Pandemic Anxiety Fear, Stress, and Loss in Traumatic Times

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For Max, Sloan, and Quinn, the precious ones who help me
survive these times.
Contents

Acknowledgments

Introduction

PART 1: How the Pandemic Affects Anxiety Disorders

Chapter 1: Pandemic Anxiety

Chapter 2: When Does Anxiety Become an Anxiety Disorder?

Chapter 3: Stress, the Pandemic, and Its Aftermath

Chapter 4: Ambient Anxiety and the Out-of-Control Increase in Anxiety

PART II: Concerns and Strategies

Chapter 5: Technology Challenges and Competence at Home

Chapter 6: Pandemic Panic, Essential Work, and Health Anxiety

Chapter 7: Death, Loss, and Recovering: The Anxiety About Saying

Goodbye Without a Familiar Process

Chapter 8: Disappointment

Epilogue

APPENDIX FOR CLINICIANS

Section I: Considerations for Teletherapy: Modalities and the Impact on
Therapists

Section II: Telehealth Is Here to Stay: The Practice of This Practice

 ACKNOWLEDGMENTS

There are so many people who contributed to my thinking and working this
through when we were all also experiencing the stress of the pandemic. I
am so fortunate to have friends who are interested and thoughtful and
gracious with their time and expertise. Laurel Coppersmith and Susan Palo
Cherwien were very helpful in shaping my thoughts on ritual and healing,
reading and honing the concepts I wrote here. Dr. Shannon Burns discussed
ethics and therapist burnout with me and helped me avoid burnout along the
way. Mary Jane Murphy Gonzales gave me insight into adapting therapy
modalities to the constraints of videoconferencing, generously sharing ideas
about methods. Dr. Martha Straus contributed to my understanding of
engagement with teens and children via videoconferencing, as always with
her vivid and creative style making me see how it can work. Ellie Proffer
and Jessica Wehrenberg gave me an insider’s view of being a working mom
with little children that showed me how even the most competent person
can get to her wit’s end with pandemic pressure. I need to express thanks to
my patient editor, Deborah Malmud, who has talked me through several
iterations of doing therapy in a new world, and this is the one we ended up
in: pandemic anxiety! Mariah Eppes and the staff at Norton who polished
this all deserve appreciation for their attention to detail that makes this
readable. To all of these wise women, I owe a debt, and I hope this work
will do their contributions proud.
 INTRODUCTION

“What, Me Worry?” was the slogan of character Alfred E. Neuman on Mad

magazine covers in the 1950s and 1960s during the hottest years of the cold
war. The magazine seemed crazy funny when we were practicing how to
protect ourselves from nuclear holocaust by ducking under school desks.
(Yes, we did that!) The reality pressed on the world by the bombing of
Hiroshima was too hard to take in. Responding to fear of being hit by
missiles, people built fallout shelters in backyards and supported a war
against spread of communism. After 9/11, another previously unimaginable
threat, people accepted enormous changes in the way we go through
airports, to try to manage fears of attack in the age of terrorists. These and
other fears felt by the general population over the decades of my life
resulted from political crises or threats of war and terrorism; however, not
all people felt personally threatened, and most lived with those threats on
the periphery of other, more immediate, life concerns. The feeling of fear
subsided into a background anxiety or vigilance to possible risk, and often it
could be forgotten for long stretches.
Now we have to respond to danger from an invisible enemy. COVID-
19, a threat that cannot be seen, freely crosses all borders, and cannot be
handled through diplomatic channels or bombed out of existence, has
affected the whole world. People are responding with stress, fear and some
with outright denial to this reality that feels overwhelming. Worse, we
cannot push it to the periphery of our awareness because every activity of
life is affected. Grocery shopping, dating a new love interest, playing with
children down the block, working together in a building, and going out to a
restaurant or movie are only a few of the daily activities that are not the
same. Everyone has become watchful of fever, coughs, and sneezes and
aware of who is around them with (or without) a mask. This requires not
just awareness of a threat that is occasionally in our sphere. Rather, it
requires a persistent level of vigilance, which has morphed into a constant
ebb and flow of anxiety that affects nearly every person. The constantly
new, stressful, and exhausting life circumstances we confront as we each
navigate current life challenges—without good guidelines—have raised
anxiety to an intensity that for many is nearly unmanageable.
Sadly, the virus is not all there is to feel anxious about. These are indeed
turbulent times for other reasons—and these reasons have no promise of a
vaccine. Adding to the persistent vigilance against corona virus infection in
the United States is our troubling, divisive political environment that is not
going to resolve fully with the completion of the presidential election. Even
more deeply affecting, and less quickly resolvable than an election or the
pandemic, is the racial inequity in U.S. society that makes life harder for
most people of color. On top of that, our uncertainties about safety are
multiplying as the outcomes of climate change grow more dramatic with
each season of fires and hurricanes and other storms affecting every part of
the country and the world.
While we are all anticipating that the pandemic stress and fear will
resolve during the next year, its aftermath will be felt in the world of mental
health for much longer. And the times we live in will put many of us into
the high-stress situations that destroy our sense of well-being.
We live in turbulent times, and the pandemic has opened the door to
discussing the anxieties that emerge in high stress, disaster-laden ongoing
situations. This is a changed world and we can cope with it, but we all
might need some help.

Why Write About Pandemic Anxiety?

Having written The 10 Best-Ever Anxiety Management Techniques (and a
few other books on the topic of anxiety and depression), I thought I had said
as much as I wanted to about managing anxiety and depression. Then we
faced the pandemic, starting with months of hunkering down at home.
Seemingly overnight, our lives changed, and at this moment none of us
knows when normalcy will return. And even as it returns, the pandemic
repercussions will reverberate for years, and the other global and societal
pressures will not resolve quickly. It seems that 2020 brought disaster to the
top of our consciousness where it will remain for as long as we deal with
climate, politics, racism and natural disasters.
Anxiety has changed, too, and—also seemingly overnight—there is
much more to be written about it. At the time of this writing we are smack
in the middle of the COVID-19 anxiety. In my long career, this is the first
time the whole world is dealing with the same issue. This anxiety has
evolved, starting with fear of getting sick, dying, or making others sick. It
has developed in intensity as people observe in others, or experience in their
own families, additional threats: losses of anticipated wonderful
experiences, destabilizing of finances, separation from loved ones, and even
death.
The intensity then began to shift as lockdowns ended and work and
school life reemerged. So, while the feeling of active threat diminishes,
anxiety remains. It exists in the vigilance needed to keep facing the real risk
from a virus, in the stresses of financial trouble, and in the pressures to
manage work from home and supervise schoolwork. Even more, the real
experiences of grief and loss are contorted by anxiety about what is coming
or how to cope, making them unrecognizable and therefore hard to manage.
As I write, people are even expressing anxiety about returning to normal, a
‘normal’ they may not have liked for its social pressures, hecticness, or
performance pressure. That anxiety did not exist before the requirement to
shelter-in-place and stay out of crowds gave them a reason to be quieter and
slower. Yes, anxiety is changing before our eyes.

Disappointments and Grief Increase Anxiety and Also

Depression

Loss and grief have been heaped upon us. Losses of positive experiences
that are canceled without hope of a “redo” are posing crippling
disappointments to people of all ages. Many people are facing the deaths of
loved ones but cannot have the funerals, memorials, shiva, or other rituals
that comfort the mourners. Without those options, the stress of sadness and
grief is multiplied and the risks of depression and anxiety from unresolved
grief increase. When grieving is masked by anxiety about what to do
regarding funerals, we cannot work through the grief. We may not even
recognize the grief we feel over all the other kinds of losses brought by the
pandemic.
It is reasonable to predict that people who had anxiety and depression
prior to the pandemic will be negatively affected by these losses and other
stresses, and that, since we have all been exposed to such stress and loss,
many others of us will also have distress from the outcomes of this
pandemic. In the aftermath of the pandemic, even with the help of mental
health workers, recovery could take years.

Stress Also Increases Anxiety

I want to address the increasing anxiety that is not only evident from my
observations of people as a psychologist but that is also being documented
in many studies conducted both nationally and internationally about the
pandemic’s mental health effects. Anxiety is in large measure the result of
stress.
Stress is damaging at every level of health, and the pandemic, likely to
affect us for years, has brought multiple types of stress not limited to any
type of work or any individual loss. We will look specifically at the stresses
and anxieties of parents thrust into the role of schoolteacher (or learning
supervisor) while they are also managing work responsibilities in or outside
of the home, and those stresses faced by people managing work at home. I
will directly address how to minimize other aspects of stress: financial
stress, the stress felt by workers needing to restore or replace previous jobs
in uncertain job markets, the stress of people who fear infection from
exposures at work or in social environments (leading to health anxiety), the
stress of being an essential worker, the stress of having (or being) a health-
vulnerable person, and the stress caused by the many other new demands
the pandemic places on people.

Anxiety on the Rise

Ambiguity prompts anxious responses. There is much uncertainty about the
global pandemic, but there is one indisputable fact: We are all in this
together. Every one of us feels some level of anxiety about what is still to
happen. Even if you do not have an anxiety disorder, you may still have to
deal with anxiety that challenges your emotional resources. Because
anxious people feel challenged to control their emotional reactions, they
search for fast answers and people to blame, and they cling to opinions that
comfort them, no matter how far-fetched the opinions seem, because these
are ways to reduce uncertainty. Uncertainty is real and unavoidable. We are
uncertain about the exact nature of the threat and we are uncertain about
how to handle it. How do we stay safe?
Even if the best predictions about vaccines come true, it is unlikely
there will be a safe, tested vaccine that is widely distributed by the time this
book comes out. How well any vaccine will work may take years to fully
assess. While it could be an opportunity to bring about global partnership,
much remains to be seen about international cooperation. These types of
uncertainties affect every human being, and some of us will need help to
live more comfortably with the reality of uncertainty.
What This Book Will Offer
This book is meant for those in the general public who are experiencing an
uncomfortable degree of anxiety. Some of you may already see a therapist,
or you may be wondering if you should seek professional help. I will
address the changing nature of anxiety and the experience of stress, anxiety,
disappointment, grief, and loss. I will discuss how to handle the new kinds
of stress that most Americans face from information overload, work-from-
home and childcare management, or financial difficulties. Of course, I will
deal with facing the real threat of the virus and managing health anxiety.
There is also an appendix for therapists addressing the concerns and
issues they may be having with their practices, changing due to the
pandemic. I will specifically review the impact of telehealth on how people
experience therapy, and the ways therapists are working to provide the
continuum of care so much needed in this difficult time. The appendix has
two sections that discuss how therapists can prioritize self-care when our
normal ways to set boundaries, manage the workload, and relieve stress via
casual collegial contact have all been knocked askew. I am hopeful that our
personal resilience to stress and our abilities to mitigate strong emotions
will serve us all in good stead in the current and post-pandemic world, and
we will not lose our own peace along the way. We will need all our
knowledge and strength, probably for years in the aftermath, to help the
many people whose mental health has been challenged by the realities the
pandemic has thrust upon us.

A Final Word
I want to respond to this particular time in history, one not experienced in
100 years, by offering help and hope to people who are suffering from the
pandemic-prompted conditions of stress, anxiety and fear, disappointment,
and grief. This is an ambitious effort, but after 4 decades of providing
people with anxiety-management skills, I can offer a wide range of ideas
and techniques to adjust thinking and behavior that will bring fast relief for
these significant negative emotional states. Whichever way you have been
most affected by pandemic anxiety, you will find something here to help
you come through it and then cope effectively during the aftermath. It is my
hope that these ideas will carry us all—general public and therapists alike—
through these turbulent times and beyond.
PANDEMIC ANXIETY
 PART I:

How the Pandemic Affects Anxiety

Disorders
 CHAPTER 1

PANDEMIC ANXIETY

Pandemic anxiety is different from any anxieties we had before the

COVID-19 virus struck. We feel fear when we are threatened. And we were
threatened by the virus! There was initially tremendous fear of illness and
death, and destruction of the culture we know. It was also coupled with the
uncertainty of the threat. Initially, no health official could tell us with
certainty about the means of transmission, who would die from it, or even
the way that it caused the symptoms, much less how to prevent it. We were
threatened by the lack of supplies for health care in hospitals and shortages
of supplies for our homes.
We feel anxiety when situations are uncertain. And the immediate
pandemic reality was loaded with ambiguity! We felt fear and anxiety both.
After months of getting more information fear has subsided, but anxiety
lingers because much remains unknown about this virus; its widely varying
effects occur unpredictably, such as when an elder has minor symptoms and
healthy young adults or even children die. And there is still work to be done
on vaccines and therapeutics. Although the threat is still real in many ways,
people have adjusted their level of fear to more realistic appraisals of
personal risk.

Fear Is Morphing Into Persistent Anxiety

The level of anxiety has also changed. While outright fear is diminishing, it
seems that it is being replaced by anxiety. There is a similarity between
pandemic anxiety and an anxiety disorder because it is so constant. Worry
about what is still to come from the pandemic results in constant vigilance
about a real situation. As one client told me, “Everyday decisions are life
and death. Will this coffee I bought be the one that does me in because a
barista had COVID?” Vigilance to choose the coffee shop where baristas
are good about wearing masks and gloves is exhausting. Our nervous
systems are ramped up and on the lookout for risk and relief both.
Constantly listening to or reading news for new information keeps mental
focus on the pandemic. This level of anxiety is like an anxiety disorder, but
because it emerges from a real need to be aware, it can be more easily
identified and managed. This whole book will focus on how to do that.

What Is Pandemic Anxiety?

The pandemic seems to have validated anxiety for people who were already
“worriers” or “germophobes” before it hit. Now that the situation has
everyone wiping off packages or fretting over whether to visit a friend in
person, they feel their concerns were real. Compare typical anxiety worries
with the certainty of the pandemic: The coronavirus exists. It is not the
result of skewed thinking that emerges from neurobiology causing
overemphasis on the negative. That can be examined and ameliorated by
therapy. It is not the result of our personal habits or life situations or
irritants. God forbid we have to deal with such a new virus ever again in our
lifetimes, but this one is clearly not going away after a mere few months.
The certainty of its existence also comes with tremendous uncertainty about
who will be affected by illness, how it will progress, and many other effects
on our lives. Uncertainty breeds anxiety.

Pandemic Worries Are Many and Varied

Some of the reasons that this situation has created intense anxiety relate to
the broad effects of a pandemic:

With constant conversation, news, and social changes, it is impossible

to be unaware of the potential dangers of the virus.