by Sofia Chernoff, PsyD

As of today, there have been over 499 million confirmed cases of COVID-19 worldwide, resulting in over 6 million deaths globally (Johns Hopkins, n.d.). But even among those who have survived, up to 20% experience ongoing physical symptoms, often referred to as “long COVID” (Office for National Statistics, 2021). These symptoms can include fatigue, shortness of breath, sleep problems, and trouble concentrating. These symptoms can make it difficult for individuals to engage in important activities like work, hobbies, spending time with family and friends, and keeping up with household chores. People often develop negative beliefs about themselves and their abilities to cope with their symptoms that can make it even less likely that they will engage in previously enjoyed activities, or connect with other people. This lack of connection and purpose, coupled with pain and fatigue, and negative thoughts and beliefs can lead to the development of mental health conditions like depression, anxiety, and suicidality.

At the Anxiety and Depression Association of America (ADAA) annual conference in March 2022, I presented a workshop on addressing emotional distress due to COVID-19. It was my first time presenting at a conference in person since the start of the pandemic, and I was pleased to see that health and mental health professionals were interested in learning more about how CBT can help individuals who are struggling to cope with symptoms of long COVID. There is certainly a need for more research and dissemination of evidence-based information surrounding COVID-19, and I’m certain that we’ll be studying the pandemic and its aftermath for years to come.

During my talk, I presented the case of “Bruce,” a client I treated who suffered from symptoms of chronic post-COVID syndrome. Bruce was a 32-year old married African American man, and a father of two. Bruce contracted COVID-19 and was initially believed to be fully recovered. However, two months later, he presented at his local emergency department with severe abdominal pain, nausea, and chills. During his stay, his condition deteriorated and he was admitted to the ICU, where he received a diagnosis of necrotizing pancreatitis secondary to COVID-19 infection.

Bruce spent three months in the hospital before being discharged. Even after he returned home, he continued to experience physical symptoms including persistent fatigue, weakness, nausea, lack of appetite, and severe abdominal pain. Psychologically, he experienced flashbacks of his time in the hospital, hyperarousal and hypervigilance, low mood, and passive suicidal ideation. He also experienced significant functional impairment—he avoided activities with his family, he was unable to resume his work as a chef in a local restaurant, and he spent much of his time in his bedroom, ruminating. He described himself as “broken” and “worthless.”

My first challenge with Bruce was to establish a strong therapeutic relationship. Bruce had a distrust of medical professionals that pre-dated his COVID infection. He also had pre-existing negative beliefs about mental health treatment and mental health professionals. I validated his experiences, and made every effort to understand his unique needs, history, and culture. I expressed realistic optimism about his prognosis and maintained a warm, empathetic, and collaborative stance in all our interactions.

To motivate Bruce to do the work of therapy, I helped him identify his values and aspirations—in other words, what really mattered to him in life, and his large important desires for himself and his future. Bruce valued his family, his independence, and artistic expression. His aspirations included eating meals with his family, returning to work, and to his hobby, playing musical instruments. Given that his experience of his symptoms seemed to prevent him from living life in line with his values and pursuing his aspirations, it’s easy to see why Bruce’s mood was so low when he came to treatment.

Working from a cognitive conceptualization, Bruce and I then identified problems that were getting in the way of his goals and aspirations. I used CBT techniques and strategies to help him overcome the problems on his list. For example, to help Bruce with his pain and fatigue, I introduced relaxation training and mindfulness exercises that improved his coping in the moment. We also collaboratively designed several behavioral experiments to test the validity of his beliefs about pain and fatigue. We scheduled lots of activities that Bruce could still do, despite his pain and fatigue, in order to build his sense of mastery, and help him feel more in control. While Bruce was quite limited in his abilities due to ongoing pain and fatigue, he learned pacing skills that enabled him to meaningfully participate in activities that he valued the most. Eventually, we were able to identify and schedule new activities that Bruce could do in order to experience a sense of mastery, and feel more in control.

Bruce also experienced financial problems due to his inability to work. Together, we engaged in problem-solving strategies and a graded task assignment so that he could slowly and methodically take control of his finances without becoming overwhelmed. To help him resolve difficulties with his wife and children, I taught him interpersonal effectiveness skills. We also worked directly on his depression and anxiety using cognitive restructuring, guided discovery, and imaginal exposures.

At the conclusion of treatment, Bruce was better able to manage his pain and fatigue. He had resumed some of the activities that were important to him, like eating meals with his family, and playing music. He no longer felt “broken” or “worthless” but instead saw himself more realistically, as a human being with strengths and limitations just like everyone else. He reported that his relationship with his wife and children was steadily improving.

Many of the core CBT techniques that are often used for clients with medical conditions can be adapted and applied to clients suffering from post-COVID syndrome. If you’d like to learn more about using CBT with this population, a recording of my talk will be available on the ADAA website soon. And I also host a two-day workshop at Beck Institute on using CBT with clients with chronic pain and medical conditions.

References:

Johns Hopkins Coronavirus Resource Center. (n.d.). Retrieved April 11, 2022, from https://coronavirus.jhu.edu/

Office for National Statistics. (2021, January 21). Updated estimates of the prevalence of long covid symptoms. Updated estimates of the prevalence of long COVID symptoms – Office for National Statistics. Retrieved April 11, 2022, from https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/adhocs/12788updatedestimatesoftheprevalenceoflongcovidsymptoms