While the COVID-19 pandemic has often been equated to a war — with doctors on the front lines fighting vigorously against the deadly coronavirus — this mindset has been critiqued for encouraging individuals to set aside their own well-being in favor of simply surviving. Focusing too heavily on triage, however, has perhaps guided us to avoid properly dealing with mental health.
The University’s Program for Anxiety, Cognition and Treatment Lab aims to challenge this way of thinking by examining cognitive processes to change thinking, regulate emotions and improve moods.
Dr. J. Kim Penberthy, a clinical psychologist in U.Va. Health’s Psychiatry and Neurobehavioral Sciences department, said the pandemic has drastically exacerbated existing pressures as workloads increase exponentially.
“The pandemic has been the perfect storm,” Penberthy said. “We have seen a snowball effect where we have more stressors and fewer ways to cope, and the strategies we would have used were taken away.”
In March, Bethany Teachman, psychology professor and director of the PACT Lab, received a grant to develop online personalized interventions for anxiety geared towards University students, faculty and staff.
“[Our goal is] to detect when somebody feels anxious in daily life, so that we can think about matching interventions to them that help them in the moment,” Teachman said. “We collaborate closely with engineers and scientists to think about how we can detect when somebody feels anxious.”
The PACT Lab applies the fact that people tend to think differently when they are anxious.
“In most of our situations, there's ambiguity about exactly what is happening, and we have to assign meanings,” Teachman said. “What we know is that people who are vulnerable to anxiety disorders assign the most threatening, most negative meanings a lot of the time.”
Teachman said anxiety is often based on implicit associations between concepts in memory. If someone has a phobia of snakes, they may automatically associate snakes with danger, while someone with a panic disorder might associate panic with themselves.
Teachman and her colleagues directly measure implicit associations at the Project Implicit Health website, where over a million tasks have been completed. The tasks ask participants to categorize items into groups as fast as they can, measuring ideas indirectly and revealing connections that might differ from explicit attitudes about the world.
“Given that [implicit associations] arise really, really rapidly, and they happen outside of conscious awareness and sometimes they're difficult to consciously control, we want to understand them, so that then we can work to think about how we shift people's thinking,” Teachman said.
Implicit associations have been shown to be effective predictors of mental health — as shown by a 2009 study she conducted to measure implicit associations of people with panic disorder.
“What we found was that the degree of change in those panic associations — the extent that a person became less quick to associate themselves with panic — [predicted exactly] how much their symptoms subsequently improved,” Teachman said.
According to Teachman, this suggests that changing implicit associations has a direct impact on how people experience symptoms of mental illness, such as encouraging people to change avoidance behaviors and take on previously intimidating environments.
Interventions work much like the often-cited therapeutic technique of cognitive reappraisal, which involves recognizing one’s distorted thoughts and reevaluating them realistically in light of the bigger picture. According to Dr. Heather Bruschwein, a cognitive behavioral therapist in U.Va. Health’s Behavioral Medicine Center, this technique is considered a “gold standard” for treating anxiety and depression.
“You have people identify their thoughts when they're feeling anxious,” Bruschwein said. “There are lots of times where you might be having thoughts, and maybe they're true, but they're not helpful in this situation. We [often] make our moods worse or we increase our own stress because of the way we think.”
Evolutionary evidence backs reappraisal-based interventions, suggesting that we are hardwired for negativity bias.
“We [have adapted] a tendency to focus on the negative,” Penberthy said. “If a tiger tries to attack you, you really want to remember it, and you don't want to go near tigers anymore. […] It's important for us as modern humans, though, to recognize that just because we noticed the negative, it doesn't necessarily mean that is reality.”
Cognitive reappraisal is not solely about being positive — as there are many realistic negative thoughts and feelings, like grief, that should not be reframed — but is rather about structuring one’s thought patterns to take on healthier beliefs rather than ultimately harmful ones, Penberthy said.
With substantial practice, reframing can eventually emerge into an automatic cognitive process, and it has been shown to significantly decrease negative emotions as people begin to consistently apply it in day-to-day life.
“The more and more you practice [cognitive reappraisal], the better you will get at catching yourself in the moment and [asking yourself] if there is any part of this that you might be able to reframe,” Bruschwein said.
The PACT Lab’s work effectively teaches cognitive reappraisal — along with other more nuanced techniques — online for easy access.
Teachman is working closely with Assoc. Engineering Prof. Laura Barnes and Asst. Engineering Prof. Mehdi Boukhchba to develop a second website designed to help people feel less anxious by shifting biased interpretations.
This project — called MindTrails — is a free app that directly serves to encourage positive and flexible thinking. The interpretation bias training offered through MindTrails involves getting participants to repeatedly imagine themselves in uncomfortable situations by telling them anxiety-inducing stories that conclude with unexpectedly positive endings.
“We break [down assumptions] and make it easier for [people] to generate alternative ideas about how situations might go, so they're not jumping to negative conclusions,” Teachman said.
For example, if a person’s friends laugh during a conversation, an anxious person might assign the meaning that their friends are laughing at them, while a more healthy way of thinking involves assigning the meaning that everyone is simply enjoying their joke. Teachman’s goal is to create interventions to shift, in her words, “that habitual pattern of catastrophic thinking,” by giving people practice in assigning more benign meanings.
Alternatively, even if a negative bias interpretation itself is hard to break down, progress can still be made by helping people come up with multiple meanings.
“We’re hoping that with interpretation bias training, two things will happen,” Teachman said. “The first is that people won’t always jump to the worst possible association immediately. But, even when they do jump to that worst possible association, it's going to happen sometimes very quickly and involuntarily, so we hope to help them to override that association.”
Adaptations of MindTrails have been produced specifically for kids in Big Brothers, Big Sisters, for Spanish-speaking populations and for individuals who are coping with Huntington’s disease and movement disorders in addition to anxiety.
Most notably, a version for the University community called “Hoos Think Calmly” will be produced over the span of the next two years.
“What we're doing is taking our training materials and thinking about how we can adapt them to specifically meet the needs of undergraduates, and we have a version for graduate students, and we also have a version for faculty and staff,” Teachman said.
In order for interventions to be as successful as possible, the PACT Lab is currently working on matching people to interventions based on experiences and needs.
“We are using machine-learning algorithms that take sixty pieces of information about a person about their baseline and how they responded in the first session of an intervention,” Teachman said. “This is why we collaborate with engineers and with computer scientists to harness some of the great methods they have to learn from this broad array of responses.”
The ultimate goal is to be able to deliver prompt adapted interventions — help that is delivered exactly when it is needed and is designed specifically for the person who is receiving it.
Despite the state of mental health today, Teachman is hopeful that the pandemic will ultimately lead to substantial long-term progress in the way we approach mental illness.
“Lots of research shows us that as stressors calm down, most people will be really resilient,” Teachman said. “I have a lot of hope that many of us are going to be more open to the idea that we need to actively work on supporting our mental health and that it's not something that is a taboo or should be hidden or pushed aside. It needs to be front and center to the ways we care for ourselves.”
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