A Brief Transdiagnostic Pandemic Mental Health Maintenance Intervention

Abstract

The COVID-19 pandemic qualifies as a major national and global disaster. Behavioral health providers are poised to provide psychological crisis interventions to reduce the psychosocial effects. This paper presents a brief transdiagnostic mental health maintenance intervention tailored to treat adults and families with distress symptoms as a consequence of the ongoing COVID-19 pandemic. The intervention components include evidence-based techniques which have been strategically selected to address mental health distress related to the pandemic and to prevent the escalation of distress as the pandemic continues. The intervention aims to be flexibly incorporated into care based on the provider and needs of the presenting individuals. The intervention incorporates components of evidence-based treatments such as Cognitive Behavioral Therapy and associated “third wave” therapies (e.g. Dialectical Behavioral Therapy and Acceptance and Commitment Therapy). The intervention can be delivered via telehealth and includes the following modules: 1) Agenda Setting & Avoidance Identification; 2) Responding to Difficult News/Normalizing Reactions; 3) Perspective Taking; 4) Situational Control/Acceptance; 5) Maintaining a Healthy Routine; 6) Coping with Stress; 7) Insomnia Preventions; and 8) Building Resiliency & Hope. A list of pleasurable activities that can be completed at home and technology modalities to maintain social interactions is included. The intervention also includes the Pandemic Mental Health Maintenance Intervention handout to provide to patients. Research is needed to test this intervention in a randomized controlled trial and assess efficacious intervention implementation strategies.

Background

The COVID-19 pandemic qualifies as a major national and global disaster. The pandemic not only affects individuals’ physical health, but it also creates psychological distress for COVID-19 patients, family members, health service providers, and the general public. Despite the unifying effect of a sweeping global impact, the pandemic has simultaneously isolated, restricted, and altered our way of living. The Centers for Disease Control and Prevention recommend social distancing by limiting face-to-face contact with other people, maintaining at least six feet of physical separation, and avoiding social gatherings (Centers for Disease Control and Prevention, 2020). Social isolation has also disrupted work, employment status, and daily routines with little-to-no advance notice for much of the population. While essential to promoting physical health, paradoxically, these dramatic changes to normal routine can negatively impact mental health for large portions of the population. The pandemic also presents individuals with uncertainty about timing and the toll the disease may take on individuals, families, and communities. Unpredictability across physical, social, and economic domains without ready access to typically used coping mechanisms could lead to widespread, significant, and long-lasting mental health effects. Given the restrictions of social distancing and the mental health effects, there is a need to develop mental health interventions that are both informed by empirical research but also responsive to the unique demands of this pandemic.

The COVID-19 pandemic presents an unprecedented challenge in its impact to our collective well-being. Although researchers are just beginning to assess the psychological impact of COVID-19, behavioral healthcare providers are already required to meet the needs of individuals as they seek services that will support them in making sense of and coping with this outbreak and its sequelae. Given the novel nature of COVID-19, research on infectious disease outbreaks in general can provide a framework for understanding the potential impact of this pandemic. Infectious disease outbreaks, such as the COVID-19 pandemic, can be associated with depression, anxiety, guilt, grief, stigma, and post-traumatic stress (Chew et al., 2020; Brooks et al., 2020; Lau et al., 2005). Indeed, the limited research examining the mental health sequelae of COVID-19 in China suggests that the impact of this outbreak is similar to that of prior public health emergencies in that it is associated with significant increases in negative emotionality (e.g., anxiety and depressive symptoms) and reductions in positive emotionality (Lau et al., 2005; Li et al., 2020).

Although research is currently focusing on acute effects of this pandemic and isolation, research suggests that the impact of COVID-19 will be long-lasting (Brooks et al., 2020). Therefore, there is an urgent need for interventions that effectively mitigate the mental health impact to improve individual well-being, but also reduce burden to an already taxed healthcare system. Early research related to COVID-19 highlights the benefits of using technology to deliver mental health services (Dong & Bouey, 2020). Behavioral health care providers are poised to provide psychological crisis interventions to reduce the psychosocial effects of the COVID-19 outbreak. To our knowledge, there are no published brief transdiagnostic interventions in the United States tailored specifically toward coping with pandemic distress or mental health maintenance during the COVID-19 pandemic.

The Proposed Intervention

Existing models of transdiagnostic interventions emphasize eliciting stimuli (e.g., exposure to someone sick, unknown future) as causing distress rather than differences in the psychological, cognitive, emotional, interpersonal and behavioral processes as responsible for resulting distress and disorders (Barlow, Allen, & Choate, 2004; Norton & Paulus, 2017). A transdiagnostic approach identifies and targets the core processes that manifest psychological distress (Harvey et al., 2004). Consistent with the Research Domain Criteria (RDoC), put forth by the National Institute for Mental Health, transdiagnostic interventions apply the same treatment principals to address underlying processes (Cuthbert, 2014). Modular transdiagnostic interventions can be incorporated into other treatment approaches by utilizing only the relevant modules. Clinical practice advances highlight a paradigm shift towards a transdiagnostic conceptualization and treatment (Craske, 2012). In response to the public health emergency and urgent need for behavioral health interventions tailored to psychological symptoms specific to COVID-19, this paper presents a Brief Transdiagnostic Pandemic Mental Health Maintenance Intervention protocol. The purpose of this transdiagnostic intervention is to promote resilience in the face of COVID-19, which will be achieved through principles of Cognitive Behavioral Therapy (CBT) (Beck, 1997; Beck, 2011; Perlis et. al. 2005), Acceptance and Commitment Therapy (ACT) (Luoma, Hayes, & Walser, 2007), Dialectical Behavioral Therapy (DBT) (Linehan, 2015; Najavits, 2003), and Behavior Activation (BA) (Martell, Dimidjian, & Herman-Dunn, 2010). Given the prediction for increased demand for mental health services throughout and following the pandemic, behavioral health professionals need protocols that are sensitive to clients’ presenting needs (Galea, Merchant, & Lurie, 2020). The proposed intervention can be provided alone or in conjunction with existing interventions for psychiatric conditions premorbid to the pandemic. The goal of this intervention is to provide skills that can help buffer the psychological impact of COVID-19 through increasing coping and promoting resilience.

Intervention Development

The intervention includes a comprehensive set of evidence-based techniques to address mental health distress related to the pandemic and to prevent the escalation of distress throughout its duration. The intervention was created by clinical psychologists with a range of primary theoretical orientations which include CBT, ACT, DBT, and BA. The authors also include psychologists specializing in domains such as providing brief treatment for distress in primary care and outpatient psychiatric settings, treating sleep disorders, and developing brief interventions specific to infectious disease/chronic illness prevention, adjustment, and recovery. In developing this intervention, we gathered authors’ clinical experiences from the current pandemic as well as in previously similar clinical situations (e.g., working with patients vulnerable to other types of infectious diseases) to identify key techniques and principles to inform this transdiagnostic intervention. After an initial draft of the intervention protocol, authors then provided further intensive feedback for refinement and improvement. Drawing on the authors’ experiences providing care from a variety of theoretical orientations in a range of settings, the intervention aims to be flexibly incorporated based on the intervention setting, role of provider, and needs of the presenting individuals. Additionally, we include coping techniques that have been useful during other infectious disease outbreaks in the general population. These techniques include social support and assessing the positives of the situation (Chew, 2020).

This intervention is designed to be delivered flexibly via telehealth in line with social distancing and quarantine guidelines published by the World Health Organization (2020) and the Centers for Disease Control and Prevention (2020). Researchers have emphasized the need for utilizing telehealth during the pandemic (Zhou et. al. 2020; Liu et al., 2020). Fortunately, telemedicine has been documented to be feasible, acceptable to clients and clinicians, and effective more broadly (Kemp et al., 2020). For example, offering mental health services virtually has comparable efficacy to in-person care in treating depression, anxiety and trauma disorders (Andrews et al., 2018; Kuester et al., 2016). As such, special considerations were given to telehealth/mHealth as pertains to the intervention’s content and delivery. The intervention could also be delivered person-to-person when the context for delivery changes.

Intervention Summary

This brief intervention is designed and tailored to treat adults with symptoms of distress caused by the ongoing COVID-19 pandemic, which may include intensified symptoms of anxiety, depression, sleep disturbance, and traumatic stress as a result of the COVID-19 specific events and policies (e.g., quarantine). In addition, due to stay at home recommendations and orders, people are home more than usual. Such transitions may require re-structuring one’s life, such as changes from outdoor to indoor activities promoting one’s health. This intervention will be most impactful when delivered by a mental health professional; however, it is possible to provide patients with the outlined guide that will support them in implementing the skills on their own. The intervention modules are in a strategic sequential order for clinicians to easily follow. Specific considerations for the delivery are provided throughout the modules to enhance successful delivery. Dialogues are provided not as an exact script that clinicians should use but as examples for clinicians to incorporate and adapt as needed. Consistent with APA’s evidence-based treatment task force and multicultural guidelines (APA Task Force, 2016), providers need to consider the patient’s salient identities, demographic characteristics, specific regions, social statuses, disadvantages that may affect them in their presentation of COVID-19 stress and tailor the intervention to these features to enhance engagement with and effects of the intervention. Given that this intervention is designed to be brief, requiring few sessions, patients living with bipolar, schizophrenia, borderline personality, or other severe mental illnesses who may require more intensive care, may not be suitable candidates (Fonseca et. al. 2020; Chong, 2020). However, it may be beneficial for clinicians to incorporate relevant modules into their current treatment approach.

Informed by literature on stages of change in psychotherapy and consistent with other transdiagnostic treatments, the intervention includes the following modules: 1) Agenda Setting & Avoidance Identification; 2) Responding to Difficult News/Normalizing Reactions; 3) Perspective Taking; 4) Situational Control/Acceptance; 5) Maintaining a Healthy Routine; 6) Coping with Stress; 7) Insomnia Preventions; and 8) Building Resiliency & Hope. Providers should only deliver the modules relevant to needs of the presenting individual. The Agenda Setting & Avoidance Identification Module focuses on naming, identifying, and validating how the pandemic is associated with a loss of control and increased uncertainty. The Responding to Difficult News/Normalizing Reactions Module normalizes the patient’s emotional response to the pandemic and describes the function of emotions. The Perspective Taking Module is designed to help the patient think flexibly and enhance alternative perspective taking about the pandemic. The Situational Control/Acceptance Module supports the patient in distinguishing between things they cannot control (pandemic itself; emotional reactions to pandemic) and things over which they can exercise control (e.g., own behavior), thereby promoting acceptance and agency. The Maintaining a Healthy Routine Module helps the patient develop routines that promote physical activity and other healthy lifestyle behaviors while practicing social distancing. The Coping with Stress Module provides psychoeducation on grounding techniques and describes a variety of mental, physical, and soothing grounding exercises. The Insomnia Preventions Module includes psychoeducation on the importance of sleep, the three facilitators of sleep (circadian clock, stimulus control, and sleep drive), and helps the patient develop a healthy sleep schedule. The last module Building Resiliency & Hope facilitates resilience and hope through reflection and taking a growth-oriented perspective related to the pandemic. Table 1 presents a brief summary of each intervention stage and Table 2 provides a list of pleasurable home activities as suggestions, and alternative ways to communicate with others through the pandemic. The intervention also includes the Pandemic Mental Health Maintenance Intervention handout to provide patients. See Appendix A for a copy of this handout.

Table 1.

Pandemic Mental Health Maintenance Intervention Summary

Intervention Module		Brief Description
Loss of Control	1.Agenda Setting and Avoidance Identification	This initial phase focuses on naming, identifying, and validating how the pandemic is associated with a loss of control and increased uncertainty. It should acknowledge the impact of the individual’s named role transitions, which they likely did not choose. The clinician should use this opportunity to relate personally to this experience and humanize and normalize these feelings. This module also asks patients to describe strategies to get rid of this discomfort (e.g., to escape, avoid, opt-out, or excessively seeking information), and provides an explanation of how these strategies provide only short-term relief before discomfort or fear returns. The clinician should then lead the patient to question whether there might be another way. This perspective was drawn from Learning ACT (Luoma, Hayes, & Walser, 2007).
	2.Responding to Difficult News/Normalizing Reactions	The clinician will further normalize the patient’s emotional response to the pandemic by describing the function of emotions. This perspective was drawn from Learning ACT (Luoma, Hayes, & Walser, 2007) and Cognitive Behavioral Therapy (Beck, 1997; Beck, 2011; Perlis et. al. 2005). The clinician can explain the origin of emotions in terms of fear and anxiety helping to guide us thousands of years ago when we were faced with a bear in the wilderness and how the function of that emotion was to keep us safe. The clinician should then discuss how in times like this it can feel like a threat just like a bear in the woods. The clinician should collaborate with the patient to question whether this type of anxiety is helpful or not. The clinician should bring awareness and understanding to the process of mourning the loss of what the patient thought the next period of time would be. If present, the clinician should address any feelings of guilt the expressed by the client (e.g., not doing enough to help end the pandemic; not appreciating job if they still have one; feelings of irritability toward family; survivor guilt for those recovered from COVID-19).
	3.Perspective Taking	The clinician help the patient think flexibly and enhance alternative perspective taking. Speciically, the clinician will guide the patient in describing past painful/uncertain situations in which the patient felt they had little or less control. The clinician will then support the patient’s reflection on their coping thoughts and behaviors and any growth acquired from getting through the identified experiences. This perspective was drawn from Learning ACT (Luoma, Hayes, & Walser, 2007).
	4.Situational Control/Acceptance	The clinician will support the patient in distinguishing between things they cannot control (pandemic itself; emotional reactions to pandemic) and things over which they can exercise control (e.g., own behavior), thereby promoting acceptance and agency. The clinician will help the patient list things they have control over vs. what they do not have control over and help them develop acceptance of the current pandemic. Emphasis should be placed on all of the areas of life that the patient can control and should focus on how to prioritize these areas of life to improve psychosocial functioning. This perspective was drawn from Learning ACT (Luoma, Hayes, & Walser, 2007).
Coping Skill Development	5.Maintaining a Healthy Routine	The clinician will support the client in identifying active coping strategies, including developing routines that promote physical activity and other healthy lifestyle behaviors. Drawing from foundations of Behavior Activation Therapy (Martell, Dimidjian, & Herman-Dunn, 2010), the clinician will guide the patient to develop understanding on how behaviors promote emotional changes. (Note: This is particularly important for patients affected by depression or experience a lack of interest in activities.) Additionally, the clinician will help the patient develop a daily or weekly schedule by first eliciting their own preferences, prior history of successful coping, and core values. The clinician will probe for targets in the following areas: physical activity and social relatedness/connection.
	6.Coping with Stress	The clinician will actively support the client in building self-compassion and self-soothing skills. The goal of this section is to provide psychoeducation on grounding techniques and describe a variety of mental, physical, and soothing grounding exercises (Linehan, 2015; Najavits, 2003). The clinician will then encourage the patient to pick five techniques to try at home.
	7.Insomnia Prevention	The clinician will help the patient develop a routine to promote healthy sleep. This includes psychoeducation on the importance of sleep and the three facilitators of sleep: circadian clock, stimulus control, and sleep drive, which are pulled form Cognitive Behavioral Therapy for Insomnia (Perlis et al. 2005).
	8.Building Resiliency and Hope	The clinician will facilitate resilience through reflection and taking a growth-oriented perspective. Additionally, the clinician will help the patient draw attention to reflect on potential positive aspects of the current situation. This perspective was drawn from Learning ACT (Luoma, Hayes, & Walser, 2007). The clinician provides a brief discussion on the importance of limiting exposure to news updates. The final goal of this section and one of the most important is to ensure the patient understands the importance of flexibility with the established schedule and grounding techniques.

Table 2.

Suggestions for Pleasurable/Meaningful Home Activities and Tools for Social Interaction

Pleasurable/Meaningful Home Activities

Tools to Maintain Social Interaction

Reading favorite or uplifting books, magazines, comics, newspapers, etc. Make face masks to give to others Watching “feel good” movies or shows Listening to favorite podcasts or audiobooks Cooking more involved, nutritious meals Exercising (e.g., workout classes online or video) Meditating or relaxing Make encouraging cards for individuals living in quarantined assisted living facilities Call a friend or family member to check in on them Cleaning and organizing Exploring creative pursuits (e.g., writing, blogging, drawing, painting, photography, dancing, practicing instruments, Karaoke-on YouTube) Mail a small gift or handmade craft to a friend or family member Developing new skills (e.g., DuoLingo, sewing, gardening) Put up signs in your windows to provide encouraging messages to others

Phone call/Text/Email Write and mail a letter to a friend or family member and kindly request they write you a letter back Video or audio conferencing (e.g., Facetime, Google Hangouts, Facebook video on messenger, Zoom, Jitsi, Cisco WebEx, Skype, Oovoo) Social media applications (e.g., Snapchat, Instagram, Facebook, Twitter, Whatsapp, Pinterest, Tumblr, TikTok, Marco Polo) Schedule quality time with individuals you live with Chatrooms (e.g., Chatroulette, Zobe, Chat for Free, Second Life) Live streaming platforms (e.g., Twitch, YouTube Live) Forums (e.g., Reddit, Quora) Online gaming (e.g., Xbox Live, PlayStation Plus, Chess) Virtual (e-) book group Wave and smile at neighbors as they walk or drive by JQBX (shared music listening) Netflix Party (chat over a movie) Virtual spiritual or religious services

Case Example 1

Presenting Patient:

“Sarah” is a 44-year-old woman with a complaint of severe insomnia and increased stress that started in March/April in the context of COVID-19. Her husband has been furloughed and she is homeschooling her three children. Sarah works full-time remotely as a business office clerk and juggling work and home-school activities has been challenging. Many of her routines have been disrupted. For example, Sarah used to walk for exercise with a colleague during her workday. Since the transition to working from home, this routine has stopped. Sarah feels she is just “hanging on by a thread.” Looking after her three kids, homeschooling, and worrying about her husband’s lost income, takes all her energy. She feels stressed and tired all the time and has developed a new coffee habit – drinking three large cups of coffee per day to keep awake. Sarah tries to go to bed around 11:00 PM. She describes that it takes her hours to fall asleep. She often lies in bed until 3:00am. She states she feels panicked when she looks at the clock and sees the hours go by. She starts to worry about how long she will need to quarantine and the economic stressors her family is facing. Sometimes, she will start doing work on her laptop computer in bed until she feels tired at 3:00 am.

Primary Reported Symptoms:

Insomnia, Anxiety, Stress

Selected Modules:

Module 2 Responding to Difficult News/Normalizing Reactions, Module 5 Maintaining a Healthy Routine, Module 6 Coping with Stress, and Module 7 Insomnia Prevention.

Tailoring of Modules:

Module 2 and Module 6 were tailored to address this patient’s specific symptoms of anxiety and stress (i.e. loss of income). Module 5, Module 6, and Module 7 were tailored to address patient’s lack of routine and enhance patient’s quality of sleep.

Change Process:

By managing anxiety (Module 2; Module 6), reducing caffeine consumption and implementing sleep recommendations (Module 7), sleep started to improve. Her schedule started to normalize, and she was able to resume a healthy routine (Module 5). With the improvement in sleep and daily schedule , anxiety was more manageable, and patient was able to tackle some of the other stressors in her life more effectively including using problem solving to address the loss of income, homeschooling, and interpersonal relationships with her husband and children (Module 6).

Treatment Considerations:

The brief initial assessment and selected modules were completed in a 60-minute session with the patient. Patient returned for two 15-minute follow-up appointments to discuss improvements in sleep and adherence to her established routine schedule and selected coping techniques.

Case Example 2

Presenting Patient:

“Bryman” is a 27-year-old man with a complaint of increased anxiety that started in March/April in the context of COVID-19. He works at a factory and fears that the company is not taking all necessary precautions to protect workers from contracting the virus. He reports having obsessive anxious thoughts about getting sick, getting his wife sick, and family members dying. He reports having thoughts that he “isn’t doing enough” to help others get through the pandemic and worries he is not supporting his wife emotionally. Patient has a previous diagnoses of Generalized Anxiety Disorder, but reported that his anxiety has been well managed for 5 years by taking 20mg of Zoloft daily. He reports that he has been taking his medication as prescribed, but still has elevated anxiety. He reports having a consistent routine because he is still working and is not experiencing difficulties sleeping at night. Patient reports feeling somewhat “hopeless” that the pandemic will never end.

Primary Reported Symptoms:

Anxiety & Stress

Selected Modules:

Module 1 Agenda Setting and Avoidance Identification, Module 2 Responding to Difficult News/Normalizing Reactions, Module 3 Perspective Taking, Module 4 Situational Control/Acceptance, Module 6 Coping with Stress, and Module 8 Building Resiliency and Hope.

Tailoring of Modules:

Modules were tailored to address this patient’s increased anxiety since the onset of COVID-19. Module 8 specifically addressed patient’s feelings of hopelessness.

Change Process:

By identifying worries and avoidance thinking (Module 1) and acknowledging the reality of these fears (Module 2) patient felt heard and understood. The patient was then encouraged to recognize these worries in the context of the larger situation (Module 3), to take control of the things that were within his control (Module 4), and develop healthy coping skills to manage stress (Module 6). Therapist encouraged patient to recognize his efforts and strengths and utilize these to continue to do the best he could with his current situation (Module 8).

Treatment Considerations:

The brief initial assessment and selected modules were completed in a 60-minute session with the patient. Patient returned for one 30-minute follow-up appointment to briefly review modules discussed in session 1 and adherence to his selected coping techniques.

Discussion

Drawing upon cognitive behavioral models of psychotherapy, the primary objective of the Pandemic Mental Health Maintenance Intervention is to foster resilience and positive mental health during an unprecedented time. These aims are achieved through the provision of emotional validation, psychoeducation and guided learning to promote active coping skills rather than avoidance, and the development of an active schedule that promotes physical health, social connection, and sleep.

The Pandemic Mental Health Maintenance Intervention has many strengths which include transdiagnostic, brief, appropriate for a broad range of patients, and can be delivered via telehealth. Although the intervention is informed by evidence-based treatments and encouraged by clinical anecdotes, it has not been tested and proven to be efficacious in a sample population. Further, it is not designed to replace existing evidence-based treatments for psychological disorders. The intervention is designed to be brief; however, psychological consequences of COVID-19 could be long-term and thus more intensive treatment may be needed for those more affected by COVID-19 (i.e. patients who experienced death in the family, front-line medical workers). Future research should test this intervention in a randomized controlled trial and assess efficacious intervention implementation strategies.

The COVID-19 pandemic had a rapid onset and research examining the impact are still limited. Non-intervention research is needed to ascertain the specific psychosocial consequences of COVID to better inform tailored interventions. Given the potential positive impact of behavioral health professionals in addressing pandemic stress, mental health psychosocial interventions tailored for the pandemic are needed now. Thus, we encourage clinicians to utilize these modules with appropriate patients as needed. Drawing from experts with rich experiences in diverse settings, we present the first known intervention protocol for addressing COVID-19 pandemic stress. Future research should examine the overall effectiveness of this intervention as well as differences across patient populations.

Pandemic Mental Health Maintenance Intervention

Below, we provide a sequential overview of the intervention, its goals and key concepts in each module, as well as concreate examples. Modules should be selected and prioritized based on patients’ presenting concerns. Dialogues are provided not as exact script that clinicians should use but as examples for clinicians to incorporate and adapt as needed. Length and number of sessions is dependent upon individual patient characteristics (i.e. ability to understand concepts, number of presenting concerns).

Note: Each first session should begin with 1) a brief intake to collect salient presenting symptoms, 2) rapport building, and 3) a description of this brief treatment.

1. Agenda Setting and Avoidance Identification:

   • Have them name and identify how the pandemic is associated with a loss of control and increased uncertainty. Specifically, have the patient acknowledge the real impact of the patient’s named role transitions.

     • “Welcome and thank you so much for agreeing to meet today for this pandemic-related mental health service.”
     • “To begin, can you tell me how the pandemic has impacted your daily life? Specifically, how has it impacted work, and the way or frequency you interact with others? What kinds of emotional responses have you had to the pandemic?” [Clinicians probe for anxiety and other feelings about uncertainty in social, financial, relational, health domains, e.g., anxiety about having COVID-19 or giving it to someone else, anxiety or sadness about losses.]
   • Explore how the patient has tried to get rid of discomfort (e.g., to escape, avoid, and opt-out) and begin to show the patient that those techniques only provide short-term relief.

     • “Have you done anything to control the discomfort you are experiencing from the pandemic? How have those strategies worked for you? Were you able to permanently get rid of the discomfort? Have these techniques brought you closer to how you want your life to be during the pandemic?”
     • “Many individuals try to avoid or escape uncomfortable emotions. Those techniques may be helpful in the short term; however, the feelings often return. Have you or others you care about experienced this? Do you think there are other ways one can cope with these responses?”
   • Help the patient see that trying to control their emotional response can be unhealthy and how acceptance of emotions provides an opportunity. Then review the steps toward emotional acceptance.

     • “One alternative to trying to control emotions is inviting emotions to be present with you. Although we try, humans are not able to directly control emotions. For example, try not to feel anxious right now. If you feel anxious, [(imagine that I will start screaming at you/I am going to pinch you) every single time you feel anxious], okay? You can feel anything but anxiety. How are you feeling right this moment?”
     • “Instead of controlling our anxiety and other feelings about the pandemic, we can learn to acknowledge that it exists and is present. It takes less of our emotional energy to notice our emotional response to the pandemic than to fight with it.”
     • “There are four steps to accept an emotional experience. The first step is to observe or bring awareness to the feelings in your body. The second step is to take a few deep breaths around those feelings in your body. The third step is to expand and make room for those feelings. The last step is to allow the feelings to be present and try to make peace with them. We will keep talking about this and how we might do this together today, okay?”
2. Responding to Difficult News/Normalizing Reactions:

   • Normalize the patient’s emotional response to the pandemic.

     • “This is a new experience, and everyone is responding in their own way. There is no right or wrong way to respond. How you feel may change frequently.”
     • “When individuals are faced with a scary event, there are different ways in which they can respond. These responses include: fighting, freezing, or running from the event or emotional response to the event. These are all very normal responses to a new experience that is scary.”
   • Briefly describe the function of emotions.

     • “I know we might not always think about them this way, but emotions are sources of information that are neither good nor bad. Try to think about emotions like the air in the room. When it is cold, we get goosebumps; when it is hot, we sweat. Emotions are similar. Each emotion is a different source of information. Think about when you feel angry. Usually when we feel angry, it is information telling us that there has been an injustice done to ourselves or someone that we care about. Think about times when you felt sad. Usually we feel sad when we have lost something we care about or we are afraid we are going to lose something we care about. You see, we need emotions. They are not things to fear but rather information for us to consider. And, emotions tend to be tied to the things that are important to us.”
     • “Let’s talk about the emotion of fear or anxiety. This comes from the oldest part of our brain. This part of the brain doesn’t think, it just reacts to situations as they arise. Our brains developed this way, in part, to protect us from danger. For example, let’s say a tiger came running towards us, fear and anxiety would serve a purpose here. They would help our body react without having to think about it. What does our body do with fear and anxiety? What does your body do when it is anxious? [Get some examples] That’s right. It speeds up our heart rate, our breathing, makes us jumpy (like we want to run), makes us sweat, etc. All of these body symptoms of fear/anxiety are purposeful – they make it easier for us to avoid that tiger. Now, the challenging thing, is that even if the things we fear or are anxious about today are less dangerous than a tiger, our body still reacts the same way... So now, we have reactions at inconvenient times or places, when it may not be helpful. The goal of this is to think about ways to deal with these reactions when they come up in ways that are helpful.”
   • [Optional Module] Exploring loss of someone close due to COVID-19.

     • “Loss can be extremely difficult in general. In fact, it is probably one of the hardest emotional states that we as humans all have to go through at some point. Losing someone during this pandemic is extremely challenging because many of the ways we normally cope with grief include religious and cultural ceremonies, like funerals, that involve gathering with the community. It is normal to feel a range of emotions during loss. These can include anger, fear, loneliness, rage, sadness, and shock. Whatever you are thinking or feeling, it is important to acknowledge that emotion and know that there is no “right” way to cope with loss. Instead, it is important you show yourself kindness and honor that emotional experience by allowing yourself to feel exactly what you are feeling when you need to feel it. I would encourage you to be fully aware of your grief and like an outside observer just notice what it brings up for you – we call this mindful grieving.”
   • [Optional Module] Explain mourning the loss of an anticipated future. Note: consider omitting this section if the patient has recently lost a loved one.

     • “Many of us had an idea of what the next few months would look like. We all had some sort of plans such as weddings, vacations, graduations, birthdays, and business related or work-related plans. Even our day-to-day activities and plans have been disrupted. Your plans have changed because of this pandemic. There is a part of us that has to mourn the loss of what we thought would be our future for the next couple of months and also what the months following may include. Just as if we were to lose something that we cared about, there is a similar mourning process for when our future is greatly altered. It is important to offer yourself kindness during this time while also acknowledging the grief.”
     • “Our brains are designed to work by relative comparisons. That means, our brain is often comparing us to friends, neighbors, or colleagues. We compare what they own, how much money they have, and how they are doing. [Ask for examples.] Our brains can also compare us to ourselves. Do you ever do this? You may compare yourself to an earlier version of yourself, or even a future version that hasn’t happened yet. The tricky thing about our brains is that no matter who we are comparing ourselves to—a neighbor, friend, colleague, former self, or future self—our brains always seem to tell us that we should be doing better. This can make us feel guilty and that we are ‘not doing enough’ even when we are doing the best we can.”
   • [Optional Module] Address guilt related to the pandemic.

     • “Some patients report feeling guilty because they are not out doing something about the pandemic. Have you felt this way?” [If yes, continue. If not, skip to Unit 3]
     • This is a completely normal reaction. Many of us who are not nurses or doctors wish that we could do more. This is an okay reaction and means that you care about society as a whole. Remember, you have not done anything wrong by staying home; in fact, it will make a big difference if you stay at home as much as possible and support those around you the best that you can.”
     • “Some people might also feel guilty about things that used to be everyday parts of their lives – caring for a loved one like a parent, grandparent, or partner who relies on them, going to the grocery store or pharmacy for essential supplies like food and medicine. Although guidelines do recommend social distancing and staying home as much as possible, there are some things that are unavoidable. Remember that you do still need to keep yourself and your loved ones healthy and make sure that you have food to put on your table. You can only take care of yourself physically and emotionally if your basic needs are met.”
     • “Guilt may also come up in the context of the new normal. With many people working from home right now, shifting to a totally different work environment can be challenging. You may experience guilt about not being productive ‘enough’ while working from home, especially if you are also juggling caring for loved ones/children. If you have young children at home, you may feel guilty about how you are doing either keeping them entertained or helping them keep up with their online learning. It is important to remember that there are no rules or standards right now – we have never faced this type of situation before.”
3. Situational Control/Acceptance:

   • Help the patient identify things over which they have control vs. things they cannot control.

     • “I think it’s important that we take a minute to reflect on the things that we do not have control over and the things that we do have control over. What are some things that you can control in the situation? What are things you cannot control?” For things you can control, go ahead and take action. For things you cannot control, it is important to recognize when you’re encountering it and instead try to work toward accepting that there isn’t anything you can do about it right now.”
   • Help the patient develop acceptance.

     • “Let’s talk more about trying to accept what you cannot control. Recall a time you have been stuck in traffic. Remember how it is easy to get upset, weave lanes, honk your horn, all in attempt to change the traffic? How often do these strategies work in making you feel better? Often it is more helpful to recognize you’re stuck, not that being stuck is OK, but there is likely nothing you can do to change the traffic jam at the present moment. This acceptance opens an opportunity to do what you can to make yourself feel better until the traffic clears, like opening a window, putting on your favorite music, or safely calling a loved one.
     • “Unfortunately, we cannot change some of the bigger things happening around us. What we can change, though, and what is in our control is how we respond to the situation. [To include if patient has a trauma history: when we have been through difficult times in the past, especially if we had those times as children, facing stressful life events like the pandemic can make us feel defeated or stuck again.] The important thing is to realize you have the ability to choose how you respond to these situations.”
4. Perspective Taking

   • Have the patient describe past painful/uncertain situations in which they had no control. Then have the patient describe how they survived those experiences and any growth they acquired through the process.

     • “Tell me about a situation that you survived that was originally scary or out of your control. This could be something as simple as taking your driver’s test for the first time, becoming a parent for the first time, or trying something new at work. These things are all scary and full of uncertainty; however, you can, and have, gotten through these situations. What did you do to get through these moments? Looking back on these situations, can you reflect on any growth that resulted because you persevered and got through? Not always, but often-times, these experiences tend to show people how strong they are and what they are capable of doing.”
   • Have the patient reflect on any silver linings of their current situation.

     • “Can you think of any benefits to having more time at home for the next couple of months?” [More time with family, more time to clean/organize/fix things around the house, more time for leisure (watching TV shows, reading), having time to reflect on growth in the future]
5. Maintaining a Healthy Routine:

   • Help the patient understand that you don’t have to “feel” like doing something in order to engage in a behavior.

     • “Sometimes we don’t feel like doing activities that we know can make us feel better, or we think that we will do them when we feel the motivation to do them. It can be beneficial to schedule activities to make sure we are doing things to enhance our mood. For example, you can get up and get dressed each morning as if you were going somewhere, if that enhances your mood.”
   • Help the patient develop a daily or weekly schedule based on their values while incorporating intentional body movement.

     • “When we discuss things within our control, it can be helpful to maintain some sort of schedule to ensure you are doing behaviors that make you feel better. Let’s take a few minutes to brainstorm how you would like your days to look during the pandemic. Are there things you usually do every day that you can continue doing? Are there specific meal times that work best? Are there things you can do to monitor your movement? Some people find it helpful to schedule in exercise or walks. Others find it helpful to set an alarm to get up and move every hour.”
   • Help the patient brainstorm ways they can stay connected with others.

     • “It is important that you do not feel alone throughout the pandemic. Even if you live with others, it can be helpful to maintain communication with other friends and family. Are there people you can call or video chat with throughout the week?”
     • “If you are living with someone, it is also healthy for you to schedule time apart from that person. This varies by individual, but some patients need alone time, which can be very helpful in mood maintenance.”
     • “We also want to think about who we choose to become connected to and use for support. For example, now isn’t a good time to call that negative family member of yours – the one who always puts you down and makes you feel worthless – now is the time to reach out to friends who support you and encourage you in your goals.”
     • “You may also find support from online support groups, 12-step recovery programs, or individuals who may have similar life circumstances, but do not personally know you. These can be great spaces for sharing your feelings and getting support from others who can be truly objective about your life circumstances. Have you thought about any of these?”
   • [Optional Module] If relevant, discuss medication (psychotropic and non-psychotropic) adherence with patients.

     • “Many individuals often find it difficult to take their prescribed medications when not having a daily routine, going through difficult times, or experiencing more stress than normal. Has this been your experience?” [If answer is yes, continue] “Let’s take a few minutes to discuss techniques other individuals have used to help them remember to take their medications during these difficult times. Some individuals find setting an alarm on their phone or asking a friend or family member to remind them as helpful. Would you be open to trying one of these techniques?”
6. Coping with Stress:

   • Begin the discussion of emotional grounding exercises.

     • “Some days coping is a little bit harder. On these days it is okay to do things that you know will make you feel better. For example, on these occasions, wear your PJs all day or spend the day just watching TV if that makes you feel better. The important thing to remember is that this will end eventually and that this current schedule will not last forever.
     • When emotions are particularly high, you can engage in emotionally grounding exercises.”
   • Provide psychoeducation on grounding techniques.

     • “Grounding is a set of easy strategies that can help you create distance from emotional pain such as anxiety, fear, and sadness. It is a way to distract yourself by focusing on something else. Although grounding does not take the emotional pain away, it can be used to get through difficult emotional experiences and prevent things from getting worse. There are three types of grounding exercises which include mental, physical, and soothing. Just like running a marathon requires work and training, grounding techniques take practice. People benefit differently from different skills. Try out a variety of the techniques and make a list of the ones that work best for you.”
   • Describe mental grounding exercises and provide examples.

     • “Mental grounding exercises help the mind focus. Here are some mental grounding exercises for you to try.”

       • “Count to 10 over and over again.”
       • “Describe your environment in detail, using all of your senses (smell, touch, taste, hear, see).”
       • “Play a Categories Game with yourself. For example, try to think of famous people that begin with each letter of the alphabet, types of cars, or TV shows.”
       • “Think of something funny to jolt yourself out of your mood.”
     • Describe physical grounding exercises and provide examples.

       • “Physical grounding exercises is the focusing on one’s senses (touch, smell, taste, sight, feel). Here are a few physical grounding exercises for you to try.”

         • “Look at old family photos/videos.”
         • “Run cold water over your hands for one minute or hold a piece of ice.”
         • “Take a long hot bath or shower.”
         • “Grab tightly onto a chair or hard surface as hard as you can (notice the sensations of the tight grip).”
         • “Use a grounding object such as a ring, bracelet, piece of paper and touch it when you feel unpleasant emotions.”
         • “Play a calming song/sound.”
         • “Jump up and down.”
         • “Repeat a pleasant word to yourself over and over again.”
         • “Light a scented candle.”
         • “Eat a hard candy.”
         • “Pet your cat/dog.”
     • Describe soothing grounding exercises and provide examples.

       • “Soothing is talking to oneself in a kind way. Here are a few soothing exercises for you to try.”

         • “Say a coping statement over and over again. For example, you can say ‘I will get through this.’”
         • “Offer yourself kind statements. Pretend you are talking to the child version of yourself. You can tell yourself – ‘it’s okay to be scared during this time.’”
         • “Think of your favorite movie, color, animal, or season.”
         • “Sing the words to an inspiring song, quotation, or poem.”
         • “Plan a treat for yourself, such as making your favorite dinner to eat.”
         • “Bring to mind things you are looking forward to in the future.”
         • “Hug a pillow as if you were hugging yourself.”
     • Have the patient reflect on the discussed exercises and pick five techniques to try at home. [Have them write the chosen techniques down on a piece of paper]

       • “We have talked about several different ways for you to ground yourself and cope with undesired emotions. Can you pick five of the exercises to try at home? Try to pick at least one from each category and write them down on a piece of paper.”
       • “Also, it would be good if you could keep track of which ones are helpful and work and which ones do not. Everyone is different, so it takes some practice to figure out what works best for you. If you try something, and you hate it, or it doesn’t work, then choose something else to try. Even if something doesn’t work we are learning and collecting information about how to help cope in the future.”
7. Insomnia Prevention:

   • Ask about sleep patterns and describe the importance of sleep.

     • “Another important thing to consider is maintaining adequate sleep. Sleep not only impacts the amount of energy that you have, but it can also impact your mood, such as how sad or anxious you are. Some research suggests that healthy sleep can decrease anxiety and depression, which are commonly experienced in a pandemic.” How has your sleep been affected so far? [Clinicians – pay attention to comments about them avoiding sleep/not wanting to go to sleep; staying in bed later; changes in other drivers of sleep (e.g., caffeine, lack of activity). Use these answers to guide focus in the next section]
   • Describe the three facilitators of sleep: circadian clock, conditioning, and sleep drive.

     • “There are three facilitators of sleep: circadian rhythms, conditioning, and sleep drive. Let me take a minute to explain each.”
     • “Let’s start with circadian rhythms. We tend to get up when the sun comes up and start to get sleepy when the sun goes down. We call these our circadian rhythms. During the pandemic, you want to make sure to maintain these rhythms. To do this, you want to maintain a consistent wake time, bed time, eating schedule, and exposure to sunlight. These are all cues to inform your body what time of day it is. Without these cues, some individuals develop what we call ‘social jetlag’, or an inability to sleep at preferred times. You don’t need to necessarily sit in the sun to get exposure; however, you need to make sure that your eyes can see the sunlight coming in through a window.”
     • “The next thing is what we call conditioning. Have you ever felt sleepy and then when you go to bed it’s like a switch goes off and you are wide awake? This may be a sign that you have conditioned your brain to associate bed with wakefulness instead of sleep. You can strengthen the bed-sleep connection by only going to bed when sleepy, getting out of bed if you don’t fall asleep quickly, and moving wakeful activities out of the bedroom (e.g., watching TV, playing on your phone, and even reading). Another behavior to limit is working while in bed. It can be helpful to set up a designated work station, so work is not coupled with sleep.”
     • “The last thing that contributes to our sleep is what we call sleep drive. The more active you are throughout your day, the stronger your sleep drive is at night. When you are not physically active or if you nap, your sleep drive will lessen at night.”
   • Help the patient develop a consistent sleep schedule.

     • “It can be helpful to have a consistent sleep schedule. What would be a good sleep schedule for yourself? This is one of those things you can control!”
   • Discuss tools the patient can use to help get to sleep if they are having difficulties.

     • “Some patients report having some difficulty sleeping because of elevated stress and anxiety. This is one helpful technique you can do to help yourself fall asleep. Schedule 20 minutes during the day, not close to your bedtime, to worry about things. Take the full 20 minutes to think about all the things that could come up for you to worry about at bedtime. Write down the full list of things you are worrying about. The next step is to go through each item you listed and write down what you can do about that worry or if you are unable to do anything about it write that down. Accomplish all the tasks you can do in service of fixing that worry. The last step is to fold the paper in half and put it on the table. Tell yourself you have finished worrying for the day.”
8. Building Resiliency and Hope:

   • Help the patient gain resiliency by asking them how they want to reflect back on the pandemic. [Clinicians – spend a little time exploring this section and identifying values driven behaviors]

     • “If we fast forward to the end of the pandemic, what do you want the days to look like? How would you like to spend your time?”
   • Discuss the importance of limiting the amount of news/pandemic related information consumed each day.

     • “Being up-to-date and informed about the news is important, especially during a pandemic. However, if you are obsessively watching or reading the news it can exacerbate the stress and anxiety you are experiencing and may even make it more difficult for you to fall asleep or stay asleep at night. What have you noticed?”
   • Discuss the importance of being flexible with the established schedule and coping techniques.

     • “We have spent a lot of time today creating a schedule for you and discussing coping techniques; however, it is important to remember that there will be good days and bad days. On the bad days, it is okay to be flexible with the schedule. If you don’t adhere to the planned schedule, it is important to be nice to yourself and offer yourself kindness, because we are in the midst of a pandemic. This means that you are likely to experience more stress than normal. Practice the grounding exercises so that they can be more helpful to you on the bad days”
9. Summary of Concepts Discussed:

   • Thank the patient for engaging in the session and review the concepts discussed.

     • “Thank you so much for your participation in the session today. I want to take a minute to summarize our session together:

       • It is okay to feel whatever it is that you are experiencing right now.
       • It is important to recognize the possible heightened stress and anxiety levels and offer yourself some kindness.
       • Focus on the things you can control and not on the things you are unable to control.
       • Maintain a schedule for eating, physical movement, social connection, and sleep can help you maintain healthy moods.
       • Remember to practice the five grounding exercises.
     • Again, thank you so much for your time today. And, you should be proud that through all of this you took the time today to learn some new strategies to help manage your mental health and well-being.”

Appendix A

One Page Pandemic Mental Health Maintenance Intervention Handout

As the current COVID-19 pandemic is known to cause stress and anxiety, it is important to focus on your mental health in addition to your physical health. The following intervention is focused on addressing mental health. Here are some techniques for emotional grounding exercises, and important ways to decrease stress during this time:

• Emotional Grounding Exercises

  • It is important to remember that COVID-19 will end eventually, and that your current schedule will not last forever!
  • On the days that coping is harder, it is okay to do things that will make you feel better such as wearing PJs all day and watching TV!
• Grounding Techniques

  • Grounding techniques are a set of strategies you can use to help create distance and distract yourself from emotions like anxiety, fear, and sadness.
  • Grounding techniques help prevent things from getting worse!
  • There are three types: mental, physical, and soothing exercises. It is important to find the one(s) that work best for you!

  1. Mental Grounding Exercises (Focus on your mind)

     • Try counting to 10 over and over again!
     • Describe your environment using all your senses (smell, taste, etc.)
     • Play a Categories Game with yourself, like thinking of famous people that begin with each letter of the alphabet.
     • Think of a funny memory to change your mood.
  2. Physical Grounding Exercises (Focus on your five senses)

     • Look at old family photos/videos.
     • Use a grounding object such as a ring, bracelet, piece of paper, and touch it when you feel unpleasant emotions.
     • Play a calming song/sound.
     • Jump up and down.
     • Light a scented candle.
     • Eat a hard candy.
     • Pet your cat/dog.
  3. Soothing Grounding Exercises (Give yourself a pep talk)

     • Repeating a coping statement. For example, you can say, “I will get through this.”
     • Offer yourself kind statements. Pretend you are talking to the child version of yourself. You can tell yourself – “It’s okay to be scared during this time.”
     • Think of your favorite movie, color, animal, or season.
     • Sing the words to an inspiring song, quotation, or poem.
     • Plan a treat for yourself, such as making your favorite dinner to eat.
     • Hug a pillow as if you were hugging yourself.