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CBT-Informed Interventions for Essential Workers During the COVID-19 Pandemic

Abstract

Essential workers during the COVID-19 pandemic face heightened levels of anxiety and depression due to increased work demands, lack of adequate personal protective equipment, fear of contracting the virus, and fear of spreading it to loved ones. This is a time of urgent need for mental health support for workers affected by the pandemic crisis. Clinicians may employ empirically supported interventions derived from cognitive behavioral therapy (CBT) and related therapies. Psychological First Aid, an evidence-based crisis intervention, may be utilized to emphasize basic needs and support, but is intended as an acute disaster intervention. Given that a pandemic is an ongoing and prolonged stressor, additional CBT-informed interventions are likely needed to fully support essential workers during these times. It is recommended that clinicians help essential worker clients meet their basic needs by modifying health and sleep habits where possible and helping them advocate for their needs using interpersonal effectiveness skills. Empathic listening, validation of the crisis at hand, and values clarification can aid the therapeutic relationship, help them feel a renewed sense of purpose and meaning in their careers and with their families, and facilitate behavior change consistent with chosen values. Self-monitoring through a daily diary can help clients focus their thoughts and recognize maladaptive patterns in their thoughts and behaviors. In tandem with these techniques, behavioral activation and coping strategies including relaxation, distress tolerance, and acceptance promote engaging in positive and adaptive activities. Finally, therapists can help clients reduce anxiety related to the pandemic by helping them limit information intake.

Among healthcare workers on the frontline of the novel coronavirus (COVID-19), heightened depression, insomnia, anxiety, and distress are common (Lai et al. 2020). In addition, Dutheil et al. (2020) predict that posttraumatic stress disorder (PTSD) will be a downstream consequence of the stressors brought on by the pandemic. In a recent survey conducted by Shanafelt et al. (2020), frontline professionals are most commonly concerned with becoming overworked, the rapidly changing demands placed on their work roles, becoming infected and infecting others, inadequate personal protective equipment (PPE) in the workplace, lack of access to testing, and concerns about family members. Additionally, essential workers are potentially experiencing unprecedented moral injury in their professional lives, facing patients who may die despite their best efforts, superiors who may not be adequately supporting them, etc. (Greenberg et al. 2020). Several factors, some of which are specific to COVID-19 and are unprecedented in prior pandemics, may be exacerbating these difficulties, including national shortages in testing equipment, PPE, and ventilators necessary to care for critical patients (Ayanian 2020).

These concerns are similar to those faced by essential workers in past pandemic crises. Specific worries most often cited in the literature fall into three domains: concern that essential workers will become infected themselves (Gershon et al. 2010), will become or are overworked (Matsuishi et al. 2012), and will have access to too much or too little information about the pandemic (Etingen et al. 2013; Matsuishi et al. 2012; Van den Bulck and Custers 2009). When the search is broadened to include vulnerable populations in addition to essential workers, another specific worry is revealed. One study focusing on individuals with preexisting conditions which put them at additional risk during the H1N1 pandemic revealed fears that those around them were not taking adequate precautions to protect their health and safety (Stephenson 2014). This concern may be more relevant to non-healthcare-related essential workers whose occupations preclude them from strictly adhering to social distancing guidelines, and whose coworkers may not be following all appropriate safety guidelines.

The current literature identifies two main mental health concerns of essential workers during a pandemic: increased anxiety (Bai et al. 2004) as well as increased workload and demands resulting exhaustion (Matsuishi et al. 2012). These increased demands include heightened personal protective requirements, as well as lengthened and additional work shifts (Bai et al. 2004; Matsuishi et al. 2012). This change in work shifts can also lead to experiencing exhaustion and fear that one will experience increased exhaustion in the future (Matsuishi et al. 2012). Given the unique nature of the COVID-19 pandemic, there is a lack of clear guidelines for best mental health support practices for essential workers experiencing heightened distress. Experts who have served on the frontlines of past mass crises (e.g., terrorist attacks, Ebola outbreaks, etc.) have broadly recommended ensuring sufficient preparation of workers for the challenges at hand, bolstering social support, and providing referrals for professional support as needed (Greenberg et al. 2020). However, clear recommendations for how clinicians might offer support in such situations are not made.

Psychological First Aid (PFA) is an evidence-informed frontline intervention that was developed to protect against post-trauma reactions and other negative sequelae of potentially traumatic events (Ruzek et al. 2007). However, PFA was primarily designed as a response for survivors of mass trauma, including events such as natural disasters and mass shootings. Thus, it is unclear if all aspects of PFA are appropriate for individuals affected by a pandemic. Specifically, PFA is divided into eight core components, many of which focus on supportive and empathic listening, and help with more basic physical and safety needs of a disaster that has most often already passed (Gray and Litz 2005). In contrast, many of the concerns during the COVID-19 pandemic are ongoing and center on caregiver burden in hospitals, isolation, worries about contracting the virus, etc. While such approaches may be effective for individuals affected by a public health crisis such as COVID-19, there is a lack of empirical research to support its use, as well as a lack of guidance as to how it would be adapted to address the ongoing and prolonged nature of a global health crisis. Additionally, research focusing on healthcare workers and other essential employees during the current and previous pandemics indicate that these individuals are likely to face increased worry, anxiety, and depression. As such, approaches that focus on these syndromes may be more appropriate for most essential worker clients.

Furthermore, evidence from extant work in crisis intervention cautions against single session psychological debriefing approaches, such as Critical Incident Stress Debriefing (CISD; Mitchell and Everly 1995). In CISD, individuals who were exposed to a potentially traumatic event, such as police officers or emergency medical technicians, are invited to attend a 3 to 4-h group session where the event itself and reactions are reviewed. However, there is growing evidence to suggest that there is insufficient support for this approach, and further, that it may even exacerbate psychological distress (Litz et al. 2002). Thus, CISD is not recommended for use during crisis intervention.

The current state of the literature presents a different definition of “essential worker” from its current use. Indeed, the definition of “essential worker” varies throughout the literature. Several studies focusing on the mental health concerns of essential workers include only medical personnel (Matsuishi et al. 2012; Wong et al. 2012), while others widen the definition to include emergency workers such as police department workers and fire department personnel (Gershon et al. 2010). However, widespread orders to shelter-in-place enacted in the initial response to the COVID-19 pandemic (DeWine et al. 2020) and subsequent transitions to millions working from home where possible requires a broadening of the definition of “essential worker.” While definitions vary between states, some of these newly defined essential workers include individuals involved in postal delivery, food distribution, construction, and internet services (DeWine et al. 2020). While research regarding how to help essential workers is limited, information on the needs and worries of these newly defined essential workers is near nonexistent.

In sum, while the current state of the literature is able to adequately describe the needs and worries of some essential workers during a pandemic, as well as the struggles that mental health professionals may face when working with these individuals, it does very little to offer specific guidance to mental health professionals who may be referred clients for support during the pandemic. Highlighting the concerns identified by essential workers during COVID-19 and other health crises, this paper aims to offer more specific guidance and CBT-informed recommendations that mental health professionals may use to address concerns that essential employees are likely to face during the COVID-19 pandemic.

Intervention Strategies

Meeting Basic Needs

Borrowing from PFA (Ruzek et al. 2007), the first concern in an acute crisis is ensuring that basic needs are met, including safety, physical health, eating habits, sleep, etc. Clinicians may help clients problem-solve barriers to safety and physical health where possible. Primarily, clinicians may guide clients to creating a consistent eating and sleeping schedule, as these are crucial to maintaining one’s mental health (Owen and Corfe 2017). When working with essential workers during the COVID-19 pandemic, this may entail asking clients if their work schedule precludes them from eating three meals a day, hydrating properly throughout the day, attending to a regular sleep schedule, and problem-solving as needed.

Given the effects of sleep on psychological well-being, clinicians may help guide clients through proper sleep hygiene techniques. Guidelines from cognitive-behavioral therapy for insomnia (CBT-I; Geiger-Brown et al. 2015) suggest that creating a regular bedtime routine is a crucial first step to improving sleep. For frontline professionals who are working longer shifts than previously expected and sometimes working into the night, this can be understandably difficult. In such scenarios, working with clients’ specific needs will be critical in helping them create a schedule that works for them, whether this means incorporating naps where possible or creating a weekly sleep schedule that can maximize the time they have.

Additionally, limiting caffeine, alcohol, and nicotine intake before bedtime as well as eliminating alerting activities in bed, such as watching television or using a computer or phone, are helpful in regulating a healthy sleep–wake cycle and ensuring a good night’s rest (González and Aston-Jones 2006; Morin and Benca 2012). Morin and Benca (2012) suggest that this is because alcohol, caffeine, and bright lights can affect circadian rhythms that regulate sleep–wake cycles. Short naps and exercise during the day are also recommended where possible.

Finally, optimizing the sleep environment is important for proper sleep hygiene. Clients should ensure that the bed is limited to sleeping and sex, and not used for TV, work, reading, or phone activities (Barnes et al. 2017). Limiting the associations made with the bed ensures that clients are able to easily sleep at bedtime. Additionally, sleep hygiene guidelines recommend keeping the bedroom dark and at a cool, comfortable temperature to optimize sleep.

Empathic Listening and Validation

While ensuring basic needs are met, critical tools for crisis intervention drawn from basic CBT skills and PFA include warmth, empathic listening, and validation (Hara et al. 2017; Ruzek et al. 2007). Empathy and validation, defined as accurate listening and nonjudgmental acknowledgement of the experience of the client, are identified as cornerstones of CBT and a positive therapeutic relationship (Koerner and Linehan 2004). During a pandemic crisis, it is critical that therapists validate the impossibility of the reality essential workers face. The increase in work burden, fear of virus exposure, inadequate PPE, etc. are all legitimate concerns. In line with Pederson’s (2015) recommendations, clinicians should engage in active listening, accurate reflection, direct validation of the client’s concerns, validation in the context of the situation and the client’s specific history, and radical genuineness (i.e., respect for the client as a person).

It is critical to differentiate validation (engaging with the unique experience of the client) from normalization (suggesting that what the client is experiencing is similar to the experience of others). While both techniques may be useful, validation is important in ensuring the client feels heard (i.e., “I can see how debilitating this has become, and how it might be affecting your family;” Pederson 2015). Additionally, traditional cognitive restructuring techniques that focus on evaluating the reality of client fears may not be appropriate during a pandemic (Greer et al. 2010). As such, clinicians should acknowledge and validate the real risks that essential workers face, including fears that some patients within the care of frontline healthcare workers may die. Consequently, validation as a first step in intervention creates the space necessary for collaboration and future-oriented change where possible.

Values Clarification

Cognitive-behavioral approaches, and particularly more recent approaches used in Acceptance and Commitment Therapy (ACT; Hayes et al. 2006), focus on values clarification. Values and clarification of those values help clients engage in the motivation necessary to pursue activities and goals (Twohig 2012). Values differ from goals in that they are pursued throughout life rather than obtained, and additionally, provide meaning and guided purpose for the things we do. Most often, values that are identified are related to career and relationships (Fitzpatrick et al. 2016), which is in line with stressors identified by frontline professionals. When working with clients who are essential workers, this could involve having clients elaborate on why they chose their career, and refocus their goals on working in a field that can serve others and potentially save a life. Additionally, this can help clients work through stress and better engage with their own coworkers, clients, and patients (Castro et al. 2016). Values clarification can lead to behavior change, making one more likely to approach rather than avoid stimuli that cause anxiety, which in turn, serves to reduce anxiety (McCracken and Yang 2008; Fitzpatrick et al. 2016). A focus on values and flexibility increases the ability to act in accordance with one’s values and subsequently improves mental health, a process called values-based action, which can reduce depression and distress (Bramewell and Richardson 2018).

In addition to improving workplace stress, values clarification can also help workers improve motivation for action towards other values in their life, such as family. Specifically, workers during COVID-19 have cited stress related to their families and other interpersonal relationships (Shanafelt et al. 2020). For a client who identifies family and keeping family safe as primary values, clinicians may consider focusing on how a client can pursue this value, including taking the steps necessary to ensure that family members are not exposed. Taken together, by focusing on values clarification, clinicians may help increase motivation towards behavior change and values-based action. Identification and clarification of clients’ values sets the stage for concrete steps that can be taken to pursue what is meaningful to them. This may take the form of increasing interpersonal effectiveness in the workplace or at home, advocating for better work conditions, etc. Using values as a foundation for positive change can help increase a sense of agency, which can decrease distress and anxiety.

It is worthy of mention that clients may only have control over certain things in pursuit of their values during the COVID-19 pandemic. While clinicians can help their clients focus on family and career values by committing to behavior change that will lead to family safety and effectiveness in the workplace, infection during the course of work in the pandemic may ultimately be outside of the client’s control. It is important to emphasize agency in what the client can change, but to also foster a sense of acceptance for cannot be changed.

Interpersonal Effectiveness

Essential workers serving during a pandemic fulfill a necessary role that is both psychologically and physically taxing. It is necessary that they care for themselves and that those around them support them during this especially difficult time. A 2020 guide to supporting healthcare workers during the COVID-19 pandemic highlights several ways these individuals should be supported by their places of employment (Shanafelt et al. 2020). Given that healthcare workers are experts in their own experience, their requests and concerns should be taken seriously and considered valid. Workers should also be provided with appropriate physical protection given the significant concern of infection and transmission of COVID-19. Additionally, their physical needs should be met, including allotted time for breaks and food, and care should be taken not to overwork these individuals. Finally, they should be supported if they and their families must be placed under quarantine.

Considering concerns of increasing workloads and exhaustion (Matsuishi et al. 2012) and worries around taking on new roles at work (Ayanian 2020), it is necessary that essential workers’ physical needs are met. However, because of the increasing demands placed on healthcare workers and the threat of an overtaxed healthcare system, not all organizations may be caring for their workers as necessary. It may be necessary for essential workers to advocate for their own needs and rights. Advocating for one’s own needs and rights may also be helpful at home, such as if one wishes to set boundaries with family or roommates about inappropriate and unhelpful conversation topics, or about television news access. For this reason, it is recommended that therapists working with this population support their clients who wish to advocate for their needs at work or with employers, or whose work is impeding their ability to adequately care for themselves.

One way to support this endeavor is to teach clients skills to increase their confidence in advocating for themselves. By teaching individuals how to effectively make requests, clinicians may help essential workers deny a request to take on an extra shift, ask for time off, or ask for increased transparency from managers or supervisors. This can also be helpful for making requests at home, such as when asking a family member to comply with social distancing guidelines. DEAR MAN, cited as an effective skill from Dialectical Behavior Therapy (DBT; Linehan and Wilks 2015), helps clients make requests by first Describing the conflict using factual information that both parties would agree on. They should then Express their own feelings and opinions about the conflict. Next, individuals should Assert themselves by directly making a specific request. Last, they should Reinforce their request by expressing appreciation and/or explaining how the other party would benefit from complying with the request. While they are making the request, they should remain Mindful, and not allow the other party to change the topic of conversation or become sidetracked. They should Appear confident throughout. Lastly, they should be willing to Negotiate if needed.

Self-Monitoring and Behavioral Activation

Given the increase in risk for anxiety, worry, depression, and exhaustion, it is recommended that therapists help their clients monitor their own thoughts, emotions, and behaviors, and the effects these factors have on each other. Self-monitoring can help clients begin to recognize and understand patterns in their cognitions, as well as the resulting effects on their emotions and behaviors, and vice versa (Huppert 2009). The sole act of self-monitoring in and of itself can also have a positive effect on mood and behaviors (King and Boswell 2019). Clients’ self-monitoring can also serve to aid the therapist. The clients’ record of their experiences offers the therapist data about those events and feelings as they are experienced in the moment, which can help guide therapy.

Self-monitoring can take many forms depending on the clients’ needs and the therapist’s goals. Most traditionally, self-monitoring requires clients to record their thoughts, emotions, and resulting behaviors throughout the week on a sheet of paper or worksheet as they experience a heightened emotion (Huppert 2009). However, this may be tedious for essential workers who are burnt out and unable to fill out detailed forms of this nature. Therapists can ask their clients to keep a more fluid daily diary where they can record both good and bad events of the day. This document can serve as an objective measure of how the client is spending their leisure time, and how it affects their mood. It can also help the therapist and client collaboratively look for patterns that may prevent engagement in pleasant activities, so these may also be addressed and modified.

Lastly, a diary can help keep clients mindful of smaller, positive events that occur in their lives and keep them from being overshadowed by the negative. Self-monitoring in a diary format could also be used to track the effectiveness of behavioral activation. Behavioral activation involves actively scheduling pleasant and active activities, and tracking its effect on mood (Veale 2008). The therapist and client can work together to choose activities which the client will find enjoyable, but will realistically be able to implement given work and social distancing restrictions. As essential workers are increasingly overtaxed at work, and closures or restrictions of childcare facilities lead to increased responsibilities in the home, essential workers are likely to face increased exhaustion. The literature on depression suggests that individuals who are depressed often decrease or cease their involvement in pleasurable activities and activities that give the individual a sense of pride and/or mastery (Veale 2008). These activities, which could include even small pursuits such as mindfully watering one’s plants and taking notes of their growth, are rewarding and help individuals feel fulfilled. Conversely, decreased involvement in these activities exacerbates depressive symptoms.

Coping Strategies

Therapists working with essential employees can also teach their clients other specific coping strategies to manage their increased stress and anxiety during this time. These coping strategies can refer to specific skills used to help the client manage their increased stress and anxiety. Relaxation techniques are commonly implemented in CBT to help clients regulate their physiological stress reactions. These relaxation techniques can take a variety of forms, including guided imagery, breathing exercises, progressive muscle relaxation, and mindfulness exercises. These techniques help clients recognize signs of stress in their body, and relax in order to alleviate the stress response. They also help clients remember to slow down and become more thoughtful and intentional in how they respond to stress, which can help them implement other skills taught therapy (Dugas et al. 2010). These techniques can help essential workers recognize the physiological signs of stress, such as increased heart rate or muscle tension, so that they can respond to it effectively. This can also help these individuals respond to physiological signs of stress nonjudgmentally, as to not exacerbate their stress response.

In times of acute distress, distress tolerance skills can help individuals endure strong emotions and urges and ultimately move past these stressors without further aggravating the situation. Some distress tolerance techniques focus on reducing physiological stress, such as aerobic exercise, which has been shown to reduce anxiety (Jayakody et al. 2014). Additionally, immersing one’s face in cold water reduces physiological stress by activating the parasympathetic nervous system (Kinoshita et al. 2006). While distraction is typically not recommended in moments of anxiety given that it can lead to avoidance, distraction techniques have proven useful in moments of extreme acute distress and/or when other pressing matters must be attended to first (Thwaites and Freeston 2005), such as frontline healthcare workers treating ill patients. Lastly, some essential workers may find it beneficial to find meaning in their difficult situation by reframing (Vernooii-Dassen et al. 2011). For example, a nurse or doctor who worries about becoming infected may find solace in the idea that their work can contribute to the growing base of knowledge about the treatment of patients with COVID-19.

Another coping approach involves teaching acceptance of things that cannot be changed. Through acceptance, clients are encouraged to acknowledge their own limitations and focus on factors over which they do have control, rather than continuing to resist and struggle. As such, they are also taught to recognize that their distressing thoughts are harmless (Smout 2012). One technique used in ACT, cognitive defusion, is used to do just this. Approaches to cognitive defusion include repeating distressing thoughts out loud until they lose their meaning, or attributing different characteristics to it, such as size, shape, and color (Hayes et al. 2006). Acceptance techniques focused on accepting and dismissing distressing thoughts may be helpful to implement with essential workers who are distressed about becoming infected themselves, passing infection on to loved ones, or about their limited capacity to help others during the pandemic.

Given the social distancing restrictions necessary to slow the spread of COVID-19, many individuals may be feeling isolated and lonely (Stephenson 2020). Even essential workers who may still be in contact with coworkers, clients, and patients likely have decreased contact with significant others in their lives, including friends and family members. This decreased contact and loneliness may exacerbate feelings of anxiety and depression. Conversely, increased social support may be protective against anxiety and depression (Zhou et al. 2013). Additionally, talking to others may have served as a coping strategy for stress in the past, and now they may think reaching out to friends and family is no longer an option, or that doing so over the phone or teleconferencing services may not be as effective. As such, it may benefit essential workers to reach out to friends and family members with whom they may have lost contact. Therapists can work with their clients to plan for reaching out to others, including choosing appropriate and safe ways to do so, when to reach out to others, and who it would be helpful to contact. This strategy can be incorporated into behavioral activation “homework” assignments in the context of therapeutic intervention.

Additionally, “coping cards,” or index cards on which salient lessons are recorded, can facilitate memory of and use of coping skills in everyday life. While in session, therapists can work with clients to write powerful self-statements and effective coping strategies down on cards. Access to reminders of lessons gleaned in-session can help clients remember to implement these skills (Wang et al. 2016). Essential workers may find it helpful to keep coping cards with soothing self-statements on them when going to work, and/or to place coping cards reminding them to practice relaxation techniques in a location where they will be visible when they return home from work.

Lastly, clients and therapists should collaborate when reviewing coping strategies and implement functional analysis strategies. The therapist can ask clients what skills they have used in the past, and whether or not they have been effective. After teaching and implementing new skills, the therapist and client can work together to review whether the skill was effective. If it was not effective, they should review factors that made implementation of the skill difficult and troubleshoot ways to improve implementation. Therapists can also ask clients for ideas about coping skills they can practice. Through working together collaboratively, the therapist can get an accurate sense of what skills would best benefit their client, and how to optimize their implementation. Additionally, working collaboratively can improve rapport between therapist and client, and helps the client learn how to analyze patterns in their own behavior and emotions (King and Bowsell 2019).

Limiting Intake of Information

Finally, prior research conducted during and following pandemics has highlighted the detrimental effects of exposure to too much information about the health crisis, as well as the negative effects of limited access to information. Among hospitals during the H1N1 pandemic, staff who were provided with more information about the crisis, details about how the infection spreads, and guidance regarding how employees should protect themselves felt more protected and less anxious relative to staff who worked at hospitals that offered limited information about the pandemic, and were less transparent about reasons for frequent hospital policy changes (Matsuishi et al. 2012). Specifically, staff employed at under-informed hospitals reported worrying that they did not know how to protect themselves, how to prevent transmission, and that they were unclear about their hospitals’ expectations of them.

On the other hand, unfettered access to negative news stories and alarming headlines can also have negative effects on one’s mental health. Sensationalized news stories can spread misinformation or misleading messages (Wang et al. 2019). This can lead to disproportionate increases in anxiety or worry. Additionally, given that many individuals receive news updates through push notifications on smartphones or social media, sensationalized news stories can present themselves at any and all times throughout the day. This can give the illusion of a never-ending barrage of negative information.

The amount of time spent consuming this information may be related to negative effects. Results of one study conducted during the avian flu outbreak showed a positive correlation between television viewing and worry related to the virus, even when controlling for age and education level (Van den Bulck Custers 2009). This effect may apply to information transmitted between family members or peers, in addition to information gleaned from television news or other media sources. In families during the H1N1 pandemic, children’s worry about the virus is related to their parents’ expression of fear, after controlling for preexisting anxiety and worry (Remmerswaal and Muris 2011). While access to too little information can lead essential workers and other at-risk individuals to fear that they are not able to protect themselves and their loved ones, exposure to too much information from a variety of sources can also lead to excess worry.

Given the negative effects of too much or too little access to news and information, prior research conducted during pandemics shows that there is a “just right” level of information access. This “just right” level of access and intake related to the pandemic leads to individuals appropriately engage with safety behaviors, such as receiving a vaccine when it becomes available, social distancing, wearing a face mask, and staying home when experiencing symptoms (Etingen et al. 2013). For this reason, it is recommended that individuals, especially essential workers who are at increased risk of infection and transmission, responsibly limit their access to information about the pandemic. Individuals may prefer to limit intake to information related to prevention and treatment (Wong and Sam 2011). Additionally, they may wish to limit their intake to trusted sources, such as their own healthcare providers. Alternatively, they may wish to call one of the many COVID-19 information hotlines, or visit websites created by state and federal health departments and the Center for Disease Control.

Clients may also find it helpful to set specific time limits media intake. For example, clients may want to limit watching television news and/or checking news applications on their phones to between the hours of 2 and 4 PM each day. This could limit the perception of a constant stream of negative news and clear the client’s mind to focus on other tasks, or to recognize positive events and news without this information being occluded by new negative information. Another more extreme example could be to appoint a specific, trusted individual as their “news source.” This individual could be in charge of updating the client at regular intervals, such as once a day or every other day, with only important updates related to disease transmission and protection. They may also wish to balance these updates with positive news. Lastly, clients may also want to talk to coworkers and housemates about setting reasonable boundaries about conversation topics related to the pandemic in order to avoid rumination.

Conclusion

Essential workers face difficult and unprecedented challenges during the COVID-19 pandemic. In a time when essential employees are working with inadequate PPE, worried about contracting the virus and spreading it to loved ones, and exhausted from extra shifts at work, these frontline personnel are at risk for increased anxiety, worry, depression, and possibly PTSD (Ayanian 2020; Lai et al. 2020; Dutheil et al. 2020). Currently, there are few resources available for ongoing crisis intervention for global health crises such as COVID-19. Critical Incident Stress Debriefing (CISD; Mitchell and Everly 1995) is not recommended for acute crisis intervention due to limited empirical support and possibly iatrogenic effects (Litz et al. 2002). Psychological First Aid (PFA; Ruzek et al. 2007), one of the few evidence-informed crisis interventions available, emphasizes management of basic safety needs, empathic listening, increasing social support, and providing mental health support and referrals as needed.

Preliminary support for CBT interventions for crisis intervention suggests that basic CBT skills may be effective in treating the anxiety and depression that may result from a health crisis when paired with PFA principles. Clinicians should first focus on meeting the client’s basic needs, including safety (Ruzek et al. 2007), eating (Owen and Corfe 2017), and sleeping modifications where possible (Geiger-Brown et al. 2015), while incorporating warmth, empathic listening, and validation (Hara et al. 2017). Additionally, a focus on values clarification (Twohig 2012) may help essential workers feel a renewed sense of purpose and meaning in their careers and with their families during an especially trying time. Values clarification can provide the motivation necessary for behavior change, including strategies that can improve mood and agency, such as behavioral activation (Veale 2008) and interpersonal effectiveness (Linehan and Wilks 2015). Given that some stressors and potential negative outcomes as a result of the pandemic may be outside of the clients’ control, therapists may also work with clients to build distress tolerance and acceptance. In this vein, mindfulness and relaxation strategies may be especially helpful. Finally, limiting intake of information from news and social media outlets will be beneficial for essential worker mental health (Etingen et al. 2013).

The COVID-19 pandemic brings with it unprecedented challenges and tribulations for essential workers who are on the frontlines of virus exposure. It is critical that mental health professionals step forward during this time to support workers who are facing psychological distress due to the pressures of their jobs. This review touches on several evidence-based interventions that may be helpful for clinicians who are serving frontline workers during this time and future health crises. With the help of evidence-based acute crisis intervention, mental health providers stand at the frontline of supporting the psychological wellbeing of those who support us.

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Benhamou, K., Piedra, A. CBT-Informed Interventions for Essential Workers During the COVID-19 Pandemic. J Contemp Psychother 50, 275–283 (2020). https://doi.org/10.1007/s10879-020-09467-3

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Keywords

  • Cognitive-behavioral interventions
  • CBT
  • Crisis intervention
  • Pandemic
  • COVID-19
  • Frontline professionals
  • Essential workers