Treating anxiety and stress in front-line workers: A step-by-step CBT guide

The COVID-19 pandemic has led to unprecedented anxiety and trauma for front-line health-care workers. APA has provided guidance on conducting a diagnostic “intake” evaluation. This guidance explains how to conduct up to four structured sessions of brief CBT-informed psychotherapy, specifically for anxiety and acute stress, with a front-line health-care professional during the pandemic.

This guidance is not intended for serious mental illness, complex trauma, acute suicide risk, or other conditions/situations that require an extended or in-person treatment approach. In all clinical encounters, we recommend that clinicians flexibly rely on their competencies, expertise and wisdom, best-available research evidence, and most importantly — patient values, culture, and preferences.

The overarching rules for these sessions are to “Be Genuine. Express Empathy.” Frame the visits as a consultation.

1. Begin the consultation.

• Welcome patient to your virtual office just as you would your traditional office.
• Ask open-ended question(s) about their status — health, job, family, etc. Ask about functioning and level of distress; assess suicide and other risks as needed.
• Ask patient about their goals for the consultation(s). As much as possible, frame treatment around those goals. Ask how you will know treatment will be a success and be complete.
• Request permission to set agenda for the session. If yes, agenda will be to discuss anxiety and its purpose, teach a new method for identifying anxiety, and explain how to overcome it.
• If no (or if they demonstrate significant distress or retell a traumatic episode), consider abandoning this protocol and use relational, emotion-focused or trauma-focused approach for session with goals of reducing distress and improving functioning.

2. Discuss anxiety and emotional avoidance. Ask about patient’s experience.

• Provide education about anxiety and its purpose.

• Physical sensations of anxiety: Muscle tension, breathing increase, fast heart rate, flushed skin, digestive changes (both upper and lower gastrointestinal system), sensations in hands/feet.
• Feelings of anxiety: Putting words to the feelings helps to process the emotion: e.g. scared, terrified, fearful, panicky.
• Ask patient about sensations, feelings/words or experiences of anxiety.
• Purposes of anxiety: Survival (run or fight); excitement (roller coaster); anxiety is also necessary in some circumstances to motivate action.

• Provide education that avoidance is a natural behavior/reaction to anxiety.

• Ask if patient is ignoring important thoughts or information because they feel uncomfortable (e.g. I could get sick or get others sick), or avoiding anxiety triggers (e.g. not grocery shopping; not interacting with family/friends; not doing self-care).
• Is patient worried/scared of anxiety (anxiety about anxiety)?
• Is patient catastrophizing their circumstances? Feeling unavoidable doom?

3. Provide hope. Explain how to overcome anxiety through tolerance and habituation.

• Provide education that anxiety and acute stress are normal reactions to abnormal situations.
• Explain how habituation can overcome avoidance behaviors and ultimately reduce discomfort.
• Explain how habituation and extinction works:

• Goal is to flatten the anxiety/discomfort “curve” through boredom.
• Extinction = overcoming the “reward” of feeling better momentarily when you avoid anxiety-provoking stimuli.

• Explain that you will work with them to develop imagination-based and modified “in vivo” exposure exercises to facilitate habituation and/or emotional tolerance. (Do not engage in activities that would expose patient to actual health risks for self or others.). Before starting, find out which experiences/thoughts are the most upsetting to them.

4. Develop an anxiety hierarchy of health-care experiences.

• Work with the patient in session — maybe 5–10 minutes — to start brainstorming a list of anxiety-producing thoughts, feelings or situations (real or imagined) about their health-care work. Ask them to write or type the list.
• After they identify 5–7 experiences on the list, ask the patient to rate each item on a 1–10 SUDS scale (high numbers = higher anxiety).
• Explain that they should put the items in rank-order of lowest to highest. Offer verbal praise; tell them it is nice work, a good start or something similar.
• Assign homework of completing the hierarchy, using the same steps as above. This is very important, as we will use this as a primary tool during treatment.

5. Review the Coping Cat FEAR Model, which will be used to help manage anxiety and acute stress.

• Remind the patient of their lowest ranked item on their anxiety hierarchy. Explain that you are going to ask them questions for each item on their hierarchy. The questions spell the word, “fear.”
• Feelings: Identify anxiety, discomfort feelings related to hierarchy item #1 and/or related to health-care worker role. Ask the patient to write them down.
• Expecting Bad Things to Happen: Identify unhealthy thoughts, ideas or expectations related to hierarchy item #1 and/or related to health-care worker role. Ask patient to write them down.

• Review examples of unrealistic or unhelpful thoughts in the Cognitive Distortions Checklist below.

• Alternative Ideas and Steps: Identify alternative, realistic ideas and steps to cope with discomfort, anxiety, and/or avoidance; engage in self-care; effectively and safely deliver healthcare services.

• Explain thought monitoring and cognitive restructuring (i.e. how to talk back to your unhealthy thoughts.)

• Teach healthy cognitive skills, such as: seek accurate information, seek mentoring to important make decisions, tolerate anxiety for real threats; identify when you exaggerate risk for a threat; identify what is vs. isn’t within your power to control.
• Help the patient remember earlier successes in similar situations to help them develop ideas of fortitude, hope, tolerance and patience.

• Teach alternatives to avoidance or overreaction:

• Social activities: check-ins with co-workers, family and friends; working in partnership with teams.
• Personal activities: stress management breaks; time-outs for bodily care and refreshments; recognizing when you are in control and taking charge appropriately.
• Self-informative activities: scheduled times to seek accurate Information; self-limiting news media.

• Results and Self-Rewards: Help patient identify the effects of healthy ideas and behaviors; encourage rewards for successes.

• It is important to notice how healthy coping leads to more satisfaction with life, family/friends, and even personal values.

• Ask patient to teach back the Coping Cat FEAR model and review any areas of misunderstanding.
• Explain that future consultations will be using this FEAR model to help develop emotional tolerance and improve coping in general, and specifically for each item on the anxiety hierarchy.

6. Ask patient for feedback about usefulness of consultation, and if they felt understood.
7. Make next appointment, if appropriate.

1. Begin the consultation.

• Welcome patient to your virtual office.
• Ask open-ended question(s) about their status — health, job, family, etc. Ask about functioning and level of distress; assess suicide and other risks as needed.
• Request permission to set agenda for the session. If yes, proceed. Agenda will be to apply Coping Cat FEAR model to help improve coping.
• If no (or if they demonstrate significant distress or retell a traumatic episode), consider abandoning this protocol and use relational, emotion-focused or trauma-focused approach for session with goals of reducing distress and improving functioning.

2. Review anxiety hierarchy.

• If not complete, problem-solve briefly about how homework can be completed in future and complete hierarchy in session.
• If/when complete, ensure each item on the anxiety hierarchy has a 1–10 SUDS rating and are in order from lowest to highest rank (low anxiety = low numbers).
• For each item on the anxiety hierarchy, determine if their primary coping method has been avoidance (e.g. not thinking, feeling, or doing something) or overreaction (i.e. thinking, feeling, or doing too much of something).

3. For the lowest-ranked item, work through FEAR model (described above). Ask patient to record their responses.

• Depending on whether their primary coping method has been avoidance or overreaction, tailor the “Alternative Ideas or Actions” section toward healthy habituation strategies for avoidance, and distress tolerance and moderated behaviors for overreactions.

• Feelings
• Expecting Bad Things
• Alternative Ideas or Actions
• Results

4. For each successive session, plan three experiments/exercises to practice between sessions in order to improve coping for items from the hierarchy, progressing from lower SUDS-rated items to increasingly higher SUDS-rated items as successive sessions occur (as described below).
5. For each successive session, select the next lowest item in the hierarchy, and work through the FEAR model as described above. Create experiments/exercises for hierarchy item #2. Do the same for hierarchy item #3 if there is enough time, or address item #3 in the next session.
6. Ask patient for feedback about usefulness of consultation, if they felt understood, and if they feel knowledgeable/comfortable to do the experiments.
7. Make next appointment, if appropriate.
8. When completing successive sessions, discuss whether FEAR model continues to be useful, or if another approach or more intensive treatment is needed, or (if appropriate) when treatment will be complete.
9. Complete treatment when clinically indicated and with patient’s agreement (whenever possible).

• Mind reading: Thinking you know what others are thinking without any reason to do that. For example: “If I take a break, others will think I’m shirking my responsibilities and criticize me.”
• Exaggerated concern for others’ thoughts: Giving elevated status to what others think. For example: “If people think I’m not doing enough, I’ll lose my job when this is over.”
• Catastrophizing: Believing that the future will be horrific, and you won’t be able to manage it. For example: “Everyone will get sick, overwhelm my work, and I won’t be able to bear the burden.”
• Discounting: Deciding what you’ve done is unimportant compared to others. For example: “I only worked 16 hours but everyone else is working more than that. I never do enough.”
• Overgeneralizing: Even if there are only a couple of examples, you think those examples apply to all of life. For example: (After seeing a news story about a health-care worker dying) “I know I’ll get sick even though I am using all the safety precautions.”
• Shoulds: Adding moral pressure to yourself inappropriately. For example: “Others work around the clock, so should I.”
• Personalizing: Taking an excessive amount of responsibility or even blame. For example: “If I take time to rest, I would be selfish and put others at-risk.”
• Blaming: Identifying yourself as the sole reason for negative outcomes. For example: “A patient was placed on a ventilator because I didn’t do enough during triage. It’s my fault if the patient dies.”
• Unfair comparisons: Comparing yourself to others in a way that minimized you and exaggerates others’ importance. For example: “My needs shouldn’t count compared to the patients. The needs of survivors are much more important than my own.”
• Super person: Exaggerating your capacities to the point of making yourself indispensable. For example: “Only I can do…”
• All or none thinking: Concluding that things are only one way or the other, that there are no shades of gray. For example, “I am a good employee only if I work all the time.”