We are all facing a situation we have never faced before. As providers of psychological support for anxiety and low mood, we know only too well how much strain this pandemic will put onto people trying to adapt to these uncertain, unpredictable and largely uncontrollable times.Therapists and Practitioners are in the same stressful situation as everyone else. Facing social isolation, distancing from those we care about and adapting the way we work, parent and live our lives in a very short period of time to this novel situation. We too may be scared about access to enough resources for our families, our income and worried about the people we love and care about getting unwell. On top, many will be adapting to working from home and supporting the increasing access need for psychological support we will see at this time. This may also be at a very uncertain time for self employed therapists. So we are likely to be seeing more people under stress, at a time of great stress for us too.
We recieved lots of requests for worksheets from our anxiety and depression CBT series booklets to help people coming forward to services as a result of stress and worry about the COVID-19 outbreak. We wanted to do something more specific to help people and to help our fantastic therapists and practitioners have a resource they can use at this time. So we have created a guide to managing stress and anxiety during the virus outbreak that is available on our website home page as a PDF or can be clicked to read as a flip book online. It brings together a range of evidence based techniques from across our workbooks people can put into action straightaway to help to reduce stress, bolster mood and keep the immune system fighting fit.
We also wanted to talk more about stress. Stress is something we all feel at times, due to work, things in our personal lives or our wider environment, such as this outbreak. Stress is often not discussed in great detail within CBT books and training however, as it does not currently fit under the categories of a single disorder. People often use the word stress to subjectively describe feeling a range of differing emotion responses within the body like anxiety and depression. We all have a stress response system in our body. Let's go a bit deeper about how we experience a stress response to a situation we face, what happens, the impact it can have and what can be done to help. We were also asked if breathing can help manage stress and why it isn't routinely used in practice in IAPT and CBT for anxiety, so let's look at that too.
Stress and the body:
Our nervous system is divided into the Central Nervous System (CNS), the brain and the spine and the Peripheral Nervous System (PNS). The PNS is made up of the Autonomic Nervous System (ANS) and the Enteric Nervous System (ENS) which is in our gut and sometimes called the 'little brain'. They are constant communication with each other through chemicals like hormones and neurotransmitters, sending information back and forth about how the body is functioning and what is happening. Our ANS is a control system. It acts mainly unconsciously and regulates our body functions like heart rate, digestion, respiratory rate, pupillary response, urination, and sexual arousal. Our breathing is the only function of the ANS we have conscious control over. It has two parallel sets of nerve systems that have to work together in balance. The parasympathetic (rest and digest) and sympathetic (arousal response) systems. Both directly communicate with and affect the functioning of the central and enteric nervous systems. Usually these two systems are in balance.
The parasympathetic nervous system helps us rest and digest. It’s responsible for managing lots of body processes that help us feel calm and at ease. This system is active when our brain tells us that everything’s going well, no emergencies need attending to, and we can devote our time and attention to eating, digesting, sleeping, and generally hanging around and feeling relaxed. The sympathetic nervous system helps us to take action when we need to because of some kind of stressor, threat or danger. Our body responds with the adrenalin response releasing the hormone cortisol, this is often called the fight, flight or freeze response (or if you have done our training, you will know it as the fight, flight, freeze, flop, faint or friend response, to be more precise!). This system is active when our brain tells us that there is something that has to be dealt with like stress or a threat of some kind. Each of the responses is chosen by the body and implemented by the ANS, the process taking 1,3000 of a second to launch, according to the threat or danger in the situation and the proximity of it.
The immune system and stress:
Stress in short bursts can be helpful and motivating. When we face a longer term situation the stress response can be less helpful. Stress in a situation that is ongoing, uncertain, unpredictable and outside of our control such as this, can mean stress adds to the situation making us feel worse, not better. It is understandable why we experience the arousal response in a situation like now. It is our body's way of trying to get us to get out of the situation, if we can. When the threat remains or is in the future, we can't fight or flight to run away from it. So, we get caught in a cycle of sympathetic arousal, with stress, worry, tension and secondary physical symptoms like gut upsets, headaches, aches and pains and so on. Long term stressors suppresses the immune system from working optimally. The immune system is a collection of white blood cells called lymphocytes and phagocytes, that travel through the bloodstream. They move in and out of our tissues to defend the body from antigens such as bacteria, viruses and cancerous cells.
When we are under stress, it reduces the immune systems ability to fight off antigens because it reduces our white cell numbers. This leads us to being more susceptible to infections. Short term suppression of the immune system is not dangerous. But we all want our immune systems working optimally right now. There are things we can do to reduce stress that will boost our immune system.
Reducing stress and keeping the immune system fighting fit:
Activities that switch on the rest and digest parasympathetic system are important to manage stress, reduce tension and worry and bring the ANS back into balance. These include Progressive Muscle Relaxation (PGMR), Worry time periods and refocusing attention on a task, the APPLE technique to manage uncertainty and refocus on a task, mindfulness, relaxation and of course, getting a good night's sleep and keeping in a routine, all of which will help. Our guide to managing stress and worry helps to use all these techniques and points people to reputable resources and links for more support.
Breathing, stress and anxiety
So, let's just quickly think about breathing and answer the question we were asked. Many people often say it is confusing why many older, but still in use resources contain breathing techniques, but they are not taught or recommended on accredited CBT courses or listed in the competence framework of evidence based CBT as an effective tool for the management of anxiety and depression. There are also lots of things floating around social media about breathing right now. So can they help and if so, when?
We have 2 different types of breathing. Take a deep breath now. What do you notice? Most people when asked to take a deep breath raise their shoulders upwards and their chest expands. This is chest breathing. Remember, breathing is controlled by our autonomic nervous system. Our body controls it, we do not need to think about it and it keeps us alive by doing it for us, even when we sleep. Breathing is the only part of the ANS under our conscious control though. When we are asleep, we don't chest breathe. We deep breathe. Most of the time we deep breathe when we are not consciously paying attention to the breath. Deep breathing can reduce stress, there is a good evidence base that supports it. Chest breathing however, switches on the arousal response! not what you want to relax. Equally, when you ask people to focus on their breathing and breathe deeply, people take a sharp inhale of breath and chest breathe instead. When we feel anxious and breathing increases to take in more oxygen, people focus on their breathing and often breathe more shallowly and faster, which then works against the body trying to take in more oxygen. It can lead to hyperventilation and induce panic.
When people have an anxiety disorder with heightened autonomic arousal, focusing on breathing can also become a safety seeking behaviour that backfires 'I must slow down my breathing and focus on it to stop me having a panic attack' which conversely leads to shallow chest breathing and a panic attack being more likely. They can also do it for too long and if they don't panic, attribute the reason they did not have a panic to the chest breathing, leading to vicious cycle of increasing an unhelpful behaviour. Equally in many diagnosed anxiety disorders, internal focus of attention on physical symptoms and thoughts is exactly what we are trying to break the cycle of, not give a strategy for them to do it more which we know increases affect. We want them to focus externally outside of these symptoms at that time. So, for these three main important clinical reasons, this is why you won't find breathing in up to date resources that follow the Roth & Pilling Competency framework for the effective delivery of CBT used for up to date CBT protocols and teaching for the anxiety disorders. So if someone has an anxiety disorder, our advice is no. We do not recommend it for patients with an anxiety disorder in treatment for that disorder for these reasons and we stick to the competence framework.
Deep breathing for stress management
For general stress management, deep breathing can be helpful, in those without an anxiety disorder. Deep breathing, properly done, is a key part of yoga. But, telling people to 'breathe deeply' is only helpful if people are given the context and instructions alongside it on how to deep breathe properly and to not chest breathe.
True deep breathing can switch on the rest and digest system. To use it requires practice at neutral times, once or twice a day, 1-2 minutes is enough time. If you think about yoga, you are usually relaxed when doing it and focused on the position and holding it. Not thinking about internal thoughts or feelings of anxiety at the same time! Where breathing techniques are used in CBT is outside of the context of the diagnosed anxiety disorders in physical health protocols where stress is a problem on symptoms, for example, such as in the evidence based Hunt protocol for CBT for IBS. For IBS as a physical long term condition, not an anxiety disorder, it is exacerbated by stress. This makes sense with the link between our gut function and the constant communication between the ENS and our ANS and CNS. Stress tells our gut there is a problem that needs to be dealt with and switches off rest and digest for the arousal response, leading to gastro-intestinal changes and, in turn, more IBS discomfort in it's own vicious cycle.
When you can harness true deep breathing through practice at neutral times, be that through yoga or other practice, you can use it when stressed just for 30 seconds and it can be enough to switch on rest and digest.
So how do you do it properly for stress reduction?
Get comfortable. Some people find it easier when lying down. Then, put one hand on your chest and the other hand on your belly just below your belly button. Inhale by keeping your tummy muscles tight, in through the nose for about 5-6 seconds. As you breathe in, feel your belly rise. As you breathe out, feel your belly lower. The hand on your belly should move more than the one that's on your chest as you practice.
Exhale for longer than the inhale, slowly and in a sustained way for 8-10 seconds. Imagine you’re trying to blow out lots of candles. It can help to hold a finger up about a foot away from your face and tighten your belly and blow a blast of air at your finger so you can feel it on it. This will give you a respiration rate between 4 and 6 breaths per minute. You only need to practice for 1-2 minutes, then if you need it, use it at other times for about 30 seconds, just 2 or 3 deep breaths.
So is it ok for general stress management and in certain protocols, yes, it can be helpful outside of an anxiety disorder, but always make sure the context is there, you practice takes place daily at neutral times to help switch on rest and digest and so when you need it you can do it easily and deep, not chest breathe. Would we recommend it right now? it can be helpful for busy clinicians yes, it can help those in need of general stress management techniques. Remember too though that COVID-19 can affect breathing and ability to deep breathe, so we wouldn't advise it for anyone with symptoms.
We hope this helps!
Stay well and safe and thank you for all you are doing to help people right now.