Richelle Moen: Stress around post-COVID reintegration can mimic social anxiety

A little over a year ago, when I dared imagine the loosening of pandemic-era restrictions, I naively envisioned ripping off my mask and throwing it to the ground. At the beginning, mask-wearing felt burdensome, but then I, and just about everyone else around me, got used to the security it provided.

Now, after months of riding the mask bandwagon, political leaders are celebrating rising vaccination levels and falling infection rates by appearing in public bare-faced — and telling other fully vaccinated folks that it is safe to do so, too. Surprisingly, hearing these announcements didn’t cause me to rip off my mask the way I’d once fantasized I would; while I’ve lately been spending more mask-free time with vaccinated friends and family members, I’m still carrying one with me wherever I go — and putting it on when I’m in indoor spaces like the grocery store. I feel more comfortable operating that way, and I’m not sure when I’ll give up my mask for good.

My cautious reaction to the loosening of public health restrictions isn’t all that unusual, said Richelle Moen, a licensed psychologist and assistant professor at the University of Minnesota Medical School’s Department of Psychiatry. Moen teaches psychotherapy there to residents, but she also provides private therapy for individuals and families — as well as leading groups for younger and older adults living with anxiety and depression.

Moen said that these days, a common topic in her groups is anxiety around the return to normal life after the pandemic eases.

“We are focusing on reintegration, or moving back into connecting with the wider world,” she said. “One of the things I am seeing in my groups is that people’s reactions to this experience, their concerns around moving back into the world post-pandemic, mimics some the symptoms of social anxiety.”

Recently Moen and I talked about how the gradual return to a more normal version of life has become a source of stress not just for her patients — but also for many of her friends and family members. During our conversation, she shared tips and tools for managing re-entry — while paying careful attention to your mental health.

MinnPost: What kinds of concerns are you hearing from members of your therapy groups?

Richelle Moen: What I’m hearing is that as people who’ve been out of the workforce due to COVID are back interviewing for jobs, or as people are considering returning to activities like getting together with their friends or family members, they are experiencing a lot of anxiety. Their concerns are centering around becoming re-engaged with others — with or without masks.

Some of these anxieties might be around the ways that up until now they have been dealing with the pandemic and the required restrictions on our behavior. Now that some of those restrictions are being relaxed, they may still be feeling more anxious than their friends and family members, who might be critical of them and their decisions. They say things like, “Why aren’t you doing what the CDC is saying?” We’ve been discussing possible responses to these kinds of questions. They could say something like, “I don’t know why I’m feeling anxious about this, but I’m just not ready to go back to regular life yet. I’m still uncomfortable.”

MP: We’ve been sheltering in place for a long time now, wearing masks whenever we leave the house and trying to protect ourselves and our loved ones. It’s understandable that some people aren’t going to be able to turn on a dime.

RM: We are talking about the impact of 14 months of hearing from the CDC and the rest of the world, “Don’t touch anything. Don’t be with anyone. Don’t breathe around anyone. Be 6 or 16 feet away from others.” If you already tend to be a little anxious or have some OCD symptoms, you’ve probably already been feeling more fearful of the world. Then, COVID has really intensified all of those feelings — not just for you but for everybody.

For people who are already wired that way, it’s just more intense. Looking at the literature, what I see is that some of these behaviors I’m seeing in my patients, some of this anxiety about re-entry, is mimicking the symptoms of social anxiety.

MP: Are some groups particularly prone to feeling anxious or reluctant about moving back into normal life?

RM: Reintegration has been particularly hard for some children. The first studies about this are coming out about now and we’re finding rising cases of anxiety and fears among young people that have been created by the necessary-but-disturbing COVID restrictions that we’ve all lived with for the past 14 months. This has meant that some children are afraid to go to back to in-person school. They’re choosing to stay online, even when given the option to be back face to face with their friends and teachers.

Another group of people who are experiencing anxiety about re-entry are people who’ve experienced a loss due to COVID. If you lost a loved one to COVID it will understandably intensify your fears. You’re already grieving, and grief itself falls under the definition of an anxiety disorder. You already have this intense fear and then you realize that life is filled with so many unknowns. It’s a difficult combination.

MP: That makes complete sense to me. For many people, COVID has become this clear example of the hard truth that no one is guaranteed protection from life’s dangers.

RM: Yes. And for so long we did not have clear guidelines about how to keep ourselves safe from this virus. So if you’ve been focused on protecting yourself and your loved ones for all this time, it can be extremely stressful. What I’m hearing in my groups now is that they are overwhelmed by all these what-ifs.

MP: Are you seeing varied reactions to re-entry causing frictions in families?

RM: In my young-adult group, a lot of them are questioning science. They’ll say things like, “How do you know the vaccine is safe?” After we talk more, trying to get to the root of their questions, patients will say things like, “My mom is so anxious.” They are telling me how in their households they are getting overwhelming messages of anxiety and fear. They’ll say things like, “My mom has been telling me to wear my mask forever. Now she’s not willing to stop wearing the mask even though we’ve all been vaccinated.”

When I work with families I try to figure out who’s the more anxious one, the parent or the kid, because children often absorb the anxiety of their parents.

MP: Though COVID-19 feels like it’s been around forever, somehow it does seem like some of the “all-clear” messages we’ve been getting lately seem sudden. It’s easy to understand feeling a little uncomfortable with just going back to normal.

RM: It took us 14 months to get to this place and now very quickly we’re being told, “Masks off by July 1. No worries about anything.” Pretty much everyone knows someone who got extremely sick from COVID. For example, my own brother now has a heart condition related to it.

MP: What have you observed about how your patients are charting their own paths forward in this brave new world?

RM: What I’ve seen happening in my groups and in my practice is that people are assessing their risks and everyone is going to have a different perspective on how far they’re willing to go in terms of re-entry. We need to have grace for and respect of other people’s limits. I’m saying if you have higher risk factors like diabetes or your immune system is compromised, then maybe it’s OK to delay your return and wait for a few months or maybe even six months before you take off your mask. But it is important to limit what rules you impose on others.

MP: How do you work with patients who are still significantly limiting their own outside interactions?

RM: What I have to do as a psychologist is sort out what part of a person’s reaction is social anxiety vs. a valid medical reason for why they are not going to see other people. Some people are going to turn down different events because they are concerned that no one is going to be wearing a mask. If your reaction to re-entry is mimicking social anxiety, it may get to the point that you turn down so many things that you become increasingly isolated. In those cases, you may need to think about starting to reintegrate in small, gradual ways.

MP: What are some of the ways that people can start the reintegration process?

RM: In the psychological literature, there’s been talk about an approach called systematic desensitization, where you re-enter the world in little steps. It’s related to exposure therapy. To do this, you gradually expose yourself to the idea of reintegration, say by being around people in small, safe quantities. Maybe you get together with one person, then later maybe another small family. Then you start asking yourself, “How can I feel comfortable going to the grocery store? What do I need to do to start feeling OK with doing that?”

MP: Is there a point where you think that you need to step in with more significant interventions?

RM: I would first carefully assess the situation before I do an intervention. I would talk to the client and then learn more about situations that make it difficult for them to get out into the world. I would ask questions like, “Could you walk into a store, even at 11 pm, to grocery shop?” “Would you be comfortable going in if hardly anyone else were there?” “Do you need everyone to be 6 to 10 feet away from you to feel safe?” “What’s your baseline?”

A client might say, “I did talk to a neighbor the other day. It was over the fence, but I know she doesn’t go anywhere, so I felt it was safe.” I’d say, “OK. What do you need to trust a person? Is it knowing whether they’ve been vaccinated?”

Once I am able to get a sense of the rules a patient has established for themselves and their loved ones, we would work together to figure out what baby steps they can take to slowly return to normal life.

MP: How do you encourage patients to take those steps toward normalcy?

RM: Once I understand a client’s thought patterns, we can then talk about their actions and the realities that influence those actions. I ask questions like, “What thoughts come to mind when you think about leaving the house or getting together with someone?” If their response is, “I have a medical condition and I am afraid that I am going to get COVID and die,” or “I’m afraid I will get sick and won’t be able to do my job,” that’s different than saying, “I am afraid I am going to say the wrong thing. I need to re-learn how to interact with people.” The second response is more clearly social anxiety.

I advise my clients to take baby steps to help themselves increase their comfort by managing their anxiety. We decide together what those baby steps are going to be. Then we slowly keep adding to these steps because we want to progress, to be able to be face to face with people again. I want my clients to lift some of the restrictions themselves. They can do it gradually.

MP: Is a gradual pace important?

RM: If right now you are feeling struck and overwhelmed, if it feels like the world is telling you, “We’ve got to do this right now,” and that feels overwhelming, it’s OK to move at your own pace. Just understand that the more you allow yourself to safely be around other people, eventually you will get less and less anxious.

Maybe you can ask yourself, “Where can I safely start with this reintegration?” Do you feel comfortable going to meet your book club outside? Or, if that feels like too much, could you see two friends? Maybe meet on a patio for coffee? Or how about starting with just one friend? I always start where the patient is willing to start.

MP: How do members of your groups talk about re-entry?

RM: They challenge each other. They give themselves homework assignments. They’ll say things like, “Why don’t you get out a little more? Why don’t you try to see your sister who has two grandchildren?”

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The good thing about group therapy is that people are concerned about what other people think about their actions. We have concerns around this with reintegration, like, “Am I being judged?” or “Am I not being a good citizen?” Your fellow group members are there to be a sounding board, a way to safely practice with others.

We need to realize that we all make mistakes. We’re all working under different timelines. We should try to have grace for ourselves and others. Working through this in a group setting helps us build that understanding.

MP: It is easy to make a mistake. The other day, I got out of my car and walked into the lobby of my doctor’s office without wearing a mask. I just forgot that I wasn’t wearing it. When I realized what I had done, I quickly grabbed my mask and put it on, but I felt sheepish. The experience helped me to realize that everyone can mess up.

RM: What if you got into the doctor’s office and they said, sternly, “You have to wear a mask”? If you were sensitive and easily criticized, you might have left the doctor’s office and not come back because you felt humiliated or ashamed. But if you have grace for yourself, you’d realize that you’d just made a mistake and put on your mask. It’s not a big deal.

Having grace for yourself should also extend to having grace for others. With family and friends it’s important to respect their feelings, fears and boundaries. Some people, depending on their concerns around whether others will wear masks, or if they will be judged if they don’t wear a mask, might not be willing to come to a family event right now. We have to have grace around that. But, if in a year or even three to six months from now, the person is still not willing to come to an event, at what point do we say, “This is a problem. You need to seek help from a therapist?”

I have clients who say that they will not stop wearing masks in public ever. It may be that they will eventually work through this concern as they begin to see other people not wearing masks and not getting sick. I try to have grace and patience with them and I advise them to have grace and patience with themselves. They may just need to keep following the science and wear a mask for a few more months.

MP: What are some of the other tools that you are teaching anxious clients as they consider moving out of COVID isolation?

RM: I’m hearing a range of concerns, like: “Will I stand out if I continue to wear a mask?” or, “Am I going to look ignorant?” or “Even though CDC says I can stop wearing a mask now, what if I am still too anxious to stop?” I am advising my patients to write down the pros and cons of their decisions and consider what changes they’re willing to make. What if you still wore a mask at the grocery store or in a mall, but the boundary would be demanding that someone else put on a mask or take off their mask?

MP: And how do you suggest people respond when a loved one criticizes their approach to re-entry?

RM: What I suggest for my patients who have family members with different ways of living is for them to ask themselves, “How do I tolerate someone saying something that feels disrespectful or critical?” I explain that sometimes people make comments or ask questions because they are curious and they gathering information for themselves. Maybe it is helpful to think of those questions that way — rather than thinking of it as criticism. Or, if these comments are criticism, we talk about how they can be OK with that. I tell patients that one possible response is for them is to say, “It may look crazy to you, but for now I’m still going to do this. I’ll probably change someday, but this is what I’m comfortable doing for now.”