Health Psychology & COVID-19 - what have we learned about how best to cope during uncertain times?

Dr Ceri Phelps is a registered health psychologist, chartered by the British Psychological Society, and Senior Fellow of the Higher Education Academy.  She leads the Psychology and Counselling provision at University of Wales Trinity Saint David and carries out research into the psychosocial aspects of cancer. Here, she discusses what we have learned about how best to cope during uncertain times...

As an academic who has been researching in the field of health psychology for almost twenty years, I have lead a number of research studies where the research has focused upon understanding people’s responses to health-related anxiety and uncertainty, and importantly, identifying how best to support people through such situations.  As the researcher, I was often able to explore these issues through a very human but also fairly objective lens – “What theories explain that person’s behaviour? Why is person X struggling to cope more that person Y? Why are people reluctant to seek help? How do people manage their fears – indeed – what is the “best way” of helping people manage their fears?” And how should we, as health psychologists and health researchers, offer solutions to these difficulties?  It always felt important, worthwhile, and solution-focused – research projects explored unique issues, offered practical suggestions, and were time-bound.   Psychological theories and studies clearly informed our understanding, we knew how best to measure what people were experiencing, and we (mostly) knew how to judge the “success” of an outcome.   More importantly, I always felt hugely humbled to be allowed to become part of the lifeworld of my research “participants” who so willingly shared their emotional stories with me in order to benefit others…..

So I am reflecting on this today, more than half way through the 21-day initial Covid-19 lockdown (temporarily ignoring the “good advice” I give my colleagues about having structure to your day when working from home by typing this whilst sitting in bed sipping my green tea and listening to the early morning birdsong) and am wondering:  can any of this learning be applied to what we are all now going through? To understand what I myself am going through –no longer a researcher on the periphery looking in and trying to understand other people’s experiences – but ultimately trying to understand my own experience… and what my friends are going through, and my family, and my colleagues… and even my beloved horse who I have convinced myself must be wondering what he’s done wrong as he sees so little of me these days….

I don’t have the answers.   None of us know what the future holds for us right now, and yet I can see every single one of us (including my horse) just “doing our best”, just “getting on with it” and just “trying to find the positives” in each day.  So I thought I would share some of the things I have learned through these years of research, from my own research and also of those that have inspired me - not in the hope that it provides magical solutions but perhaps because I hope it will remind us all of how we are all just trying to cope in our own ways, with our own unique fears and anxieties.  Sometimes we get it right and sometimes we get it wrong, but it’s working through each day the best we can that ultimately makes us human, and makes us “us”, in a time when perhaps all we can truly do is “be”.

How do we cope with uncertainty?

The answer is – generally badly!   As human beings we want to exist in an internal state of equilibrium or homeostasis.  We like to feel good about ourselves and we like to feel we have control over our lives.    The experience of stress, anxiety or worry happens when we are thrown off kilter – when we find ourselves feeling threatened and unsafe by events we see as outside of our control.   We don’t like feeling this way, and we want to fix it somehow.  If there is an easy solution we will try and find it, and if we can’t resolve the problem easily then we struggle psychologically and emotionally.  In health psychology, we know that we all choose to cope in different ways, and with different things, and we know that coping with ongoing stress and uncertainty is not only hard but can lead to physical health problems.   So we have a huge challenge ahead of us– how we try and “cope effectively” with this ongoing, uncertain, chronic situation that we have never seen before. 

We know, for example, that in the field of medical testing we can say that people often feel better once they know the outcome of their test result, and that the waiting period is often the most stressful.  Why? Because with knowledge comes facts, treatment or surveillance options, and actions…things that give us some sort of control back.   But how does this apply to our Covid-19 situation…I’m not sure it does!  We simply don’t have answers or certainty and the success of treatment currently is highly uncertain for various reasons.  So, we can’t solve or tackle this problem head on – does this mean we are doomed to months of anxiety and low mood? Certainly not… Because we also know that, when we can’t actively change our situation, we can become very good at managing how we feel about that situation – taking control of our emotions and our thoughts…. Not always easy, but we can certainly try… and sometimes this can be easier than we think…

What do we know about helping people cope with anxiety and uncertainty?

For those experiencing significant distress or severe mental health problems (Covid-19 related or otherwise) access to expert psychological support and counselling is key.  Even this however has become transformed in the new world of social distancing.  Luckily, we know that offering psychological support through online counselling can be effective, although it needs to be delivered by experts to avoid the many potential pitfalls. 

However, we also know that for many of us dealing with a whole range of daily worries or concerns, learning a little bit about what we mean by “coping well” can be really helpful.   We know for example that that the provision of some simple self-help tips can help people cope better with their worries and anxieties.   In my early research I was delighted to find that a simple written self-help coping leaflet (then turned into a digital story) was found to reduce distress in some women undergoing genetic risk assessment – just a simple list of possible techniques (thinking of a calm and favourite place, talking to people about positive things, writing about your worries for a short period each day, doing something you enjoy each day), and an acknowledgement that feeling anxious was a normal response – seems to help.  Surely some of these suggestions may be useful right now as we face our daily COVID-19 anxieties?

The outdoors and our health

We see more and more information telling us about the positive psychological benefits of being out in nature, of green spaces, green prescribing, social forestry, to name but a few.  How on earth (excuse the pun) does this help us in our current allocated “exercise from home” routine? Some of us of course are lucky – I for example have a wonderful view of farmland from my front window, and seeing the buzzards flying overhead moves my soul.  But what about those who cannot access such green space?  Research has shown that we can gain psychological benefit from trying to somehow capture the wonderful elements of nature and the outdoors within our home  – in a project with ladies with breast cancer we found that daily engagement with an indoor garden bowl, decorated with personally meaningful items, led to a number of positive emotions and a little sense of control – the biggest difficulty was encouraging people to give it a go – but now, with a little more time on our hands – this could be a really positive daily activity.  If this is not possible, engaging with “virtual nature” can also reduce anxiety and lead to a sense of calm in troubled times…

The importance of switching off from our worries

My final point of reflection is one that often seems most controversial – and this is the fact that we have learned through our research that, sometimes, simply avoiding reality can be a good thing! With a huge caveat….the word “sometimes”…. The stereotypical image of an ostrich with his or her head in the sand typifies the typical “avoider” and is often seen as a negative way of coping.  Certainly in relation to avoiding the behaviours that the government are expecting us to engage in this would be completely morally inappropriate.  However, it is perhaps the very fact that so many of us are trying so hard to engage in these behaviours that brings with it huge anxieties, frustrations, and low mood.   In health psychology we know that the careful selection of “avoidant strategies” can provide us with a massively important “psychological breather” that may actually help us  sustain our coping efforts during these difficult times.   This doesn’t mean I am encouraging you to completely avoid reality or to engage in maladaptive coping behaviours (yes that bottle of wine in the evening may stop you from worrying for a while, but will probably only make things worse the next day) but to think about choosing specific times each day where you choose to “actively distract” for a short while from not only your worries, but also from the news, and importantly, from the negative threads we see in social media.   Ultimately we need to be mindful to use the opportunities provided by our internet-based world wisely to make a positive rather than negative difference to our daily lives in ways that are meaningful to us.

What does all this mean right now?

And so these meanderings bring me back full swing, to the start of my PhD in 2001, and the wonderful mentoring of my supervisor, Professor of Clinical & Health Psychology, Paul Bennett.  Back then, we essentially encouraged people facing uncertainty and anxiety to try and recognise and break their own “worry habits” and to try and learn ways of being in better control of their worries, rather than their worries control them.  Is this appropriate advice in the current crisis? I would like to think it may help - a little at least – because at the end of each day right now all we can do is reflect upon how we have tried our best – behaviourally, psychologically, and emotionally – and as long as we can accept that we have tried then we should all, in my opinion, consider that a personal daily triumph.

Note to Editor

References

Bennett P., Phelps C., Hilgart J., Hood K., Brain K., & Murray A. (2012) Concerns and coping during cancer genetic risk assessment. Psycho-Oncology. 21(6), 611-617

Phelps C., Bennett P; Hood K., Brain K., & Murray A. (2013). “A self-help coping intervention can reduce anxiety and avoidant health behaviours whilst waiting for cancer genetic risk information: results of a phase III randomised trial.”, Psycho-Oncology, 22(4), 837-834

Phelps, C., Minou, M., Baker, A., Hughes, C., French, H., Hawkins, W., Leeuwenberg, A., Crabtree, R. and Hutchings, P. B. (2017).  Necessary but not sufficient? Engaging young people in the development of an avatar-based online intervention designed to provide psychosocial support to young people affected by their own or a family member's cancer diagnosis. Health Expectations, 20: 459–470. doi:10.1111/hex.12473

Phelps, C., Butler, C., Cousins, A., & Hughes, C. (2015). Sowing the seeds or failing to blossom? A feasibility study of a simple ecotherapy-based intervention in women affected by breast cancer. Ecancermedicalscience, 9, 602. http://doi.org/10.3332/ecancer.2015.602

Hughes L & Phelps C (2010).  “The bigger the network the bigger the bowl of cherries. Maybe there’s a cherry for every little problem you might come across.”:  Exploring the acceptability of, and preferences for, an ongoing support network for known BRCA 1 and BRCA 2 mutation carriers.  Journal of Genetic Counselling, 19(5), 487-90

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