Mental Health First Aid during the Pandemic

Note: this article was written during the 5th wave of the Covid-19 pandemic in Hong Kong

During this very stressful time in Hong Kong it sometimes feels like we are waiting to exhale, holding our breath, waiting to be able to feel that final relief when we know things will be ok . Whew.

But the pandemic continues and every week there seems to be a new event or policy that can bring on a new wave of anxiety. School holiday rearrangements. War in Ukraine. New covid-19 isolation centres. Vulnerable individuals hospitalised, and dying. People leaving. It seems never-ending. The solution is that we need to learn to live with anxiety, not escape it.

First aid treatments of anxiety during the Pandemic

As when we apply first aid to a physical injury we can apply clear steps to provide first aid to the mental health issue of anxiety. Firstly, we need to assess and monitor the experience of anxiety. Secondly, we need to have immediate solutions to treat anxiety in its most threatening form – when we experience anxiety attacks. Lastly, we need to have an organised treatment plan which reduces the chance of anxiety attacks in future (prevention) and builds the ability to better respond should we encounter an attack in the future.

Monitor and record your anxiety score 2-3 times a day

Step one – measure and monitoring anxiety.

It is important that you gain the ability to monitor your anxiety. It is normal to feel anxious in a time of such uncertainty. Changes in policy, the status of the pandemic, interfere with our feelings of being able to control the outcome of this situation. It is normal to experience some anxiety, some frustration, some sadness when life is disrupted. Whilst it is normal, it still requires a healthy response to protect yourself psychologically. Knowing how you are doing is the first step in figuring out how to respond.

Monitoring your anxiety regularly allows you to recognise if your anxiety is becoming more than you can take on a regular basis. Take three moments during the day to rate your anxiety on a scale of 0 to 10. A score of zero indicates no anxiety. A score of 10 would indicate severe anxiety, with heart palpitations and breathlessness, perhaps requiring hospitalization. A score under five would indicate that you still feel that you can function in performing your daily tasks – being study or work. A score over five would indicate that your anxiety is starting to affect your ability to function.

Record your score a few times a day. Make a record of the maximum score you experienced during the day. Record what you were doing just before, or when that maximum score occurred. We want to use this data to create your personlised diagnostic – noting when and under what conditions you experience the strongest feelings of anxiety, so that we can build a treatment plan just for you.

Step 2 – techniques to provide immediate relief from anxiety.

If you are experiencing anxiety at a level of 7-10 you might like to use some immediate first aid techniques to treat the anxiety in your body. Essentially you want to sooth your body back into a normal automatic breathing pattern. I recommend deep breathing exercises and distraction techniques using the senses, colour or physical activity. These techniques, and others are covered in our blog on emergency responses to anxiety attacks below.

These techniques are sometimes call grounding or self- soothing techniques. They can also be helpful when you are flooded with other strong emotions including sadness and anger.

Anxiety Attacks – Emergency responses

Step 3: Build a personalised treatment plan to build better responses and prevent anxiety in the future. Every person’s experience of anxiety is unique, but there are many common elements that we can include, or exclude in a treatment plan for your anxiety. You are in the best position to monitor your anxiety. You can use the following information to decide what elements might be best for you to include in a treatment plan. Utilising an external expert, such as a counsellor, will also help you to capture information about historical triggers, and help clarifying activities that help, heal from those which may actually harm you in your recovery from anxiety.

3a) Identifying amplifiers and reducers of anxiety

By monitoring your anxiety, and reviewing your anxiety responses from the past, you can explore some of the activities which amplify your experience of anxiety. RED DOOR recently set up anxiety workshops in response to anxiety people report during the current Covid pandemic (Wave 5). Some of the things that amplify people’s experience of anxiety include excessive scrolling of news, consumption of social media and even (careless) conversations with friends and colleagues. Watch how you feel after reading the news, is your anxiety experience rating increasing or decreasing.

Think about your response to stress and anxiety. What do you do when you see that there are increasing cases, or new restrictions. Do you pass on your anxiety to others – post the bad news on the internet?. Do you want to help? What is your response? Is your response improving your feeling of anxiety, or making it worse? Being mindful of your anxiety will help you identify what escalates those anxious feelings.

It may be tempting to blame your feelings on the actions of others. “My husband makes me anxious”. Own your own feelings. People’s actions are their own. Your feelings are your own.  Whilst people’s actions can be careless, sometimes even hurtful, often our perception and interpretation of those behaviours is what hurts, rather than the actions themselves. Take a look at the section on perspectives later in this document to learn more about cognitive distortions.

Take note of those external triggers that amplify your anxiety and consider to limit them. In our anxiety workshops during the covid pandemic, actively reducing news and social media consumption has helped our participants better manage their anxiety at this time.

In addition to amplifiers, take a moment to think about those moments in the day that you feel most at peace. We are well trained to note when we feel anxious, it takes specific focus to capture yourself feeling calm. It is important to understand what people or activities that are associated with your sense of calmness or reduction of anxiety. For many people a moment in the sunshine, or a brief walk, might bring them some sense of calm. For you it may be when you take hold of a good cup of tea. Make note of these reducing activities. We need to build them into your self-care treatment plan which I will detail later in this article.

Many people respond to crises in various ways. We know about the fight/ flight response, Outflows of families from Hong Kong has been a clear demonstration of a, very natural, desire to flee from perceived danger. Some people choose to stand and fight, either in person or online. We can see that behaviour as well. Others choose to help – look at how they can add support to less fortunate. Others choose to cheer others – inserting humor or other entertainment. All of these responses can exacerbate or decrease your anxiety. Fleeing in response to perceived, rather than real danger, can solidify the anxiety-flee response. Sometimes you need to stand your ground and deal with your anxiety rather than move away. These situations are best discussed with a professional.

Choosing to help is actually a great way to achieve some sense of control at a time of uncertainty. Helping others, and volunteering, is a great for building gratitude, which is one aspect of a healthy anxiety management plan.

3b) Build a checklist.

In the longer term having a list of activities that HELP and HARM you will help you build better protection and prevent anxiety in the future.

Take the amplifiers that you identified from the exercise above, and the activities that reduce your anxiety. Put them into a checklist under the items of HELP and HARM your anxiety.  You want to build a checklist of activities that HELP you and HARM you so that you know what you need to do a daily or weekly basis.

The activities that are detailed below can be added, if you believe they might help you. Once you have a list of HELPing activities, I want you to commit to trying each one once a day or one a week, whichever frequency seems more sensible.

For those behaviours you consider potentially harmful I would recommend that you place a limit on them. For example, you can set limits on social media scrolling, you can manage the amount of times you check the news a day.

There are a set of behaviours which may seem like HELPing behaviours but may, when done to excess, become a HARM. For example, you may want to monitor your consumption of alcohol, recreational drugs, and any form of self-medication. People sometimes things that these activities help them to cope with anxiety, but actually when observed, they may notice that that they actually maintaining anxiety over time, not dissipating it.

You can build a number of items into your checklist. Have a look at our sample, read through the rest of this document, and decide what items you want to utilise to HELP you, and those items you want to start monitoring and limiting which HARM you.

3c) Check your perspective

Accepting your circumstances is, in part, a matter of perspective. Those whom are content are more likely to be able to respond positively to change when it is required, accept that some events are beyond their control and allow situations to be different than their expectations. This is because they can approach challenges with a perspective that is mindful of the extra thoughts that they may have within a situation, or in response to a stimulus, to check what is real from their “interpretation” of events.

Famous psychologist, Albert Ellis, identified a plethora of irrational beliefs that we develop as part of the way we are raised, see the world, and believe about ourselves and other people. These beliefs are filters that, like a pair of glasses, interfere with the way that we see situations. Wearing faulty filters may cause people to engage in self-defeating behaviours such as experiencing self-hatred, jealousy, self-harm, accepting abusive relationships, procrastinating, and anger.

The good news is that it is possible to change your thinking and be happier.

You can stop help yourself and remove some ineffective thinking filters by creating a constructive dispute with yourself. Experiencing faulty filters is quite common, if you discover you have been experiencing faulty filters, you can change the view. By disabling these filters, you are will start responding to what is, not simply your processed interpretation.

An article on many of the cognitive filters we can be susceptible to is attached below. I recommend you take some time to look through all the thinking filters that people often experience and then consider the type of discourse and dispute that you can create within yourself to stop some of the reactions you have.

Change the View. Challenging your thinking filters.

It is important however to pay attention to three filters which cause particular concern during this time – Catastrophising, Comparing, and Mindreading/Blaming.

Catastrophising.

Catastrophising refers to the faulty thinking filter which we can apply when exploring the future of situations in regard to negative outcomes. This is very common during a pandemic because we don’t know what the outcome will be.

Whilst it is typical to occasionally feel a negative outcome, when we go for medical checks and such, excessive worry is of no help. During the pandemic you don’t need to look much further than social media to see evidence of catastrophic thoughts.

Catastrophic thinking increases your experience of anxiety

If you tend to catastrophise regularly you cause yourself immense distress. Imagining that all situations will end in disaster is exhausting. Worrying that people will die or leave you will not make those situations any easier when they do happen, it just makes you experience the situation, virtually, again and again.

People who catastrophise need to challenge their thinking with more ‘realistic’ thoughts, and remind themselves how many times in the past situations have turned out OK. Often the worry caused by catastrophising may move people to seek out reassurance from others, and this in itself can become a problem. Try to do nothing for a while first. Whilst the anxiety you feel is unpleasant you can work to distract yourself from that experience with anxiety relieving activities. Try to create a disputing dialogue.

Use the “At least” exercise to break catastrophic thought patterns

One specific cure to reset your catastrophic thinking will be to engage the perspective taking exercise of “At least”. Some individuals can become hardwired with a pessimism bias. The pessimism bias refers to the tendency to overestimate the likelihood of negative events while underestimating the likelihood of positive events. This attitude of expecting the worst is a prominently associated with the experience of depression and anxiety and can have considerable ramifications for recovery from these conditions.

If you find you naturally comment on the negative aspects of a situation, consider changing your choice of expressions, if only for a little while. We sometimes forget that when we speak, we are feeding ourselves. This negativity loop can be hard to break. In therapy one way we start to break the process is to encourage clients to start to use the phrase, “At least” when they speak, either attached to their pessimistic dialogue or to help build some sense of gratitude.

Every cloud has a silver lining. Help yourself, and your kids, find it.

This approach may seem like chasing rainbows rather than dealing with the real issues. I would challenge you to consider if your negative viewpoints are honest, comprehensive and useful. Almost every challenge has both difficult and beneficial elements. For example, I work with teens and when it became obvious that school would be online for a protracted period of time, I asked them what they liked about online school They came up with the following things they liked. I did not ask them if they like online school more than in person school. I cannot provide them with in person school when it is not possible. Rather I am helping them see the positive aspects of a situation that can feel beyond their control.

Practicing gratitude to stop catastrophic thought patterns.

Over the longer term, practicing gratitude will help develop a more positive mindset which will help be more practiced in seeking the pleasing elements of your life, leading to a greater sense of satisfaction in general.

Practicing gratitude is associated with a stronger immune system, as well as more positive emotions and happiness. Its easy to be grateful over the big things, a bonus, the birth of a child, and a promotion. The real benefit for individuals in practicing gratitude over the smaller things – a sunny day, a successful cake, a kind gesture from a friend, technology that works without trouble. That is where the magic happens.

Practicing gratitude regularly, either through journaling or keeping a gratitude jar, helps to develop the habit of gratitude. When we practice gratitude regularly, we start to mentally contrast negative news stories and voices around us, looking for the positive element rather than amplifying the negative.

Exercise- the gratitude jar. I particularly like this exercise because both adults and children can use it Take a jar and label it your gratitude jar. If you have children, you might like to decorate this jar with stickers and plastic gemstones. Once the jar is “complete” you can start to fill it. Using small note paper – such a post-it type or note paper write one or two things that you are grateful for.

Other thinking filters to overcome – the combination of mind reading and blaming.

Mind reading occurs when we assumptions about people in the absence of all the evidence, because we are convinced, that at some level, we know what they are thinking. Whilst on some occasions we may guess this right, we may also get this wrong. For example, I often talk with clients who assume work colleagues talk about them negatively or think a particular way about them. In my experience we tend to overestimate how much people talk about us, and how judgmental of us they may be. Most people are usually worrying about their own performance, and what they need to do, rather than the role we play.

Occasionally people let us down, even hurt us with their actions. Sometimes these actions are intentional. Many times, they are not.  It is good to be able to accept disappointment and the imperfections of others. If you find that you become stuck and the process of blaming others for your position in life, or in a situation you give away some of the power to fix that situation. Accepting someone’s behaviour is not an endorsement of that behaviour, it is simply acknowledging that bad realities exist, and that life can be unfair.

During a pandemic people can combine both these mind reading and blaming filters, especially when regarding the decisions of governments or health authorities. A pandemic such as Covid has not been experienced during most expert’s lifetime, even if they studied previous case studies. So, governments and health authorities can make decisions that, sometimes, look like mistakes. We make ourselves additionally anxious when we assume that they are making those decisions because they don’t care about the outcome for us as individuals, or that they want us to suffer. I don’t agree with many governments’ approaches to managing the pandemic, but I find it helpful to remember an adaption of Hanlon’s Razor, “Never attribute to malice that which is adequately explained by incompetence”.

When society is responding to a pandemic there will be setbacks. Overcoming mistakes or setbacks is a part of life and allows us to build resilience. Ask yourself, what actions by the government, or your company, or building management is really aimed to cause you harm? Are these people intentionally trying to hurt you, or is it possible they are doing the best with the information that they have, and the fears that they hold? We don’t have to give in to policy that we find unacceptable, but it will help you’re experience of anxiety to better try to understand that those making decisions are not personally trying to upset you.

The final filter to eliminate – Comparison.

It is common to consider our own attractiveness, status, success, and personal worth relative to others. During a pandemic regularly comparing yourself and your circumstances to those of others can increase your anxiety. Feeling jealous because friends left Hong Kong to live, temporarily, overseas, will not help your need to stay here. It increases your sense of worry – there must be a reason that people needed to flee. Ask yourself if that is really accurate.

Comparison is a guaranteed path to misery.

When you compare you tend to look at the world through a lens of “winners and losers” you will always find others who have achieved more than you. This is disorienting, and artificially casts you in the role of loser.

Additionally, comparisons are often driven by inaccurate information. . We often compare snapshots and these are often superficial and incomplete. For example, you might feel jealous of people sitting by the pool in Singapore whilst you have to work from home. That is nice for them. They have a pool. They can have dinner at a restaurant. You can’t, right now. That doesn’t mean things will always be that way. This doesn’t mean that everything is going well, or will go well for those people.

Comparing yourself with others will only echo the feeling that life is unfair. Some people are born with more advantages such as social connections, wealth and looks. The world is an uneven playing field. When we focus on comparisons we brood on this unfairness rather than focusing on what we have the power to achieve.

3d) Add calming activities to your daily diet

Specific activities which help to calm the body can help, not only in times of a crisis, but also to build a regular routine of self-soothing and calming.

Activities that help introduce a sense of calm in your life:

Try meditation

Meditation is a good way to bring about, a sense of peace, and help you better manage stress. These benefits do not end when the meditation exercise ends, they can be carried into the rest of your day and employed at times when you encounter something that makes you feel anxious.

Meditation is an umbrella term for the many ways to a relaxed state of being. There are many types of meditation. Committing to even a few minutes of meditation a day can help. Anyone can practice, and benefit from meditation.

During meditation, you focus your attention and eliminate the stream of thoughts that may be crowding your mind and creating a state of stress.

Some of the types of meditation you might like to try include:

Guided meditation. Sometimes called guided imagery or visualization, with this method of meditation you form mental images of places or situations you find relaxing. These meditations often ask you to engage your senses and therefore act as good distraction to calm your breath and stop trails of intrusive thoughts. You can find guided meditations on YouTube or Spotify.

Breath focused meditations. This type of meditation is based on being mindful, or having an increased awareness and acceptance of living in the present moment, all whilst focusing on your breathing patterns. Mantra focused meditations. In this type of meditation, you silently repeat a calming word, thought or phrase to prevent distracting thoughts and to create a sense of calm.

Colouring books – colouring activities create a sense of calm. Colouring books are extremely popular as a result of the positive effect possible from regular colouring. Colouring is not just for children. Teen and adults benefit from colouring activities as well. Doodling is also a great way to create a sense of calm if you would rather create your own artwork.

Other calming activities.

Going for a walk, especially in nature, is one way to bring calm into your day. Some people find making art projects – sewing, knitting, woodwork a great way to achieve calm. During the pandemic many people have taken to baking as a relaxation technique. You can experiment to find out what works for you.

3e) Healthy habits

Practicing healthy habits, especially getting enough sleep, will help you better manage your anxiety. It doesn’t take more than a few nights of poor sleep for frayed tempers and foggy minds to impact your ability to cope with challenging circumstances.

Adults require 7-9 hours of sleep a night. Teens and children require more. Sleep is required to recover from the day, including processing the psychological toll that living in pandemic conditions creates. If you have trouble getting to sleep, or staying asleep, try employing many common sleep enhancing activities such as creating a calm bedtime routine, having a shower and a bath, banning technology an hour before bedtime and from the bedroom. The following article focuses on improving your sleep habit. You can consider medications such as melatonin, if your doctor agrees.

In addition to sleep other eating habits such as diet and exercise can help to better manage your experience of anxiety. The opposite is also true -being overweight and possibly hypertensive, consuming too much alcohol, sugar, smoking, or medications, can actually increase your experience of anxiety and anxiety symptomology.

A special point I’d like to offer is to please watch your consumption on alcohol in response to anxiety. Many jokes are made about “wine o’clock” as a stress response. If you find that you can not limit your consumption to one drink a day, then start to reflect on your relationship to alcohol. Many people find that they need to consider if their alcohol consumption is helping or harming them. There is no shame in taking a break if you need it. If you would like to read more on this topic our article below may help. #

Sleep training for adults.

3f) Utilise your social supports

Friends are important. In times of crisis, good friends are critical. Unfortunately responses to the Covid pandemic often break down social support systems and individuals can feel isolated. You may need to actively build new support mechanisms and networks to ensure that you have good people to talk to during periods of stress.

It is important to talk to people who actively help you to reduce your experience of anxiety. They may simply be the people who listen to you, and say that times are tough right now. If you follow the guidelines of monitoring your anxiety regularly, you may like to record how you feel after interactions with various friends. Talking to some friends may may you feel better, and others the opposite.

Some people seem determined to offload their anxiety onto others. If you have friends like this, perhaps ask if you can change the topic of conversation as it makes you uncomfortable. A good friend will heed such a request. If a friend can not “change the channel” , you may choose to spend less time with that person.

Times of crisis are, often and unfortunately, a time when we learn how strong and helpful our bonds with other people really can be. During the pandemic some of your friends may let you down. If this happens you will probably feel abandoned and upset. People can disappoint us sometimes. I also suspect, that if you look around you, you will notice that other friends have been more supportive and helpful than you originally anticipated. These revelations can be unsettling. Forgive yourself for expecting more of some friends than they could provide, but also be thankful for those people who show up, and offer support.

3g) Mindful Communications

Winston Churchill once commented, “We are masters of the unsaid words, but slaves to those we let slip out”. He was referring to sharing secrets, but this saying can also apply to how we communicate with others during a time of heightened stress.

This is particularly applicable to our communications on social media. Whilst we may have read an article which alerts us to a perceived risk, think if you really want to share it with others online. Ask yourself – is this communication helpful? Is is accurate? Is it factual rather than sensational in its content? Is it necessary for people to know this information? Is it kind for me to share this information? If you answer no to those questions consider holding off on sharing that information online.

This has been particularly true in continuing news or headlines which have been proven to be suspect or written for sensational purposes. For example, media feverishly published that Hong Kong has/had the highest death rate in the world, based on the deaths per capita calculations of the data site Our World in Data. Whilst it terrible that so many people have died, the context of the data always needs to be considered – i) this is at a certain point in time looking backward, not forward, ii) this is a per capita calculation so a relatively small population like Hong Kong with 7.4 million people looks worse than the US and iii) this number does not project any particular individuals chance of dying. If you are vaccinated and generally healthy in Hong Kong, you have a very good chance of surviving Covid. It is tragic that much of this would have been avoidable if more people, particularly older people, had received full vaccination.

So why do media publish such headlines? Because it is sensational and sells papers. Even long after this number subsides they will write that Hong Kong had the world’s worst death rate because it sells. It was these same publications which circulated horror stories of reactions to vaccines which, many have driven, resistance among the older population to agree to vaccination ahead of the fifth wave. It does not help. The news isn’t always accurate or helpful, and whilst its important to stay informed, we need to, unfortunately, be mindful of that.

You may often feel overwhelmed and anxious, and it is appropriate to talk to someone about those feelings. Friends who you know well will be a good first point of call. Consider the recipient if you post about your anxiety on line, and if you do, own your feelings. For example, write “I feel worried how my kids will be affected by interruptions in their schooling” rather than “Kids have been completely ruined by online school”. The later style of statement is may cross the line between simple venting and trauma dumping. When in doubt, keep the shares on your personal life within your private circle of friends.

3h) Pack away your baggage

At times when you are under great stress you want to reserve the energy that you have, and will need, to fight the battle you need to fight. In a pandemic, it is the worry about infection, treatment options inside an environment of miscommunication. You need to utilise your energy to keep yourself as balanced and focused as you can be.

In order to do this it may be similar for you to call a halt to any other fights that are ongoing in your life, with your inlaws or other family members, or with your neighbour or child’s school. Those fights can wait.

Unresolved trauma from the past has a way of becoming unpacked when we are presented with a new threat. For example seeing the government struggle to cope with the current wave of infections and severely sick people may remind you of your own feelings of abandonment. It may be time to put the weight of those traumas behind you with some professional help.

3i) Ask for help if you need it

If your anxiety is crippling, is persistent, or requires you to perform organised routines or practices please consider to seek additional support. You may be advised to visit a counsellor, a psychologist or a psychiatrist in order to help build a different treatment plan. Medications for anxiety are nothing to be ashamed of. We are living through a time of great uncertainty and if your doctor recommends a little extra help, perhaps consider taking it.

Putting it all together

You now know the elements of a treatment plan and you can put it together for yourself to help frame a checklist of practices that should help you during times of heightened anxiety. For some of these activities it may help to join a class to create a dedicated time to perform such activities. I recommend online art therapy and yoga classes for this time.

Even if you want to put everything into practice you may feel trapped trying to navigate your negative thought patterns or overcoming pain from the past. That is when a professional counsellor or psychologist might help. There is no shame in visiting a counsellor.

The question is not why to consider counselling, rather it could be, “why not”.

The scientific benefits of counselling are extensive, and include:

  • Improved wellbeing and health
  • Improving your relationships (friendships, professional relationships, romantic relationships and relationships with family members)
  • Decreased feelings of depression and anxiety
  • Help you get through tough times (pandemic, illness, breakups, disappointments)
  • Accept yourself and improve your self-esteem
  • Build resilience
  • Overcome past challenges and hurts
  • Help to remove roadblocks in your life which make you feel stuck
  • Feel supported and feel seen
  • Better express yourself
  • Improve your ability to manage your emotions
  • Help you feel more hopeful
  • Improve your motivation
  • Better understand yourself and discover more about yourself
  • Find your purpose in life

Counselling is for everyone. It is not just for those who are feeling anxious or depressed. Everyone benefits from receiving counselling. Wouldn’t you like to have improved relationships, better understand yourself, and feel more motivated. Give counselling a chance to help you feel stronger and do better. Certainly in times of heightened anxiety, talking to a qualified counsellor will help.

About the author

Angela Watkins is the Head Counsellor at RED DOOR Counselling in HOng Kong. Angela is an experienced counsellor and trains and teaches counselling in Hong Kong. For more information about how counselling might of benefit to you, you can send her an email at angelaw@reddoor.hk

This article reflects the professional opinion of Angela Watkins. If you are unwell from Covid please seek the advice of a doctor or hospital. If you are feeling regularly overwhelmed by anxiety you should consider counselling in person or online.

#mentalhealthmatters #covid19 #anxiety #meditation #arttherapy #counselling #friendship #cognitivefilters #immunity

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