Covid metamorphosis: Exposure therapy can lessen the anxiety of re-engaging with society

(Arkansas Democrat-Gazette/Celia Storey)
(Arkansas Democrat-Gazette/Celia Storey)

As a clinical psychologist, I've marveled at how my patients' worries have shifted as the pandemic has dragged on.

Initially, when we naively believed the coronavirus would be a short-term stressor, my patients' fears focused on day-to-day survival: How do I get toilet paper? How do I keep my kid from touching her face? Several months in, the focus has shifted to anxiety about decisions: Should I send my kid to school? Should I return to the office?

Now that more people are getting vaccinated and a return to somewhat-normal life is on the horizon, my patients' anxieties have morphed once again, with many of them fretting about how they will re-enter public life after having avoided it for a year. While they've been outwardly rejoicing about the world reopening, they've been privately panicking.

Despite the fact that the pandemic has generally been an anxiety-provoking experience, it has resulted in less anxiety and dread for many people in some parts of their lives. "Covid-19 protocols not only officially sanctioned, but specifically encouraged, avoidance of the outside world," said Simon Rego, chief of psychology and director of psychology training at Montefiore Medical Center in New York. This officially sanctioned avoidance came as a relief to those who dread certain aspects of public life, such as large crowds, socializing or exposure to germs; they could now avoid anxiety-provoking triggers in the name of public health.

Avoidance is a four-letter word in the form of therapy I practice: cognitive behavioral therapy. That's because although avoidance minimizes anxiety and dread in the short-term, it maintains it in the long-term.

"Avoidance prevents a person from learning that catastrophe most likely won't occur, and even if things go badly, they would find a way to cope and get through the situation," said Jonathan Abramowitz, a psychology professor and director of the Anxiety and Stress Disorders Clinic at the University of North Carolina at Chapel Hill. For example, people who are anxious about social gatherings will never learn that they can successfully navigate such events and will continue to steer clear of them.

In addition, prolonged avoidance can engender anxiety and/or dread, even in situations we previously found to be manageable, such as work commutes. "People who regularly commuted in traffic were accustomed to this experience, because it was part of their routine," he said. "But now that it's no longer part of their routine, the prospect of commuting again feels daunting."

As we resume "normal" life, we will have to relearn even simple skills that we haven't used in more than a year. Many of my patients have been telling me that they cannot imagine themselves getting properly dressed, never mind going to their office or a crowded restaurant. But they also desperately want to see loved ones and re-engage with the world.

The good news for these patients — and for anyone dreading the impending return to normalcy — is that they can work on gradually re-entering public life, using the principles of exposure therapy.


Abramowitz defines exposure as "a process where you deliberately confront anxiety-provoking situations with the goal of recognizing that those situations are not as dangerous or aversive as you expected."

Individuals engaging in a course of exposure therapy gradually and systematically expose themselves to people, places, things and/or emotions they wish to avoid. (Although research has shown that exposure need not be gradual to be effective, most of my patients prefer this approach.) For a person who avoids parties, for example, this might mean starting off with an outdoor visit with one neighbor and slowly working up to a large event.

If you're feeling anxiety, dread or queasiness about the prospect of emerging from your covid cocoon, consider following these "rules of exposure":

◼️ Make a ranked list of circumstances you want to avoid.

Think about the people, places or things that make you uncomfortable. These can be general (going to a mall) or specific (a school fundraiser). Rank them according to how much you wish to avoid them.

◼️ Create a specific plan.

Start with the lowest-ranking item on your list and outline how you will tackle this situation. Rego cited the example of people dreading their commute: They might "start by planning a drive on an off-hour, accompanied by someone they trust, staying in the slow lane."

When you feel confident that you can manage a certain situation, which might entail several practice sessions, move to the next one on your list. If you have something specific coming up that you're really dreading (a backyard summer wedding, for example), plan exposures for yourself leading up to it so you feel more prepared by the time it arrives.

◼️ Be mindful of your anxiety or dread.

Expect to feel mildly to very crummy during your exposure practices.

"It's OK to feel anxious and uncomfortable," Abramowitz said. "We're human, and we haven't faced many of these situations in a year." Your only goal should be to get yourself to and from these experiences, not necessarily to enjoy them. (And, let's face it, even with lots of practice, you might never enjoy them.) The more exposures you do, the more confident you will be about your ability to tolerate these dreaded situations.

◼️ Help kids formulate an exposure plan.

Children who have been largely isolated could be anxious, too. Kids might face a number of challenges as they head back out into the world, according to Jill Ehrenreich-May, a psychology professor and director of the Child and Adolescent Mood and Anxiety Treatment Program at the University of Miami.

For example, she said, many teens whose "only social outlet has been online games" are daunted by the prospect of returning to in-person socializing. In addition, some younger children who have been spending unusual amounts of time with their parents might have separation anxiety once their parents resume working outside the home.

Ehrenreich-May recommends that parents work with children who are old enough to create a "sensible" exposure plan. "Having a plan really supports kids' feelings of self-efficacy," she said. "Parents can encourage their kids, emphasizing, 'We'll take baby steps, and we can do this.'"

For younger children, you can frame forays into the post-pandemic world as "adventures," noting that you'll be spending time trying new things with them and reassuring them that you'll always be accompanying them on these excursions.

◼️ Set expectations with relatives and friends.

Let loved ones know that you might not be thrusting yourself back into life with the same vigor that they are. This might mean, for example, saying no to sharing a beach house this summer with your entire extended family (but maybe saying yes to driving down to the beach for the day to spend time with them).

Abramowitz suggests taking an assertive approach: "You can sit this person down and say, 'This is something that I need to work through. Everyone is at a different comfort level with this whole thing. This is not about you, it's about me.'"

Exposure practice won't transform you into a life-of-the-party type. But it will help you manage the demands of post-pandemic life with more confidence and less worry. And given all we've endured in the past year, that will feel like a big win.

Ilyse Dobrow DiMarco is a clinical psychologist and author of "Mom Brain," which will be published in May by Guilford Press.

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