1. Introduction
The World Health Organization (WHO, 2020) on 30 January, 2020 declared COVID-19 as a Public Health Emergency of International Concern (PHEIC) because it has brought about many impacts. Enforced social isolation in the context of a pandemic has brought about negative experiences to people during the quarantine. For example, Courtin & Knapp (2017) found that perceived social isolation and loneliness lead to a wide range of psychological symptoms, including depression and anxiety, and impact negatively on quality of life. Aylaz et al. (2012) discovered that loneliness is a potent risk factor for depression and cognitive disorders,
International Journal of Social Science Research (IJSSR) eISSN: 2710-6276 | Vol. 4 No. 2 [June 2022]
Journal website: http://myjms.mohe.gov.my/index.php/ijssr
PSYCHOLOGICAL INTERVENTION FOR CLIENT SUFFERING MENTAL HEALTH PROBLEMS BY COVID-19
WITNESS: A CASE REPORT
Nguyen Phuong Lan1*, Pham Thi Tham2 and Huynh Cong Du3
12 Faculty of Tourism and Culinary Arts, Ho Chi Minh City University of Food Industry (HUFI), VIETNAM
3 Department of Psychology, University of Labour and Social Affairs (ULSA2), Ho Chi Minh City, VIETNAM
*Corresponding author: [email protected]
Article Information:
Article history:
Received date : 9 June 2022 Revised date : 17 June 2022 Accepted date : 20 June 2022 Published date : 30 June 2022
To cite this document:
Nguyen, P. L., Pham, T. T., & Huynh, C. D. (2022). PSYCHOLOGICAL INTERVENTION FOR CLIENT SUFFERING MENTAL HEALTH PROBLEMS BY COVID-19 WITNESS: A CASE REPORT.
International Journal of Social Science Research, 4(2), 230-239.
Abstract: Since the declaration of World Health Organization (WHO) on 30 January 2020 that COVID- 19 as a Public Health Emergency of International Concern (PHEIC), this pandemic does not really end so far. There is an urgent need to offer psychological intervention for client suffering mental health problems due to COVID-19. This paper treated the client using Cognitive Behavioural Therapy (CBT) in combination with Mindfulness based-intervention (MBI). The result showed that intervention was experientially positive.
This report describes a case of a client who experienced mental health problems of depression, anxiety and stress brought about by the Covid-19 witness. The client received 4 sessions of psychological intervention using CBT and MBI. DAS-21 scale was conducted to measure the mentioned symptoms.
Keywords: mental health problems, CBT, MBI.
Cognitive behavioral therapy (CBT) holds that one’s emotional experience is dictated by one’s interpretation of the events and circumstances surrounding that experience (Hofmann et al., 2013). CBT is a psychotherapeutic treatment that helps people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior and emotions (Beck et al., 2005; Hofmann et al., 2012). CBT is the first treatment option for treating anxiety disorders and has been considered very effective in this regard (Ghahramanlou, 2003; Hofmann & Smits, 2008). Using the CBT, several empirical studies conducted to answer the question if it has effectiveness on problems related to stress, depression and anxiety.
Interestingly, Toneatto and Calderwood (2015); Watkins et al. (2011) revealed that CBT can be effective in reducing depression and anxiety. A recent experimental study conducted by Ghorban et al. (2019) found that CBT could reduce depression, anxiety, and stress.
CBT and COVID-19 pandemic: the current global pandemic and subsequent forced quarantines and physical lockdowns have dominated every aspect of people’s lives worldwide. The pandemic measures have dramatically increased anxiety and fear related to contracting the virus, acquiring required medical supplies, receiving timely medical assistance, and accessing basic necessities and food items. Social, economic, educational, and recreational opportunities were abruptly ceased by governments during the pandemic, which further exacerbated perceived threats to safety and security (Benhamou & Piedra, 2020); Tyrer, 2020; Kini et al.;
2020). These limitations brought about negative experiences of social isolation, impairment of basic needs, and fears of the virus, new cases of anxiety and depression have been on the rise, and CBT can be useful in managing any of mentioned mental problems because it offers highly flexible techniques under conditions of social isolation and virtual health care delivery.
Recently, there has been a good amount of interest in mental health benefits of mindfulness (Brown and Ryan, 2003). Mindfulness, which involves bringing a certain quality of attention to moment by moment experience (Kabat-Zinn, 1990), is the heart of Buddhist meditation practice and psychology (Germer and Fulton, 2005). Mindfulness practice brings about many psychological and mental health benefits. For instance, mindfulness enables its practitioners to develop a stronger observing self and thus becomes less identified with the contents of consciousness (Segal, Williams & Teasdale, 2002). Mindfulness also allows us to stay present to the other person without being caught up in destructive emotions (Doherty, 1997). Moreover, mindfulness allows covert desensitization to unpleasant thoughts and negative feelings that make one suffer from himself (Breslin 2002).
Mindfulness has both a mental and a physical component and emphasizes a mind-body connection. In addition to its spiritual associations, mindfulness can be a worthwhile practice for those who wish to reduce depression, manage pain, or cultivate personal awareness.
Interventions based on training in mindfulness skills are becoming increasingly popular.
Mindfulness involves intentionally bringing one’s attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises (Baer, 2003). Mindfulness also involves paying attention in a particular way on purpose, in the present moment and non-judgmentally. Its practice is based on the premise that only in the experience of the present moment can one accurately perceive what is really happening, when life is fully appreciated without the need to judge it, and when effective
Brown and Ryan (2004) argued that acceptance of what is taking place in the present moment is very important because it facilitates the process of developing mindfulness. Its practice in daily life will free people from their self-judgment, negative thoughts and bring care and kindness to themselves physically, mentally, emotionally, relationally, and spiritually (Germer, 2009).
The purpose of this paper is to present effectiveness of psychological intervention combining CBT and MBI for the client suffering mental health problems by covid-19 witness.
2. Case Presentation Personal information
Ms. Mai is a 50-year-old married woman who has been living with her husband and her parents but her father died six years ago. Her religion is Buddhism. She looked for a psychotherapist by herself with a 6-month history of insomnia after a few months taking sleep pills, the symptoms of which were so bad that did not dare to go out.
History of presenting complaint
Mai describes a 6-month history of insomnia, which began one month after she witnessed her neighbour diagnosed with Covid-19 died. She experiences apprehensiveness when out of her home, initial insomnia and irritability, and she has withdrawn socially because she thinks that she is infected with Covid-19. She is not unable to do ordinary activities and has difficulty concentrating on her work. In her 6 recent months, upon listening to the siren of an ambulance or reading the news via medias/ social network such as Radio, Facebook, Tivi about illness or death related to Covid-19 pandemic, the client has shivering and is accompanied by sweating, which makes her difficult to sleep and sometimes she is sleepless throughout the night. The client is angry that she can't sleep. The more he tries to sleep, and the harder it is to sleep. When thinking about illness or death, the client feels short of breath and suspects that he or she is positive with Covid-19 and all family members must avoid or wear a mask to prevent infection, and thus also do not go out to avoid spreading disease to others. She has become a self-care giver at home, ruminating that “I am scarring in the hospital and dying slowly like my father”.
She began drinking more orange juice and taking bath more often in an effort “to stay away from Covid-19 and to be able to sleep”, she says.
History of past illness
Mai has a 6-month history of insomnia. Initially, she reported a disturbance in her sleep after witnessing her neighbour diagnosed with Covid-19 died, saying that she was seeing this death like her father who died of virus infection six years ago after having been confined for months to the hospital. This event has made her hard to sleep, which was followed by a succession of days of sleeplessness. Mai described this sleep disorder as the most horrible she had ever had.
She talked to her doctor regarding her sleep problems and was given sleeping pills. The medication did not help and Mai was becoming more worried about it. She sought a psychotherapist.
History of family
Mai belongs to the middle class, is married and has 2 children. She is currently quite satisfied with her incomes as well as her family life. The client's small family is living with her elderly mother whose husband passed away 6 years ago. Mai is a caring wife and a filial daughter. She loves cooking for her whole family and diet.
According to Mai, her father was a very loving person, but a serious illness, which she said was caused by a brain infection or some virus she did not remember, took his father’ life away forever. While her father was in the hospital, she took care of him for a long time (6 months);
she heard the ambulance every day and saw many patients who shared the same fate as her father. After the client's father died a few days, she was hospitalized because of exhaustion and took one month of treatment to recover.
Case summary and diagnosis
Given that Mai’s father died 6 years ago of virus-related causes and her recent witness of neighbour’s death of Covid-19 pandemic, she is afraid of being infected and spreading disease to others, leading her to self-isolation and sleep difficulty. There is a high probability that her irrational belief about the Covid-19 virus and that her sleeplessness is related to depression, anxiety and stress causes. This summary stated may serve as a source of evidence for a diagnosis below.
A set of non-official and standardized tools was administered to the client to find out possible problems:
Tool 1: Symptoms of COVID-19. According to CDC (2021), people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.
Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. This list of symptoms was administered to the client as a non-official measure to find out evidence of the client's irrational belief.
Tool 2: Depression Anxiety Stress Scales – Short Form (DASS-21). The DASS-21 is a self- report scale designed to measure the negative factors of emotional states of depression, anxiety and stress, which is suitable for clinical settings to assist in diagnosis and outcome monitoring, as well as non-clinical settings as a mental health screener. Each of the three DASS-21 scales contains 7 items.
The results revealed that Ms. Mai had no COVID-19 related symptoms based on the non- official tool. However, on the DASS-21 scale, her score on Depression is 8; Anxiety 15, and Stress 13, which confirms that the client has no signs of depression and stress, but only anxiety disorder at a high level.
Case Formulation and Intervention
To facilitate the client with an effective invention, five Ps Framework model in counselling are utilized. The model developed by Macneil et al. (2012) as a pathway to look at clients and their problems systematically and holistically taking into consideration 5 factors: presenting problems, predisposing factors, precipitating factors, perpetuating factors, and protective factors.
Presenting problems: In her first call for counselling, Mai shares concerns that he is not able to sleep since her witnessed her neighbour diagnosed with Covid-19 died, and that she is afraid of being infected by Covid-19 and spreading the disease to others. She further revealed that upon listening to the siren of an ambulance or reading the news about illness or death, she shivers and is accompanied by sweating. That night it will be difficult to sleep and sometimes sleepless throughout the night.
Predisposing factors: Mai reports that her father died due to a serious illness caused by a brain infection or some virus and that she looks after him for about six months in the hospital in which she heard the ambulance every day and witnessed her father’s death as well as many.
After the client's father died a few days, she was hospitalized because of exhaustion and took one month of treatment to recover.
Precipitating factors: Mai reluctantly hears the siren sound of an ambulance and she also reads the news via Medias/ social networks such as Radio, Facebook, and Television about illness or death related to Covid-19 pandemic. This makes her so anxious about her health that she is not able to sleep, hence angry
Perpetuating factors: The client is angry why she can't sleep, the more he tries to sleep, and the harder it is to sleep. When thinking about illness or death, the client feels short of breath and suspects that he or she has Covid-19 and all family members must avoid or wear a mask to prevent infection, and thus also do not go out to avoid spreading disease to others. She has become a self-care giver at home, ruminating that “I am a scarring of hospital and dying slowly like my father”.
Protective factors: The client follows Buddhism and is interested in cooking family meals;
hence she likes to cook and takes her family. She is loved by her husband in the same way, she loves husbands and parents.
3. Intervention
The assessment results indicate that the client experiences anxiety at high level which can be considered as autonomic arousal, situational anxiety, and subjective experience of anxious affect (Lovibond, S.H. & Lovibond, P.F., 1995). It is possible to intervene here by simply normalizing and validating the client’s anxiety about being Covid-19 infected, in which logical analysis using gentle Socratic dialogue, a technique in CBT to help the client challenge her emotional reactions to her father’s death related to virus and her recent witness of her neighbour’s Covid-19 related death (Etoom & Ratnapalan, 2014).
Thought record is a technique in CBT used for exploring, examining, and ‘reality-testing’
automatic thoughts (Beck at al., 1979), in which, the Daily Record of Dysfunctional Thoughts prompts patients to generate a ‘rational response’ to negative automatic thoughts. The columnar thought record format was developed and divided into two additional columns to their design to encourage the expression and examination of evidence for and against the negative automatic thought (Padesky and Greenberger, 2015).
In addition, mindfulness strategies can assist in helping the client Ms Mai cognitively diffuse from present to future events (Harris, 2019).
To help Mai deal with her problems and return to a normal life, the two major therapies of Cognitive Behavioural Therapy (CBT) and Mindfulness-Based Intervention below are utilized for her anxiety disorders. The intervention consists of 4 sessions as below:
Cognitive behavioural therapy (CBT). This is the most widely used therapy for anxiety disorders. CBT addresses negative patterns and distortions in the way we see the world and ourselves. CBT is one of the most effective treatments for anxiety and depression, and has been shown to be helpful for many people, including children, adolescents, adults, and older adults.
In this case the following techniques used:
Session 1: Cognitive activation
Cognition activation is to help Mai evaluate if her anxiety has an evidence basis or not. Based on the test results with the explanation of the therapist, the client agrees and realizes that her anxieties are related to negative beliefs about his father's death, and also to the context of the ongoing epidemic and that her anxiety about getting Covid-19 infected are not supported by any evidence.
Session2: Behavioural activation Behavioural activation
Behavioural activation techniques were also utilized. This technique is based on the theory that, as individuals become anxious or depressed, they tend to become increasingly withdrawn and withdrawn, which may perpetuate or worsen their symptoms. Therefore, treatment in this case will create a healthy environment that encourages client participation to help her reduce avoidance and isolation while improving mood. When the client feels better, there will be positive thoughts.
Schedule of activities:
Because work-related activities and outside exercise are limited in the context of the covid-19 epidemic, clients are encouraged to participate in activities at home such as cooking, cleaning the house, and watering the plants in the garden. The schedule of activities is reflected in the commitment to act during therapy. A commitment to action is intended to help the client become aware and in control of her thoughts. After one week of engaging in those activities mentioned, the clients reported that that her sleep was getting longer and she agreed with the
Mindfulness based-intervention (MBI). This is a meditation technique known as 'mindfulness meditation'. This meditation helps the client focus on the present moment, simply paying attention to whatever they are experiencing, whether pleasant or unpleasant, without trying to change it. At first, this approach was used to focus on physical sensations (such as breathing), but later it was used to focus on feelings and thoughts. MBI helps clients stop thinking about the future or the past, or try to avoid unpleasant thoughts and feelings. The client in this current report was ask to practice the mindfulness in connection to activities below:
Session 3: Body mindfulness activities
The body scan practice is to help Ms Mai stay focused on the different parts of the body and anchor her awareness in the present moment; and to stop “running away from herself” but being mindful about what is happening to her body. The technique taught for the client is how to inhale and exhale for relaxation while noticing to one tense part of the body and softening it using relaxing breaths. Outside this session, the client was asked to practice breathing using the above body scan technique in all situations: do anything that she can to comfort the body when she feels discomfort. For example: Watch funny movies; eat nourishing food but eat slowly and taste deeply to feel its deliciousness; Drink warm water and take a warm bath to warm the body.
After one week of practice, the client reported that she already stopped listening to or watching TV channels about Covid-19 news but she started watching comedian movies or music. She also tried to comfort her body by massaging the tense part of her body when noticed.
Session 4: Mental mindfulness activities
Mantra technique known as a tool for the mind when unpleasant feelings arise such as depression, anxiety and stress. In this session, the client was provided with relaxing breath technique, the most common anchor for the mind while trying to be able to acquire common mantra techniques such as repeating one nice word/phrase that is applicable to them in their current situation.
Since the client is a follower of Buddhism religion, she is asked to choose a word or phrase from Buddhist scriptures or in life that is meaningful to her, then inhaling and exhaling with those words to experience the value of the present moment and living in the present moment.
After one week of practicing these activities, the clients shared her experience that when she breathed with these words, she felt very strong, happy and comfortable.
4. Discussion and Conclusion
COVID-19 has caused a lot of challenges to people. Among which, mental problems such as depression, stress and anxiety have been named. Mental practitioners such as psychologists, counsellors, social workers have tried their best to address to the problems using variety of psychological intervention approaches
The current case report made use the combination of cognitive behavioural therapy (CBT), and mindfulness based-intervention (MBI) because literature has revealed that CBT has proved its effectiveness in reducing anxiety disorders, stress, depression and anxiety while MBI has helped clients accept whatever happening in the present moment. CBT and MBI were
to sleep. Since supporting clients during Covid-19 outbreak was very urgent and limited, the psychological intervention using CBT and MBI in the present case report was a good choice because the treatment had only four sessions in which CBT activities assigned to the clients were workable and mindfulness exercises were easy to practice. Although the treatment was done online with a few sessions, the client was able to identify her negative thoughts as a source of anxiety and was able to sleep better.
A combination of CBT and MBI in the current seems to be functioning well: CBT through cognitive activation techniques was able to help the client recognized her source of anxiety and irrational beliefs and behaviour activation could help the client stay connected physical daily activities as one of tools to release negative feelings and forgot sad events that has prevented her from quality life enjoyment. These findings are consistent with the previous studies proving that CBT has been shown to be effective for a wide variety of mental health disorders and has also been associated with improvements in quality of life in anxiety patients. Mmindfulness- based intervention through body mindfulness activities using body scan technique and mental mindfulness activities using mantra technique has helped the client to stop “running away from herself” but stay in awareness of the present moment; and be strong and happy in all situation.
This finding is interesting because according to a well- known mindfulness practitioner Thich Nhat Hanh (2005), when we are aware of what is going on in our bodies, our feelings, our minds and the world, we can avoid doing harm. Mindfulness protects us, our families, and our society. When we are mindful, we can see that by refraining from doing one thing, we can prevent another thing from happening. We arrive at our own unique insight. It is not something imposed on us by an outside authority. Practicing mindfulness training, therefore, helps us be calmer and more concentrated, and brings more insight and enlightenment." For this reason, it is important to implement mindfulness interventions in people who experience mental health problems of depression, stress and anxiety as the consequences of unexpected situations. It is possible to say that the decrease of anxiety of the client in this case report comes from practice of mindfulness including attention regulation, body awareness and sustained attention to physical sensations, mental mindfulness through acceptance without judgment, emotional regulation through exposure, extinction of automatic responses and reconsolidation, and changes in self-perspective that involve a greater disregard for a rigid image of the self (Hölzel et al., 2011).
Based on the abovementioned findings, the following suggestions came up:
Since the CBT-MBI intervention in this current case report was able to help the client reduce anxiety and have a better sleep. Therefore, it is strongly recommended that in any urgent need of psychological support, mental health practitioners can combine different intervention approaches with their particular and practical techniques to address directly to the problems faced by the clients. In the current case report, the cognition activation and behavior techniques of CBT were coupled with body scan and mantra techniques of MBI to facilitate the client witnessing Covid-19 pandemic. Perhaps, mental health practitioners such as can guidance counselors, psychotherapists, social workers be encouraged to implement the current intervention program in consideration to include other techniques of the CBT and MBI.
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