We all seem to be living in fear now. Casualty numbers rise day by day and the country is in lockdown. In our homes we wash our hands repeatedly, and when we are out, we view others with slight suspicion and step away from them to keep our social distance – and we do all of this under strict instructions from the government! What readers will undoubtedly recognise as a snapshot of our lives under lockdown, would have seemed to many nothing but a dystopian fantasy from the realms of science fiction only a few months ago.
As a psychologist, I have spent many years helping people who experience just such pervasive anxieties and fears to take back their lives and overcome the sense of being besieged by invisible dangers. Only a few days ago, one of my patients who has lived with fears of contamination for many years, remarked with dry wit on the strange role reversals that he has experienced in his family: “They now ask me to help them sanitise and clean the remote controls … and the chairs…previously, when I wanted to do that, they all made fun of me and told me I was obsessed with germs…Now they live in constant fear of getting infected. Welcome to my world!”
Living under lockdown when you have pre-existing mental health difficulties is, of course, really difficult. So many people who struggle with anxiety, depression, or obsessive compulsive disorder (OCD) find themselves without many of the support mechanisms that previously helped them to get on with their lives, despite their mental ill health: Human contact and reassurance from friends, family, support workers or mental health staff. (Connecting with others through technology is never really the same as face to face contact.) Social touch and hugs, those expressions of reassurance and affection, are no longer possible with social distancing measures in place. (And there is good research to show that social touch can help us to calm down when we are distressed and build resilience.)
… many people who struggle with anxiety, depression, or obsessive compulsive disorder find themselves without the support mechanisms that previously helped them to get on with their lives
With effective support less available to many people who struggle, especially with anxiety disorders and depression, social distancing can translate into social isolation, and legitimate steps to combat the spread of coronavirus and save lives, distort into excessive worry, fear, and compulsive actions that only exacerbate mental distress.
In this article I want to offer you some ideas on dealing with your anxious thoughts, intrusive worries, and compulsions – those actions you feel you have to do, in order to feel safe and reassured (or keep others safe). First, however, a word of warning, or perhaps reassurance in a strange way: Dealing with intrusive thoughts, worry, and rumination is never easy. These intruders impose themselves upon our minds. Like uninvited and unwelcome guests, they demand our attention, and we often feel obliged to cater to their needs. We feed them and nurture them, sometimes unwittingly, but so strong is their hold on us, that we feel we have no choice.
My message is quite simple, though. We are not obliged to cater for them. At best, we can evict these squatters from our minds and end their reign of terror, or, we can at least learn to live side by side with them in our own minds, paying them negligible amounts of attention.
In order to overcome them, you need to understand how they operate, how you might be contributing to their success …
Achieving this is a difficult task: In order to overcome them, you need to understand how they operate, how you might be contributing to their success in hogging your attention, and you need to develop the skills you need in order to challenge and defeat them in everyday situations.
Three simple, but hard steps to overcome intrusive worry.
I propose three simple, but hard steps that will help you to overcome the intrusive anxieties and worries you may be experiencing under lockdown. These steps are based on the academic research and clinical experience of some of the best psychologists around, and eminent psychological researchers that studied intrusive worry, anxiety and Obsessive Compulsive Disorders. At the end of this article, I will provide a few references you can use if you want to find out more.
The three steps are, Awareness, Question, and Challenge.
Awareness:
At the end of their therapy, when they are ready for discharge, I always ask my patients what is different for them now and how they manage their mental health, compared to before their sessions? I see their answers to these questions as psychological treasure: It is these, often simple, everyday practices that they have developed for themselves that helps them heal and keeps them well. One of the most frequent answers I get, especially from those who struggle with anxiety and intrusive thoughts goes a bit like this: “I am now more aware of my thinking and that helps me to manage my thoughts better and not to be so overwhelmed by them.”
What do they mean by awareness? And how does being aware help? Well, awareness in this sense is more than knowing. You would know if you are a habitual worrier, if you overthink things, or if you get trapped in a quagmire of distressing thoughts and feel you cannot get out. But for many people, knowing these things about their thinking only makes them feel more upset, because they also worry about these processes. Why do I have such a busy head? Why can I not stop these thoughts? These thoughts cannot be normal?
If you have experienced intrusive thoughts and worries, I am sure you would instantly recognise that these unwelcome guests are rarely solitary. You may have a worrying thought such as, “I just touched my face after opening that door. What if I am infected with viruses from the doorknob?” Together with these thoughts, you are likely to experience further associated thoughts. These can take the form of information that you may have come across before such as perhaps hearing somewhere the virus can remain alive on doorknobs for many hours if not days.
When they arise, thoughts carry with them associated meanings and emotions.
There may also be intrusive images, perhaps of someone who is contagious touching the door before you, leaving some viral material behind. And then there are the emotions: Perhaps fear, perhaps some anger at yourself or others, perhaps a vague sense of dread like something really terrible is about to happen.
When they arise, thoughts carry with them associated meanings and emotions, and these make it easy for further, related thoughts or images to spring to mind automatically, and before you know it, a whole train of thought can arise, trapping you in the accompanying quagmire of negative emotions. It is easy to see how someone can find it almost impossible to escape.
To make matters worse, we also have thoughts about our thoughts: These meta-cognitions involve us worrying about our worries, perhaps judging ourselves for being so negative, or spurring ourselves on to be more cautious and worried because, after all, you never know what you could be exposed to next. Awareness, in this context, is a skill you develop that operates at this second level of thinking, the meta-cognitive level.
You can start teaching yourself awareness by doing the following two exercises. The first exercise involves writing down as much as you can about your worrying thoughts, the images associated with them and all the steps you take to assuage your concerns. Try to add anything that explains your reaction to your own worries, for example, are you hard on yourself for thinking like that? Do you feel that having these spells of worry makes you abnormal? In other words, you need to practice observing your brain in action while you are experiencing these worries or intrusive thoughts, so you can learn more about how they work – and this will give you clues as to how to defeat them!
The second exercise is quite simply to catch yourself at it. Try to interject the idea to yourself that “I’m doing it again,” whenever you’re experiencing such intrusive thoughts. By reminding yourself that your worries are well-known to you, unwanted guests imposing themselves upon your mind, you are also telling yourself something about their nature: They are thoughts, your thoughts, and not necessarily a realistic reflection of the real world. This opens up a further possibility: They could be unrealistic, false, or at the very least open to doubt.
Awareness is therefore more than just knowing you tend to worry or experience intrusive thoughts and what these worries or intrusive thoughts are about. Awareness is about developing a genuine understanding of your thought processes, their nature (they are just thoughts, images, or emotions), and the ways they lead to further negative emotions, and actions, and how they facilitate the rise of further negative thoughts that occupy your mind.
Question:
Once you become aware of just how pervasive these negative thinking patterns can be, you may just want these thoughts to go away. Unfortunately, if there is one thing we have learned from the research on intrusive thoughts and rumination it is this: Trying to block out intrusive thoughts doesn’t work all that well.
Distracting ourselves might work a bit better, and can provide temporary reprieve, so we can break out of a really low mood, but does not really provide a complete, long term solution either. So it appears that temporarily accepting the presence of our worries and
If there is one thing we have learned from the research it is that trying to block out intrusive thoughts doesn’t work all that well.
anxiety is an early part of overcoming them. We also saw that there are some awareness skills we can practice, so we can both become more aware of when they sneak into our minds, and get glimpses of their true nature and the ways in which they operate and sabotage us.
This enables us to start challenging and questioning them (and ourselves), without the types of harsh self-judgements that often accompany our meta-cognition. For example, very often intrusive and obsessive worry comes in the form of “what if?” questions. “What if I am an inadvertent carrier of Covid?”; “What if my family gets ill?”
However, no matter how you try to reason with yourself when you experience these states of anxiety and distress, logic just does not prevail. Much later, perhaps when you feel better, you might be astonished at how upset and distressed you were … and how unreasonable. More fodder for self-judgement. And this is by far the hardest part for many people: In such states of worry and high anxiety, we completely accept the reality of our distressing thoughts, we do not question them and we act in ways that help us to reduce our distress – even if these are only effective for a short time. This is why developing the strength to cut into our own distress, to interrupt the chain of worry, and interject the idea that “I am doing it again”, or “I have started worrying,” is such an important first step. In one moment, I interrupt their flow, remind myself that these are “just” thoughts (albeit very distressing ones due to their associated emotions), thoughts nonetheless, and not the same as reality.
There is something else both my patients and the academic researchers noticed about these times of intrusive and distressing worry: They come and go. There is a rhythm to them. At one time you might feel yourself being sucked deep into a whirlpool of worry and distress, and then some time later, you emerge feeling fine, and more often than not, a bit bemused about why you were so upset by something so illogical. But, while in the whirlpool, those “what ifs” completely took over your mind, and it is only afterwards that you can replace them with the “even ifs” of a more balanced view. So, even if you are infected, you are likely to get treated by specialists. Even if you are seriously ill, there is help and support at your disposal. And those times of intense worry, they come and go. One of my patients recently told me that that he found that if he is able to live with his obsessions for a period of time, accepting they are there without trying to fight them, while still keeping to his daily routine, they tend to fade away. But that takes effort; it is hard work!
I believe there are two secrets to his success: The first is that he does not waste time and effort trying to control or fight off the intrusive thoughts, though they distress him a lot. He also does not engage in seeking reassurance or try to undo them by ritualistic actions; instead he gets on with his life. While feeling distressed he still does with his day what he set out to do. It’s a bit like going to work with a bad headache – very unpleasant, but not impossible. Through his actions he questions the reality of the worries he has: He treats them as the distressing thoughts they are and he realises their true nature; he refuses to feed them.
Challenge:
These first two phases of awareness and questioning take courage; they are hard and challenge our natural assumption that our thoughts reflect the world as it is. Acknowledging we are held captive by a chain of thoughts, made strong by the distressing emotions they elicit in us, is the start of coping with such intense and intrusive worries. We realise their true nature and give up our attempts to block them out. Instead, we live our lives and keep to the daily tasks we set for ourselves, despite the anxiety and the fear. The last step in this process follows on from questioning our worries and concerns by challenging them. This means that we need to start taking away their support network. What keeps them alive and thriving?
Of all the different ways ruminative worry maintains its hold over us and our minds, one of the most important is what psychologists call safety or avoidance behaviours.
We live our lives and keep to the daily tasks we set for ourselves, despite the anxiety and the fear.
These are all the actions we take to relieve our fear and worry: Spending long hours searching online for information, washing our hands over and over again – way beyond government guidelines, checking out with others that we will be OK, going for unnecessary medical tests, and those little mental rituals that make us feel safe: counting or repeating phrases mentally. All of these are pseudo-solutions. They do not address the real problem, but they allow us to feel better for a while, until the “what if” logic starts up again and no one can dispute “what if”…statements, even with strong objective evidence, because what if they’re wrong? And the cycle starts all over.
So the first part of this third step is to challenge our own safety behaviours. Not to give in to them – remember the patient quoted earlier, who found his OCD thoughts faded away if he was able to get on with things despite having these intrusive thoughts. “Even if I am plagued with doubt, I will get on with my day.” This is often called distress tolerance: You deliberately decide not to engage in the safety behaviour your worry draws you to, tolerate the anxiety and stress for a period of time, and perhaps even do something different or incompatible. If you keep that up for a relatively short period of time, maybe as little as 20-30 minutes, you may find that the pressure to engage in your safety behaviour or ritual fades, and your focus may move on too.
The second challenge to your ruminative worry or anxiety that I would like to suggest to you links back to the section on awareness and understanding how your worry and anxiety work. One of the key drivers that keep such worry-chains alive is an often secret fear that many of us harbour – I might be a bad person. Did I touch that door knob with my hand deliberately? Is he going to get hurt because I am secretly jealous of him and therefore harbour him some ill will? The bad news is that this feared self, the you that you might secretly think you are, but really really do not want to be, thrives on emotion. This may be why many people with obsessive compulsive disorder live in fear of having
Challenge starts with acknowledging the root of the problem and then turning the lens of your doubt back onto your worries and anxieties.
thought or done something to hurt others: If I can think it, I can easily do it; or, perhaps even: “If I can think or imagine it, I might as well have done it!” And this is also why logic often does not prevail in these conditions.
Challenge starts with acknowledging the root of the problem and then turning the lens of your doubt back onto your worries and anxieties. Perhaps you are so certain that you are in danger of spreading an infection to others, because you are so afraid that you might be that sort of person, that malicious. But, how do you know? Your certainty is maintained by your emotions, not by evidence or even common sense! And any evidence to the contrary is rejected, because, “what if I really am like that and just very good at fooling everyone else?” Once you acknowledge that your feared self is built up from a set of false beliefs that are based on emotion and fears, not on evidence, you can start to challenge the stories you tell yourself about yourself, other people, and the current crisis.
Coping with fear and worry during the Covid-19 crisis.
In this article I have shared some key ideas from psychological research and clinical practice on how you can deal with ruminative worry and obsessive thinking. The steps I suggest starts with developing your awareness of your worry cycles and the accompanying emotions. You can write down their content, what triggers them and how they work. You can try and change your broader metacognitions about them and start to “catch” yourself “in the act” when you are trapped in a worry cycle. This helps you to shift your understanding of your anxiety from a place of accepting every thought as a reflection of external reality, to a position where you clearly see these thoughts as thoughts and open to question.
You can work hard at questioning these cycles by acknowledging the role of emotion and skewed logic in maintaining the chains of thought that make up your rumination or anxieties.
You start to shift your understanding of your anxiety from accepting every thought as a reflection of external reality to a position where you clearly see thoughts as just thoughts and open to question.
You can practice tolerating the distress they cause, while you get on with your life, knowing that they come and go in phases or cycles, and that, after one particular cycle is over, your perspective will most likely change from one coloured by false logic or emotions to one that is able to appreciate an alternative point of view. You can also turn “what ifs” into “even ifs” – have a plan ready, so if the worst happens, you will know what to do.
You can rebel, you can challenge them by refusing them succour: Choose to forego the temporary relief afforded by your safety behaviours, reassurance seeking, avoidance, or the rituals you engage in to alleviate your anxiety. In the current context, this may mean foregoing the many hours spent online searching and consuming all the horror stories that we can so easily access. It may mean washing your hands according to the guidelines, no more and no less, and being strict with yourself about it. It may also mean choosing to accept some risk and ambiguity (“Will I get ill? And if I do, what then?”). Turning those “what ifs” around is likely to present a particular challenge, but perhaps you can get your mind to accept that, while there are no guaranteed actions we can take to avoid exposure to coronavirus, there are some best practice behaviours we can all do (good hand hygiene, social distancing, and self-isolation where appropriate), even if we become unwell, there is a system in place to take care of us and our loved ones.
Finally, you can cultivate compassion for yourself and others. If those around you always found it difficult to understand just how distressing it is for you to live in a world permeated by the dangers and anxieties that intrude on your mind, maybe now they will understand your experience a little better. It might even be possible that you can help them challenge some of their excessive fears and come to a balanced view. You can also consider the ways in which your own feared self might have been driving your intrusive thoughts and worries and challenge the emotions that distort those views of who you are.
I do not believe these steps are very complicated or hard to try out; but from my experience as a clinician, I can vouch for the very great degree of challenge they pose to anyone who experiences regular, distressing intrusive thoughts, ruminations, or OCD. Intrusive thoughts are difficult to overcome, but it can be done. You can start today.
***
This article presents only a small selection of the many tools psychologists and psychological therapists have developed to help people with intrusive worry, anxiety or OCD. In fact, several major techniques and coping strategies have been left out as it was just not possible to write about all of them here. These ideas do, however, form a really good place to start your journey away from obsessive worry today.
Another great way to take positive action and get on with your life, despite coronavirus, is to engage in the Covid-19 Five-a-day – the five areas of action based on the research underpinning resilience under lockdown. You can read more about the Covid-19 Five-a-day here.
If you would like to find out more about the ideas presented in this article, please have a look at the following sources. Not all of them are freely available online, but you may be able access at least some of them through libraries or online bookshops if you are interested:
Bennett-Levy, J. E., Butler, G. E., Fennell, M. E., Hackman, A. E., Mueller, M. E., & Westbrook, D. E. (2004). Oxford guide to behavioural experiments in cognitive therapy. Oxford University Press.
O’Connor, K., Koszegi, N., Aardema, F., van Niekerk, J., & Taillon, A. (2009). An inference-based approach to treating obsessive-compulsive disorders. Cognitive and Behavioral Practice, 16(4), 420-429.
Papageorgiou, C., & Wells, A. (Eds.). (2004). Depressive rumination: Nature, theory and treatment. John Wiley & Sons.
Stoddard, J. A., & Afari, N. (2014). The Big Book of ACT Metaphors: a practitioner’s guide to experiential exercises and metaphors in Acceptance and Commitment Therapy. New Harbinger Publications.
Wegner, D. M. (1989). White bears and other unwanted thoughts: Suppression, obsession, and the psychology of mental control. Penguin Press.
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