Mental Health: Don’t lose your confidence, Come out of the cave

Last I recall, I wasn’t a bear, I do not hibernate in the winter months. But as a result of a year of maintaining social distance, restricting contact with family members, friends and clients in person, I began to wonder if we do have something in common with the bears. 

Whereas bears are driven by instinct to know exactly when to hibernate and when to come out, social “hibernation” is not part of our DNA. 

Certainly, socially isolating is not the same as hibernating, but over the course of this year, people have been told about the danger of close contact with strangers and loved ones in both public arenas and in the confines of our own homes. The extended period of time that public health restrictions have been placed on our lives has created a second pandemic, a mental health crisis (“Stress in America 2020: A National Mental Health Crisis,” American Psychological Association). 

More and more Israelis are seeking mental health care for anxiety, depression, loneliness, marital issues and family problems.

In addition, there is an increase in the prevalence of a more serious expression of anxiety called agoraphobia. Agoraphobia is described as a fear of entering any place where escape may be difficult, including large open spaces or areas with crowds. People with agoraphobia may avoid using public transportation, going into open spaces like malls, or being in closed places, standing in line in a crowd, or generally being outside of the home. As a result of the fear of escape, and that something terrible will happen, these individuals avoid some or many of these places.

For people to be diagnosed with agoraphobia, the fear must last for at least six months (DSM-5 American Psychiatric Association 2013). 

Two months ago, I was talking to a client online. He told me that his wife, Lilly, in spite of the fact that she was fully vaccinated against COVID, was having difficulties leaving her home. She was unable to shut off the worry about contracting the virus if she would go out and reenter the outside world.

The core behavior of people with agoraphobia is avoiding places that take you outside of your home that can trigger overwhelming anxiety.

How would Lilly or anyone with similar behaviors realize that their anxiety symptoms have moved beyond the norm?

I met with Lilly online and, in my assessment, I asked her three important questions. 

1. Was her response in line with the potential threat of danger?

2. Are her loved ones concerned about her level of worry and avoidance?

3. Was she following Health Ministry guidelines to avoid getting or spreading COVID, such as practicing social distancing with people outside her household, wearing a mask, and handwashing, and nevertheless was she avoiding more people and situations than necessary?

In Lilly’s case, the answer to the first question was no, and to the second two yes, suggesting that her symptoms were more in line with agoraphobia, especially in light of the long-term presentation of her behavior of avoidance – that is, more than six months.

I believe there are many more people like Lilly suffering from the long-term exposure to this pandemic and all of its restrictions. They may have been predisposed to developing this anxiety condition, but the pandemic really helped to bring it out.

Help

The central goal of treatment for agoraphobia is to give people the emotional tools to get a handle on their anxiety and help them to gradually build up the confidence that they need to “leave the cave.”

Cognitive behavioral treatment is the best practice to help someone like Lilly. She needed to understand the triggers of anxiety that drove her to stay indoors and understand the internal thoughts about the situation that is creating the fear. 

One recommended treatment is called exposure therapy. The goal of this type of therapy is to desensitize conditioned anxiety by gradually exposing the person to uncomfortable situations. For Lilly, the aim would be to help her go outside and leave her home. Lilly was encouraged to go out with her husband for brief walks, wearing a mask, and then gradually increase the amount of time of these walks, and to very gradually enter more crowded environments like a park or a crowed city street.

Eventually, Lilly agreed to go shopping at a small local market, and in time was able to go to a large supermarket with her husband. 

The goal was to help Lilly break her emotional fear barriers in gradual steps. 

Agoraphobia can be a debilitating condition and may lead to severe anxiety and depression. My advice to people like Lilly is don’t get stuck in the “cave.” It’s time to come out. 

Lilly had the courage and support of her husband to do just that, and consequently she was able to enjoy a wonderful Passover.