Hello Doctor Duff! I am writing to you from Norway. I have been diagnosed with health anxiety about 2 years ago and since then I have been trying various methods of attacking the problem. I feel I finally have a good therapist that specializes in CBT and I am making some progress, however we both find the current situation particularly challenging when it comes to the exposure aspect to therapy. While my country has done fairly well in the pandemic there are still a lot of regulations and advisories on what to do and not do. Since my current fears center around getting the coronavirus we have a lot of trouble coming up with good exposure methods that by themselves do not expose me to the virus. I would love to hear your thought on the above and general handling health anxiety in the setting of global pandemic.

Good question – I have definitely had to be creative with my own patients in exposure work during this period of time. I think that this is one of those circumstances where a reasonable amount of caution is actually helpful and adaptive.

You are going to have to discuss the science and the current guidelines with your therapist and decide what your level of tolerance is at an intellectual level and allow that to guide your behavior. Some of this depends on what your baseline for health anxiety is – is it triggered by hearing about the virus? If so, you can use media as an exposure starting point. You can also use imagined exposure.

When it comes to developing a hierarchy for exposure, you can start with things that are logically very low risk. You can go to an outdoor area and wear a mask. This will give you the chance to start acclimating to being near other people. As with all exposure exercises, you don’t want to try to move too fast. The point is to focus on having enough repetition and duration in your activities that they become boring. Then you can move up to the next step. I guide you through creating a courage ladder in the course. Hopefully, you will be able to get vaccinated soon if you haven’t yet. That will make a massive difference. You will know that your risk of contracting COVID is super low and that your risk of serious disease is even lower.

Basically, these things allow you to have the intellectual justification for engaging with the exposure exercises. Then the next step is trying to get your body to catch up. You need enough rationale to get you out the door, then it comes to repetition and the cognitive work that you are doing in therapy. Everyone will have some degree of reacclimating to do when it comes to public situations. Even vaccinated, I still nope out what I see big crowds of people. So it’s okay if you do this gradually.

Another really important aspect to consider is exposure work that has nothing directly to do with the virus. I’m talking about internal or interoceptive exposure. Really, it’s not always the thought of the medical situation that we are avoiding, it’s the physical anxiety symptoms that come along with thinking about it. In other words, you are going to avoid situations or thoughts that make you feel panicky, sick to your stomach, tight in the chest etc. This is absolutely something that you can build a tolerance to on your own. There are a ton of techniques that are common like doing jumping jacks, spinning around, breathing through a straw, etc. to help you simulate the feelings of panic and learn how to work through them rather than escaping. This along with general anxiety coping skills like a well-trained deep breathing exercise will give you the tools you need to endure the anxiety that you predictably will feel when you are engaging with the world. Focusing on your physical health, sleep, and all that other stuff remains important as well. That gives you a bit of a “wellness buffer” rather than just jumping into an anxiety-inducing scenario open like a raw nerve.

Another aspect that you may want to discuss with your therapist is response prevention. This is a technique that comes from OCD treatment. There is a good chance that your anxiety about covid and other health issues causes you to “check” compulsively. Maybe it’s taking your temperature or googling your symptoms. There are techniques that you can work on to delay that checking and eventually avoid it entirely. The idea here is that you are not giving in and letting your anxiety dictate your behavior. If you are on medications, there is always the possibility of upping them for this period of time for some extra support while you work through this difficult roadblock.

Lastly, you may also want to spend some time reflecting, in therapy and on your own, about things that have nothing to do with the virus. For instance, connecting no passions and clarifying your values can be a great guiding light. Rather than simply trying to avoid or reduce symptoms, you can frame things more positively and strive to live a life that is more in line with your values. Focus on what you enjoy and love rather than what you want to get away from.

So those are my thoughts for you. This might take some time, but it’s totally doable. I think by balancing directly challenging your catastrophic thoughts as you are probably doing in therapy, and just letting them hang out in the background, you can start inching toward a life that you are more okay with.

Hi Robert

Podcast question – A friends young daughter who is 6 has been struggling with suicidal thoughts (she is getting psychiatric help). As someone who struggles with suicidal thoughts and a history of attempts, I want to reach out with the mom’s permission of course, and be there to listen to the child but not sure if that would be more harmful to show more people have thoughts like that or show her she’s not alone. Would love to hear your perspective

Thanks very much

This is a great question. It’s also important to recognize that suicidal thoughts do happen in kids even if you hear about them less. I think it’s amazing that you want to be there as a resource to your friend and their daughter.

Talking to mom is absolutely the first step here. Even just speaking to your friend about your own experiences or answering any questions she has can be very helpful. I’ve had a lot of people come to me to get advice about how to talk to their kids about things. For instance, a friend of mine had a suicide in the family that was unexpected and had no idea how to talk to their teens about it. Sometimes simply having some support as a parent to normalize how difficult it is and how you don’t have to be perfect in how you handle it can be such a help.

When it comes to talking with the kiddo about it, I think at age 6, the way you discuss it will vary quite a bit from kid to kid. At this age, there very well may be other factors that are directly causing the suicidality rather than just major depression or a mood disorder like that. Is there bullying going on? Family discord?

You can relate to them about knowing how it feels to feel stuck like you don’t know what to do, or like you want it all just to go away. I know these seem like big topics to talk to a kid about and they are. But it’s important. You don’t have to be explicit, but having even one person that they know they can talk to can make all the difference in the world. This isn’t the sort of thing that you need to worry about bringing more attention to. A lot of people will tiptoe around issues like this, which can make the kid feel like they did something wrong and that they are weird or broken in some way. Normalizing that a lot of people have a hard time and that there are ways to get through it and ways to find support rather than just giving up can go a long way in making the kiddo feel like they aren’t crazy.

If you are close to this family, you might also see about setting up a regular check-in. You know something like going to get their favorite fast food meal or a treat every couple of weeks to make sure they are doing okay and that they have the opportunity to talk to you if they want to. With young kids like this, you may not be able to just have a straight grown-up conversation with them. It depends on their personality and development. But even if you basically get the kid’s permission to talk to them for a little bit about what they are going through is important and that you are there for them and they aren’t very interactive, that’s still okay.

A lot of times kids are more able to express themselves through play. They don’t have the same brain development that you do. So simply spending time with them and engaging with them on their level will open the door for them to ask you questions or tell you things that are important in this situation. Here’s how I might open the conversation: “Hey, kiddo. Your mom told me that you have been having a bit of a hard time lately, is that true? Well you know I have a hard time sometimes too and I definitely had a hard time when I was a kid. Do you want to tell me what’s been so hard for you?”

From there they might describe in their own way or they might be shy and just go “I don’t know”. If they don’t know, you can say, “I know it’s hard to know what to say. That’s okay! I was wondering if we could play for a little while and I could tell you about what I’ve learned as I’ve grown up.” Then I’d probably start with explaining that it’s normal to not feel happy all the time. That it can be hard to know how to make bad feelings go away. That they aren’t weird for having these feelings. Then talk about how there are other things that can be done to help with the feelings and that talking about what is hard in life helps too.

Just like I’d want to reassure the parent that they don’t have to be perfect in their approach to addressing this, I’d want to reassure you of the same thing. Being there is the most important part.

This was sent a little while back, so I hope that things are going well now. Thank you for the great question!