Will the pandemic ever completely end? And does asking that question signal illogical anxiety or persistent negative thoughts—or a clear-eyed vision of our present reality? Over the last year and a half, therapists have been pushed to the limit listening to clients worry, ruminate, grieve, and suffer in magnified ways. And we’ve all been suspended in similar uncertainty. Psychotherapy Networker talked with Margaret Wehrenberg, therapist and author of Pandemic Anxiety: Fear, Stress, and Loss in Traumatic Times, about how clinicians can help interrupt their clients’ anxious thought loops.
PN: In Pandemic Anxiety, you describe how the pandemic confirmed a lot of people's anxieties, whether about germs or financial insecurity. When clinicians are listening to clients talk about their worries, especially in the context of COVID, how can they distinguish between irrational anxiety and a logical response?
Wehrenberg: That’s been a big problem for clinicians, because most of us have had the same kinds of worries as our clients—concerns about health, finances, family, working from home...you name it. And, of course, it really has been true that you could die from going outside and not washing your hands well enough.
As clinicians, what we really want to really focus on is: What has actually happened to this person? Have they experienced an actual problem, or are they simply fearful of something that could happen? One interesting wrinkle is that people who experience anxiety often do better when there's a real issue in front of them than when there’s a potential issue. When it's a real issue, you can take action. And taking action is reassuring. But if something could just maybe happen, anxiety has fertile ground to run rampant. So, I first ask anxious clients, "Has this happened, or are you simply afraid it could happen?"
The second thing I do is distinguish between the possible and the probable. Some of our clients are irrationally anxious, so this won’t work for everyone. But one of my clients, a very intelligent guy, couldn’t shake his anxiety until he dug into the statistics and death rates and saw that he personally was very unlikely to die from COVID. Talking about what’s probable doesn’t always mean dealing with statistics, it means looking closely at fears and bringing a little common sense into the picture.
PN: How can clinicians help clients who still might be especially anxious, for example, the parents of young children who can’t get vaccinated yet?
Wehrenberg: When anxious parents have young children, they can always have unremitting worry about what could befall their children. These general principles apply to many anxious clients: We have to be very clear with them when asking, “What’s your genuine fear here?” We have to look for the underlying reasons for the fear and anxiety. In the case of parents, does the child in reality have a medical condition that makes them especially vulnerable? If so, then let’s make an appropriate caution plan. For example, only allowing vaccinated people into the house.
Let’s make sure the caution plan covers everything, even if takes two or three sessions to go through all scenarios. That’s important because people with anxiety disorders will pull a fancy trick on themselves by not addressing one little thing, and then going back and looping on that one thing over and over. For example, if a parent forgot to decide ahead of time whether to put their child in the grocery store cart seat, they’ll loop on their split-second decision in the store to put the child in the seat. What we want is for parents to be able to follow the plan and think, “I'm as confident as I can be that I’ve protected my child as best as I can.” And then whenever the thought, “What if my child gets sick?” comes back, they can say to themselves, “Stop, I have a plan.”
The other question is whether the anxiety is coming from the feeling that the client can’t control everything. Because there’s a lot that parents can’t control. Are the anxious thoughts coming from a constant sense of dread over a lack of control? If so, then we have to look at that dread with the client, and that’s a very different conversation than establishing a caution plan.
After the thorough plan is in place, clients should know how to distract themselves to interrupt rumination. We can talk about ways to calm their body down, and we can also teach clients to ask themselves, “Do I need this worry for some reason?” when anxious thoughts arise. If the answer is, “No, I don’t need the worry,” then they can distract themselves. We can help clients prepare ahead of time what they’re going to think about to distract themselves. Singing is one of the best personal distractions from worrying. Some people recite prayers. One 11-year-old girl I know does math problems in her head. Some people plan next week’s dinner menu or redirect their thoughts to their job. We can give these suggestions to our clients regardless of whether their worries are pandemic related.
PN: What about health-related anxieties?
Wehrenberg: The pandemic really triggered health anxiety, which many people with anxiety disorders suffer from. With health anxiety, any symptom is a sign of something terrible. People with anxiety disorders see their primary care doctors at much higher rates than the general population. Normally, the physician can reassure them that they’re fine. But during the pandemic, that couldn’t happen, and it opened up a wave of health anxiety that I think we’re going to see for long time to come. We have to help our clients by telling them, “Let’s turn that worry off until the problem shows up,” and help them feel sure that when it does come up, they’ll have a plan.
PN: After this long year and a half, how do we know if a client’s worldview and underlying issues have fundamentally changed, or if they’re still reacting to a difficult, short-term situation?
Wehrenberg: For this, I’d suggest a conversation, not a technique. We can ask, “How did your beliefs about the world change? Do you now believe that the world really is not safe and never will be, in a way that you didn't before?” People with anxiety have a very strong desire to see the world as safe. They have a very low tolerance for saying to themselves, "The world is not safe, and I'll do my best to navigate life without worrying."
With anxiety, the question is always, What’s in your control? And what’s not in your control so you don’t have to worry about it? Often, when I ask an anxious client what’s completely in their control, the answer is, “Nothing.” And I’ll respond by saying, “Yeah, it’s pretty scary.” The truth is they’re right, we can’t control very much in life.
But we can influence what happens, and that’s an important distinction, and an important part of someone’s worldview. As clinicians, we can pay attention to our clients’ locus of control. Some people do make themselves more depressed or anxious by saying, “Well, that's out of my control,” or “I'm just a victim here.” To help them see that they can take action, we can help clients articulate their goals as specifically as possible. If they’re worried about finances, is their goal to keep the job they currently have, or to have any job? Then we can help clients come up with ways they can influence outcomes, even if they can’t control everything. They can work on their résumé and start networking, or they can find ways to show their boss how much work they’ve done, depending on the underlying goal.
Something else we therapists need to do is not be afraid of our clients’ fears. This was a real problem early in the pandemic because most of us had the same fears. We have to signal to clients that we can talk about any fear—of dying, of not believing in an afterlife, of being alone and lonely—all of it.
That’s hard work. Many of my colleagues have talked about how this year has been especially exhausting. So we have to give ourselves enough breaks between seeing clients, give ourselves days off, and take care of our physical health, too. During a time of incredible uncertainty, therapists put their own issues aside, sat with clients with so much fear, and were the calm voice that helped people face this crisis. Bless each and every one of those therapists for doing that.
Margaret Wehrenberg, PsyD, is a clinical psychologist, author, and international trainer. Her most recent book is Pandemic Anxiety: Fear, Stress, and Loss in Traumatic Times.
Photo © iStock/Nicola Katie