the notion that
irrevocable; for example, a person who has a breakup of a humans are resilient and have previously overcome countless
relationship and truly believes he/she will never find anyone tragic crises (e.g., recessions, war, epidemics) is also impera-
else. tive to provide a context of hope and survival—rather than
With regard to the pandemic, what most are feeling are resignation. (Note. For those in crisis, the National Suicide
the effects of transient losses. For example, if someone Prevention Lifelife (1-800-273-8255 or https​://suici​depre​
misses seeing their friends during this period of social dis- venti​onlif​eline​.org/chat/) is available 24/7.)
tancing and quarantine, the fact that the sadness is expe-
rienced is in fact because what was lost is important. The Helplessness
degree of sadness mirrors the importance of the loss.
When irrevocable loss occurs, or is perceived or believed Relatedly, helplessness is both the belief that a situation
to have occurred, the individual may go into a state of “resig- will not change and the belief that one is unable to enact
nation”—an evolved response to preserve energy when using change on a situation. In other words, individuals who feel
effort would be futile (the loss is irrevocable so the person helpless believe that there is nothing they can do to change
needs to adjust rather than continue to attempt to restore it). their undesirable circumstances; they have been convinced
However, when the resignation is triggered by perceptions of that their hopeless feelings are true. Unfortunately, help-
irrevocable losses (e.g., the world is never going to survive lessness may inadvertently create a self-fulfilling prophecy,
this pandemic, there is no way to fix the economy– it will be that is one may behave in accordance with the predicted or
bad forever, I’ll never see my friends again), it can lead to a expected outcome, thus creating a reality that confirms the
state of resignation characterized by hopelessness and help- faulty belief (e.g., if you do not study for an exam because
lessness. These two states, as well as several other triggers of you believe you will fail, you will in fact fail because you
sadness, end up contributing to and maintaining the intense did not study, not because you were destined to fail). Addi-
sadness, and people end up in a downward spiral from which tionally, feeling helpless may result in all-or-nothing think-
it is difficult to escape. When helping people manage their ing (e.g., “If I cannot fix the economy, I shouldn’t bother
sadness, the goal is to build their resilience, their ability to ordering takeout from a local restaurant to support them”).
increase behavior to access what is important to them. Taken together, individuals are encouraged to reappraise all-
or-nothing thoughts (e.g., “The economy is doing poorly but
Hopelessness I can do something to make a difference”) and expand one’s
thinking to the “bigger picture” (e.g., “The economy is doing
Individuals may begin to experience an overwhelming lack poorly but if everyone did something small, the scale of the
of hope for the future as a result of the negative impact of the impact would be enormous”). The pandemic might also be
pandemic and the constant flooding of bleak news reports. viewed as an opportunity to develop a new skill (e.g., sew-
While there are many unknowns, it is relatively certain that ing) that could be used to prompt supportive actions (e.g.,
the transition back to our accustomed lives will not hap- distributing masks to others). With these changes in perspec-
pen in the immediate future. This realization understand- tive, coupled with engaging in behaviors that are cognitively
ably adds to an individual’s experience of hopelessness and consistent, individuals can increase their sense of empower-
depressive resigning behavior. As mentioned previously, ment (i.e., the opposite of helplessness) and move out of the
stimulus control is recommended in order to combat feel- helpless frame.
ings of hopelessness. Although it is unhelpful, attending to
negative news is in our nature. Checking the news frequently Non‑bereavement Related Loss
may be contributing to hopelessness, even in hopes of more
positive announcements. We are often reinforced to check While many will experience grief related to a loss of a loved
more often due to intermittent segments of uplifting news, one due to COVID-19, this crisis has also introduced an
or anticipation of positive news, even if the overall message array of non-bereavement related loss (e.g., loss of social
conveyed is overly negative. As aforementioned, individu- connection, jobs, normalcy, economic stability). These
als are recommended to limit COVID-19 related news con- losses have been found to instill a similar grief reaction,
sumption to a specified amount (i.e., once a day for 30 min) especially when the loss is directly associated with one’s

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 Journal of Contemporary Psychotherapy

identity (Papa et al. 2014). The level and intensity of grief distress and increase ineffective behaviors which pose
varies per individual, as do the order of the stages of grief health risks (e.g., socially isolating, avoidance, washing
(i.e., denial or avoidance, anger, bargaining, sadness, and hands irregularly; Brooks et al. 2020). Engaging in a range
acceptance). While grief reactions are expected as a result of activities that balance pleasure, mastery, and social con-
of pandemic-related loss, research on grief has indicated nection is often most helpful for boosting reinforcement and
several strategies to cope with and process these losses. promoting positive moods. For example, cooking different
Expressive writing in the form of identifying and naming meals at home can be inherently enjoyable (i.e., flavorful
the experienced loss can help individuals increase awareness food), result in a sense of achievement (i.e., learning a new
of the associated emotions and recognize previous strategies recipe), and promote social connection (i.e., sharing the rec-
that were effective in coping with that emotion in the past. ipe or meals with others). With regards to health behaviors
After naming the losses, outlining ways to move forward in that individuals may struggle to implement (e.g., wearing a
or amend those loss areas can help individuals accept their mask, handwashing), basic principles of contingency man-
loss and work towards reproducing what has been lost (e.g., agement can be used to increase the desired behavior. Indi-
after job loss, reading or attending webinars on new innova- viduals can set goals for themselves, track their progress, and
tions of your field; Briggs and Pehrsson 2008). Addition- reward themselves when goals are met. This can be helpful
ally, social support is largely indicated in grief interventions. to increase behaviors that are not immediately pleasurable,
While social distancing limits physical social contact, griev- but are important to do in the current context.
ing individuals can still access social support. Phone and
online platforms can increase the social support experience Loss of Meaning
through voice or video methods, in comparison to texting
which can be less personal. As the pandemic continues, many perceive a sense of
meaninglessness due to uncontrollable circumstances (e.g.,
Loneliness unemployment, decreased social interaction, and various
other role losses). The disruptions in daily life lead many
Global quarantine and social distancing regulations have individuals to feel a loss of purpose which they normally
resulted in significantly limited social contact. As a result, derive from involvement in careers, caregiving, or other
many individuals have started to socially and physically activities. Therapeutic approaches that prioritize meaning
resign and are overwhelmed by upsetting thoughts related have been shown to be effective in improving quality of life
to loneliness. Although these reactions are understandable, (Breitbart et al. 2018). Relatedly, as aforementioned, CBT
they typically exacerbate feelings of social disconnection. emphasizes increasing engagement in pleasant and mastery-
Instead, individuals are encouraged to validate their feelings, oriented activities as a general mood management strategy.
challenge unhelpful thoughts, and problem solve in order to A helpful strategy is for individuals to mourn the unavoid-
increase connection in novel ways (Sanderson et al. 2020). able role-related losses while simultaneously shifting focus
Helpful strategies that can be used to think about the current to aspects in their control. Individuals can connect purpose-
regulations in a more balanced manner include: relabeling fully with the world by engaging in hobbies, learning new
the current guidelines from “social distancing” to “physical skills, keeping a pandemic journal, or helping others. Small
distancing;” remembering that individuals are apart now so contributions like phoning someone who lives alone, shop-
they can be together later; and reframing the situation as a ping for others, or donating to causes more directly (e.g.,
time to focus on, build, and/or create meaningful relation- blood drives, buying supplies, fundraising) hold tremendous
ships. Several practical ways to increase connection include potential for cultivating a sense of meaning and are activities
but are not limited to: Zoom video chats, facetime, Netflix that can be safely conducted during social distancing efforts.
movie parties, handwritten letters, video games, virtual exer-
cise classes, online forums, online support groups, virtual Rumination
game nights, virtual paint nights, virtual book clubs, hug-
ging a stuffed animal, and purchasing long distance friend- Individuals are being exposed to a deluge of negative informa-
ship lamps. tion about a problem that—at least in the short term—has no
clear solution. Additionally, given that this negative informa-
Loss of Reinforcement tion is relevant to the current public health crisis, it is unsur-
prising that individuals are more likely than ever to attend to
Loss of income and loss of social reinforcement are two it. Initially, increased attention to negative information may
ways the pandemic has decreased reinforcement among appear to be solution-focused or goal-directed thinking and,
individuals (Pfefferbaum and North 2020). Such losses due to the current crisis, individuals may be more likely to
can decrease effective behaviors leading to psychological continue engaging in such behavior. However, individuals can

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Journal of Contemporary Psychotherapy

easily become stuck in a cycle of ruminative (i.e., brooding and they were in contact with others, some may be struggling
dwelling) thoughts about the current situation which results with not being able to actively help during this crisis,
in exacerbated emotional distress, agitation, and/or sadness. healthcare workers may not be able to save patients, and
While this reaction is unsurprising, self-monitoring is rec- some may be feeling more privileged than others. As a
ommended to help individuals identify specific external cues result, individuals are blaming themselves, questioning
(e.g., media consumption, speaking with a friend or relative their behaviors, punishing themselves (whether intention-
who catastrophizes), emotional states (e.g., loneliness, sad- ally or not), and resigning. To manage feelings of guilt,
ness, boredom), and locations or times of day (e.g., isolated in individuals are often encouraged to identify the source
home office, late at night) when ruminative thinking is more of their guilt, evaluate how much responsibility they have
likely to occur again. Increased awareness of cognitive, behav- for it, take the appropriate amount of responsibility, make
ioral, and environmental triggers then creates a personalized reparations for any harm they might have caused, and
guide for what cues the individual should remove or avoid ultimately forgive themselves. Additionally, engaging in
from their environment (e.g., limiting news intake, schedule prosocial behaviors is recommended (e.g., sending a care
“socializing” breaks throughout the workday). However, it is package to someone struggling, ordering takeout from
important to note that if the “socializing break” is a virtual local restaurants, reaching out to someone who might be
one; changing one’s physical location during the call is crucial lonely, making a donation) to help with thoughts about not
to differentiating this break from the workday (i.e., the work doing enough and increasing one’s sense of empowerment.
environment in one’s home).

Depressive Thinking Shame

Thoughts of hopelessness and helplessness, rumination and Shame occurs when individuals engage in reputation-dam-
worry, and overall negative thinking are expected when indi- aging behaviors or those that have a heavy cost to soci-
viduals are exposed to an overwhelming amount of negative ety (Cibich et al. 2016). In the current context, a positive
information regarding the pandemic (i.e., death statistics, case COVID status can be shame-inducing due to the stigma
increases, economic collapse). In combination with a predispo- associated with being contagious, as well as the costs it
sition to negativity bias, (Ito et al. 1998) a pandemic undoubt- has to society (i.e., potential of infecting others). Shame
edly exacerbates depressive thinking (i.e., negatively oriented can be problematic if the feeling is so intense that it nega-
news focused on dangers and losses). Practicing gratitude is a tively affects self-esteem and mental health (e.g., feeling
recommended strategy that may help lessen our negativity bias worthless despite taking adequate quarantine precautions).
by transferring a portion of our attention to positive stimuli. Shame can also lead to avoidance or ineffective behaviors
Individuals can begin to assess what they are thankful for, and (e.g., not telling housemates about positive test results).
deliberately attend to simple moments of pleasure each day to The first step to manage shame is to determine if it is jus-
transfer focus to contentment rather than loss. Being mindful tified or not. Shame experienced from disease status per
during pleasurable activities (i.e., recognizing emotions) and se is not justified, but other behaviors (e.g., not wearing a
when engaging one’s senses (i.e., taste of a meal) can help face covering when symptomatic) can be. Shame can be
increase awareness of moments for which one can be grateful. functional if it guides one to rectify a negative behavior
Similarly, increasing awareness of negative thoughts and of (i.e., informing others, taking precautions). For unjusti-
their frequency can help individuals notice the onset of the fied or excessive shame, identifying and acknowledging
thought, and engage in a positively salient activity in order to the emotion is the first step to reduce the intensity. Next,
halt the depressive thinking cycle. Thought monitoring and individuals can identify behaviors driven by the emotion
cognitive reappraisal are particularly powerful ways to combat and engage in the opposite behavior (the ‘Opposite Action’
depressive thinking as outlined above. Finally, engaging in skill in Dialectical Behavior Therapy; Rizvi and Linehan
physical exercise (see below for section on sedentary behavior) 2005). To reduce the effects that shame has on self-esteem,
can be an excellent way to change thoughts through behaviors. it is important to first differentiate qualities of oneself that
do not change from having the virus, and to identify and
reframe “shame thoughts.” For example, instead of not dis-
Other Negative Psychological Experiences closing testing positive for the virus because of thoughts
that they are “bad” or “dirty”, individuals can be encour-
Guilt aged to disclose it to appropriate people in their lives and
see themselves as “brave” and “proud” for socially isolat-
Guilt has been a frequent consequence of the pandemic. ing and taking steps to protect others, which is valuable
Some may discover they tested positive for COVID after to society.

13
 Journal of Contemporary Psychotherapy

Unrealistic Personal Expectations interpretation of neutral or even somewhat negative events

as catastrophic is expected. Cognitive reappraisal is recom-
As aforementioned, the media frequently highlights biased mended to shift the individual’s perception of the increased
information and often focuses on those who appear to be meaning and significance of these negative events and ulti-
maximizing productivity and accumulating accolades during mately decrease negative emotion. Furthermore, encourag-
this pandemic. The tendency to make comparisons between ing individuals to reframe the situation which led to frustra-
these featured individuals and ourselves can lead to per- tion in a more positive way or as an opportunity to increase
sonal feelings of inadequacy, as well as attempts at radical effortful action and goal-directed behavior (e.g., problem
behavioral changes with goals that may be difficult to attain, solving) will be helpful.
resulting in increased feelings of failure and reduced self-
esteem (Vogel et al. 2014). While it is common to engage in Claustrophobia
these comparisons, it may be more helpful to practice reap-
praisal, recognizing that those featured likely represent only We propose the existence of a condition that can best be
a small percentage of the population, and that what is shown described as pandemic-induced claustrophobia; not claustro-
is highly selected for, thus leading to a biased perception phobia in the traditional sense of the psychological disorder,
(i.e., sitting on the couch and watching television is an activ- but a unique feeling of discomfort related to being “trapped”
ity many individuals participate in, but is not broadcasted as at home. This “condition” may be particularly prevalent for
it is not especially attention-grabbing). Additionally, rather those living in apartments, in cities where ample space is
than setting broad, ambitious goals that may be exceedingly rare, and/or with several other people. Such individuals may
difficult to achieve, focus should be on setting goals that are feel stir-crazy yet exhausted, exhibit negative affect, and be
smaller, observable, specific, and measurable. Research has tempted to break social distancing policies. An effective
shown that two key factors in maintaining commitment in mental strategy to combat pandemic-specific claustropho-
working towards a goal include (1) the belief that one can bia is cognitive reappraisal. In the current situation, this
realistically attain the goal, and (2) importance given to the tactic can take the form of changing one’s attributions for
outcome expected as a result of attaining the goal (Locke the quarantine: viewing staying inside as an intrinsically
and Latham 2002). Thus, it is critical to set goals that are motivated behavior as opposed to a punitive decree from
challenging enough to feel a sense of accomplishment when an external source. An example strategy is thinking of a
achieved, while not being overly onerous. Lastly, specific- specific person one knows who is a member of a high-risk
ity aids in accountability, and detailing what the goal is and population, and telling oneself that one’s decision to stay
how to measure it, as well as scheduling the time and day inside is in the service of protecting this person. Alterna-
during the week to engage in goal-focused activity, can help tively, some individuals may interpret stay-at-home orders
facilitate action towards reaching a goal. as prohibitive of going outside even for fresh air or exercise.
This type of appraisal may contribute to a feeling of being
Frustration “trapped.” By consciously reframing the situation (e.g., “I
should limit my contact with others, but going for walks
Collectively, the population is encountering an increase in outside is acceptable”), individuals can feel a greater sense
daily and repeated frustration (i.e., achieving one’s goals is of agency and control over their current circumstances and
either more difficult or currently impossible). Frustrations reduce claustrophobic feelings that may be exaggerated from
may be the result of external (e.g., experiencing interrupted these misinterpretations.
internet connection), internal (e.g., low self-confidence after
failing to meet work deadlines), or particularly salient (e.g., Chronic Stress
specific cleaning supplies consistently being out of stock)
daily experiences. Experiencing frustration may lead to an Feeling stressed or overwhelmed is one of the most commonly
increase in negative mood and result in maladaptive think- reported emotional experiences of the pandemic; a cumula-
ing such as, catastrophizing (e.g., “I am the worst employee tive effect of being faced with a variety of new challenging
ever”), overgeneralizing (e.g., “My internet never works”), circumstances. This response is unsurprising, but also prob-
and fortune telling (e.g., “If the cleaning product was out of lematic, given that the body responds to stressful external cir-
stock at the first store, none of them will have what I need”). cumstances with increased production of the hormone cortisol.
Additionally, an individual’s interpretation of any given Elevated levels of cortisol are associated with numerous nega-
event is influenced by a number of factors (e.g., current tive health consequences— including, ironically, diminished
emotions, life circumstances, relationships, the weather, etc.) immune response. Stress management is therefore crucial for
and tends to change over time. Given the heightened level both mental and physical well-being during the pandemic, and
of emotional distress an individual may be experiencing, one major tool for combating the negative effects of stress is

13
Journal of Contemporary Psychotherapy

meditation (see section below on Lifestyle Factors for addi- Lifestyle Factors
tional tools to help manage stress, most notably the section
on exercise). In fact, numerous studies over recent decades Lack of Sunlight
have demonstrated the benefits of meditation for many facets
of physical, emotional, and mental health (Lynch et al. 2018). Research suggests a strong positive relationship between
This practice may be particularly relevant at this time given sunlight and serotonin levels (Lambert et al. 2002), a neuro-
that many individuals do not have access to their regular stress transmitter central to biological explanations of depression.
relief outlets (going to the gym, gathering with friends, etc.). The pandemic cancelled many outdoor events and shut-
An abundance of meditation-related offerings exist online, tered businesses, workplaces, and other establishments. As
from formal training programs to guided mindfulness exer- a result, many are spending more time indoors, away from
cises. Thus, the first step in establishing a meditation practice sunlight. Sunlight can promote positive moods, so individu-
is taking the time to explore different meditation resources and als should aim to get at least 30 min of sunlight each day.
determine what type of meditation one finds to be the best per- This practice could take the form of walking around neigh-
sonal “fit.” By cultivating an enjoyable and sustainable prac- borhoods, sitting outside, or engaging with nature (e.g., hik-
tice, individuals are more likely to remain consistent in their ing, walking near water). Several of these suggestions can
meditation, which is key for reaping maximum health benefits. be combined with other pleasurable activities (e.g., reading,
listening to podcasts, making telephone calls). If outdoor
Irritability and Conflict activity is still not possible, light therapy lamps can also
have antidepressant benefits (Kripke 1998).
More than ever, individuals are working from home and spend-
ing more time at home, leading to increased contact with
families and roommates. Stress-induced negative emotions, Poor Sleep
boredom, and irritability naturally contribute to more conflict
in households. Of note, incidents of domestic violence have Social distancing efforts are disrupting routines, leading to
substantially increased worldwide since the onset of stay-at- less daily structure and negatively impacting sleep. Many
home orders (Boserup et al. 2020). Self-care methods and individuals also report increased screen time and anxious
relaxation strategies can reduce irritability in the long-term, thoughts at bedtime, making insomnia a problematic conse-
potentially making conflicts less likely to occur. Conflict may quence of the pandemic. Decades of research show that ade-
arise from reductions in privacy or from disagreements about quate sleep is necessary for physical health, immune func-
safety precautions due to variability in risk tolerance. Individu- tioning, and mental well-being. CBT for insomnia involves
als are encouraged to recognize that others differ in the extent working with dysfunctional beliefs about sleep, utilizing
to which they desire solitude as well as their comfort level in stimulus control, and practicing good sleep hygiene. In addi-
taking health precautions. While there are certain public health tion to getting sunlight and physical exercise throughout the
guidelines for navigating health behaviors, ideally households day, keeping a regular sleep schedule, engaging in a relaxing
can be respectful in conversations and seek a compromise. wind down routine, and limiting electronic use before bed
Specific communication strategies are also useful for antici- are all helpful strategies. If individuals cannot sleep at night,
pating, reducing, and navigating interpersonal conflicts. For they should go to another part of their home and do a calm-
example, it can be helpful to first become aware of emotions ing activity until they feel sleepy, ensuring that bedrooms
in the moment and take a “time out” as necessary (e.g., count- are used for sleep only. Finally, anxious thoughts should
ing to 10, leaving the room) before responding. If tensions are be dealt with prior to bed time (e.g., worry time) and dys-
still high, deciding on a future time to have discussions can be functional beliefs about sleep (e.g., catastrophic outcomes
effective. Communicating using “I” statements and making resulting from not achieving a “perfect” night’s sleep) can be
requests instead of demands are other helpful tactics for more addressed with cognitive reappraisal and psychoeducation.
effectively resolving disputes. (Note. For anyone affected by
abuse and needing support, call 1–800-799–7233, go to the-
hotline.org, or text LOVEIS to 1–866-331–9474). Sedentary Behavior

Telework and home entertainment—common during the

pandemic—lead to prolonged sitting and a normalization
of sedentary lifestyles. Social distancing may greatly reduce
individuals’ activity levels, since gyms are closed and organ-
ized team sports are cancelled. Even before the pandemic,
many people failed to get the 150 min/week of aerobic

13
 Journal of Contemporary Psychotherapy

exercise recommended by the American Heart Association. often leads to increased anxiety and overworking often leads
However, physical activity promotes positive moods and to burnout. A helpful strategy is to develop and implement
can be protective against depression (Schuch et al. 2018) so a behavior management plan in order to set a metaphorical
becoming more active is very important. Activities such as boundary between work and home, given that the physical
walking, running, hiking, or indoor activities (e.g., fitness- boundary is no longer in place.
centered video games, Zoom yoga classes) are all helpful.
Individuals who are beginning new exercise routines should Zoom Fatigue
consider physical activity as they would any new habit,
emphasizing starting small and being consistent. In addition, despite the usefulness of video conferenc-
ing software, a newly-recognized phenomenon is “Zoom
Changes in Eating Habits fatigue,” described in the media as a feeling of being dis-
engaged during video conferences and/or mentally drained
For many, the pandemic has caused a prolonged increase in after signing off. Virtual meetings lack many of the nuances
stress, which often leads to an increase in the consumption that make in-person interactions feel connected and organic,
of highly palatable high-fat and high-sugar foods (Adam while also presenting challenges such as internet connec-
and Epel 2007). The intake of calorically-dense foods has tivity issues, background noises, and awkward pauses or
been found to stimulate the reward center of the brain, thus moments of cross-talk. As a result, those with many Zoom
reinforcing this behavior by temporarily reducing negative- obligations may emotionally withdraw, becoming less par-
affect. However, consequences of eating such foods include ticipative in work meetings and choosing not to join video
inflammation in the body, which has been linked to various calls with friends despite already feeling socially isolated.
health conditions such as depression (Kiecolt-Glaser 2010). This unique brand of burnout can be combated with specific
Therefore, the strategy of eating such foods to manage stress behavioral strategies aimed to help individuals re-engage
and increase feelings of well-being is counterproductive. with their Zoom activities by treating virtual get-togethers
Instead, more prudent strategies involve cognitive appraisal, the same way they would treat those events in real life. For
deliberate behavioral changes, and awareness around stim- example, to get into a “work” mindset, individuals should
ulus control. For example, avoid purchasing these highly keep the same pre-work morning routine as they held before
caloric foods, since reduced access will likely equate to the pandemic, create one designated workspace in their
decreased consumption. Additionally, taking advantage of home, and practice staying engaged in meetings by asking
time at home by planning and preparing meals in advance questions. To help maintain enthusiasm about virtual social
can help override the tendency to reach for highly caloric activities, individuals should seek to create a clear deline-
foods when hungry or stressed. ation between work-related video calls and social video
calls. This distinction can be accomplished by using differ-
Changes in Technology Use ent video apps for each kind of call, changing out of one’s
work clothes at the end of the day and into clothes one would
While social connection is of utmost importance during normally wear for social events, and not taking social calls
a period of social distancing, a distinct set of challenges in one’s designated workspace area. Finally, individuals may
related to boundary infringement emerged within the social benefit from reaching out to family and friends to process
lives of those asked to stay at home, work at home, and feelings of burnout, and recruiting loved ones to help hold
socialize from home. This change is in part a result of a them accountable.
prevalent aspect of the “new normal” which includes the
utilization of videoconferencing platforms (e.g., Zoom) for Social Connectedness
work meetings, academic classes, and social calls.
On the other hand, in the service of “staying connected,”
Boundary Infringement individuals may feel pressured to respond quickly to alerts
on mobile devices or participate in virtual get togethers even
Individuals working from home were asked to do so within when their time might be better spent in solitude. Others
the context of unclear expectations (e.g., increased availabil- may participate in virtual social events only to find them-
ity) and increased demands (e.g., homeschooling children). selves begrudgingly talking about news, politics, or the pan-
Unsurprisingly, individuals struggling with the effects of demic. For those who feel sufficiently connected, communi-
boundary infringement may react by either withdrawing and cating clearly about feelings and intentions using assertive
avoiding particularly aversive work-related tasks or by being statements is important. Setting appropriate boundaries with
overly accommodating and working increased hours. How- electronic communications can also be very helpful, either
ever, neither of these responses is sustainable; avoidance by silencing mobile notifications, lengthening delays before

13
Journal of Contemporary Psychotherapy

responding to others, or skipping virtual meetups all together and effective intervention for those suffering from pandemic-
if feeling socially “worn out.” Whatever approach is taken, related psychological distress.
increasing agency within communications may decrease
feelings of resentment and, as a result, make socialization
more fulfilling. Resilience and Posttraumatic Growth

As is evident, many individuals are struggling with a pleth-

ora of COVID-related triggers; however, a variety of thera-
A Preliminary Intervention peutic strategies (indicated above) can be helpful in manag-
ing the resulting distress. In fact, highly stressful life events
To address these various concerns, our clinic has created that are often associated with periods of grief and loss are
a two-session consultation service for psychological dis- also typically associated with hopeful periods of readjust-
tress related to COVID (for materials, see Limowski et al. ment and healing (Tedeschi and Calhoun 2004). Thus, dur-
2020). The consultation service was advertised on the ing the COVID crisis, it is possible that many individuals
university clinic’s website so that the link could be easily will convey healthy response patterns—some may exhibit
shared by students and faculty. The description is as fol- resilience (i.e., maintaining baseline functioning in the con-
lows: “In order to offer our expertise in helping individuals text of disruption) and others may even experience post-
cope with psychological distress and emotional difficulties traumatic growth (i.e., improving baseline functioning in
related to COVID-19, the staff of the Anxiety and Depres- the context of disruption) as a result of dealing with a new
sion Clinic (Director: William C. Sanderson, PhD—a NY reality. Generally, individuals report experiencing at least
State Licensed Psychologist) is offering a consultation series one positive change after a potentially traumatic event (e.g.,
consisting of two 60-min online sessions with an ADC staff an increased appreciation for life, stronger and closer rela-
member.” Clients are asked to provide responses to questions tionships; Tedeschi and Calhoun 2004). Therefore, dealing
that assess their current and pre-pandemic levels of fear, sad- with the abrupt and ongoing changes of the pandemic can
ness, and emotional distress on a 10-point scale, identify and actually have positive psychological effects over time.
provide information about their most challenging pandemic- During the COVID crisis, it is understandable that indi-
related circumstance, and provide some information about viduals feel down and distressed at times; however, expect-
their mental health functioning (e.g., past/current medication ing to only feel this way won’t allow for the possibility of
use, therapy, diagnosis). Sessions are scheduled by email and even momentary health and wellness. Instead, a curious,
take place over HIPAA compliant Zoom. open, and appreciative mindset can promote self-mainte-
Our first session is based on the single-session model nance and growth. Commuting time can be repurposed in
used by Schleider (2020) and involves targeting one or two new and valuable ways, individuals can focus on meaningful
main problem areas with cognitive behavioral strategies. Our activities they may not have had time for previously, and
clinic additionally offers a follow-up session one week later new hobbies can be embraced and potentially result in long-
to further assist clients in utilizing strategies previously dis- term lifestyle changes. As regulations are slowly lifted, indi-
cussed. At time of writing, four clients have completed our viduals can also begin to practice appreciating life’s day to
brief consultation service. Issues addressed most commonly day activities that may have been previously interpreted as
involved managing job-related stress, setting healthy bound- mundane or even aversive (e.g., grocery shopping, sitting in
aries, practicing sleep hygiene, managing excessive worry traffic, running errands). Additionally, being proactive and
related to uncertainties, and reducing alcohol consumption. deliberate with one’s actions towards growth (e.g., setting
While of course, these data are very preliminary given the goals) and embracing resilience resources (e.g., individual
small sample size, it is worth noting that self-report assess- characteristics and skills, social support within communities,
ment conducted following the second session indicates that finding a sense of meaning/purpose) are also particularly
the consultation service was of value clients. Specifically, helpful in cultivating progress (Rosenberg 2020). Impor-
clients reported experiencing approximately 33% reductions tantly, while some may experience resilience and growth,
in fear, sadness, and general distress over the course of one expecting this outcome at all times is unreasonable and
week following the implementation of the recommended unhelpful. There is no “right” way to cope with the pan-
strategies. All clients rated the intervention as “very help- demic, and growth isn’t essential to survive. Instead, indi-
ful” in addressing their concerns and developing an action viduals need to simply do what works best for them during
plan (both rated as 5 on a 5 point scale). Similarly, therapists these challenging times.
conducting these sessions believed they were effective in In sum, although the COVID crisis has resulted in numer-
administering a very focused, useful intervention. These data ous problems, resilience and growth are not only possi-
are promising with regard to delivering a remote, scalable, ble, but probable. However, resilience requires a “growth

13
 Journal of Contemporary Psychotherapy

mindset”—one which acknowledges the negative but also Borkovec, T. D., Wilkinson, L., Folensbee, R., & Lerman, C. (1983).
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