Danielle Marie sat with a book in her hands and rock music in her headphones. She answered “yes, yes, yes” to the nurse’s questions, barely hearing them.
Then, an alcohol swab, a quick bite, a bandage applied, and Marie pulled him out of the room. She had survived her COVID-19 vaccination without collapsing.
“I felt,” she said, “like I was super brave.”
Marie, 38, of North Hollywood, is afraid of needles, and she’s not the only one. One in four adults – some 76 million Americans – likely experiences fear, polls show.
The deepest fear of needles comes from childhood, after a negative experience. For Marie, it was barrages of allergy shots as a child that she found painful and scary. In some cases, autism or other developmental disabilities can make the experience of getting the vaccine painful.
The hesitation over vaccines emerged amid a global campaign for herd immunity to the coronavirus, but it was a major problem even before the pandemic. The World Health Organization ranked vaccine reluctance among the top 10 threats to global health in 2019.
We can avoid vaccines for many reasons, but one root cause should not be overlooked: Many people just don’t like to be vaccinated. And some would rather die than be vaccinated routinely.
For Marie, it took a life and death situation to cope with the needle: she was terrified of making her parents or grandparents sick with COVID-19.
Fortunately, there are proven treatments that can reduce the pain and fear of receiving an injection.
The CARD system
Marie’s book and music strategy is based on an evidence-based system developed by Dr. Anna Taddio, pharmacist and researcher at the University of Toronto who focuses on alleviating pain and fear during medical procedures.
Taddio’s CARD system – comfort, ask, relax, distract – offers coping mechanisms for use during vaccinations or other procedures. In schools, children are given physical cards, but you can play these cards in your mind. (Different strategies might work better for different people.)
Comfort: For Marie, it meant choosing music she knew and loved: Juliette and the Licks. Bringing a trusted friend to serve as a role model can also be a good strategy – if they can, so can you.
Ask: Some people, Taddio says, feel comforted when they learn more about what is going to happen. Just reading this article might help!
Relax: Marie was grateful that from the waiting room she could not see the shots being fired. And when it was her turn, she was alone with the nurse. These factors helped to reduce his distress. Another common relaxation technique is deep abdominal breathing.
However, it is not all about the patient. Vaccination clinics would do well to factor in fear of needles, Taddio says. Making the sites heartwarming and convenient could help convince about 5% of adults who avoid getting the vaccine out of fear.
Distract: This strategy works for many people, says Taddio. Chat with the nurse, read posters on the wall, or act like Mary and double down with music and a book. Of course, not everyone wants to be distracted. Some are comforted by watching the injection, so that they don’t overdo the procedure in their minds.
Then reward yourself, whether it’s with a lollipop, Double-Double, cocktail or shopping spree. “If you end on a positive note,” says Taddio, “that’s what you remember.”
The key to the CARD system is choice: you choose which cards to play.
But if you have an acute needle phobia, no distractions, abdominal breathing, or chattering will make the vaccination bearable. In these cases, the fear must be tackled at the root.
Not much scares Shane Curran, but he was terrified of getting the shot. Even though he knew his asthma put him at risk for COVID-19, and even though he knew it wouldn’t hurt, he couldn’t bring himself to make an appointment.
“Knowing that I’m going to get the vaccine, knowing it’s happening,” he said, “I can’t sleep.”
Then a friend made an appointment for him – with 24 hours notice. It was Johnson & Johnson’s shot, not far away, at their local / CVS target.
“Dread,” Curran said. “Absolute dread. I have real shaking hands, nice clammy sweat, butterflies, knots in my stomach.”
The thought of facing a needle terrifies Curran, who doesn’t look like the kind of person who would be afraid. He is 6 feet 3 inches, 285 pounds, and has tattoos on his arms and legs. But a traumatic vaccine experience in childhood left her with a feeling of impending doom before a vaccination.
This fear is common, said Robert A. Chernoff, senior clinical psychologist at Cedars-Sinai Medical Center in Los Angeles. The medical term for this is “anticipatory anxiety” – in short, fear of fear.
The needle causes panic and the fear of this panic leads to terror. To break that cycle, Chernoff said, fears must be faced head-on.
One way to do this is to use exposure therapy. Here’s how it works: You are with a therapist making a ranked list of frightening stimuli: a waiting room, a white coat, a nurse with an antiseptic wipe, a syringe. One by one, with the help of the therapist, you sit with these objects, or pictures of them, and breathe until your brain learns that they are not a threat.
Studies have shown that exposure therapy is very effective. It can produce results in a few sessions or sometimes even in one.
Clinical psychologist Katherine Dahlsgaard has practiced exposure therapy with patients for 15 years. She has seen the treatment work for agoraphobia, as well as fear of insects, dogs, and costumed figures, among others.
“For someone with a canine phobia,” said Dahlsgaard, “research shows they don’t need a lot of talking about their thoughts and feelings. They need safe and systematic exposure to dogs. “
But needle phobia is different. This causes a unique reaction: fainting. An involuntary reflex – the vasovagal response – plunges the pulse and heart rate at the sight of blood, an injury, or an injection, and decreased blood to the brain can cause loss of consciousness. Other symptoms include feeling like you might pass out, sweating, or ringing in the ears.
It’s an unpleasant feeling, Chernoff said, and most people with needle phobia have this exaggerated vasovagal response. Countering her is an important skill to learn. The good news is, it’s simple. The applied tension fights the vasovagal response by flexing large muscle groups to increase blood pressure and pulse rate. This can combat feeling dizzy.
Dahlsgaard advises his patients to straighten their legs, trunk, and arms until their faces warm, then return to neutral. In other words, she said, it can serve a purpose.
Freshly equipped with knowledge of the CARD system and applied voltage, Curran arrived at the pharmacy for his vaccination appointment. He had called to make sure all of his friends knew this was happening; he wanted peer pressure not to back down.
Upon arrival, Curran’s hands were shaking, he was sweating profusely and he was hot. They went to take his temperature. Don’t even bother, he thought. “It’s a million degrees right now.”
He sat up, lifted his sleeve, looked away, tensed his muscles, except for his left arm, and it was done. He took a minute to shake off the “really disgusting” feeling of what had just happened, then sat as long as he could to observe her before stepping out into the sun and the fresh air of the parking lot.
Having faced his fear, does Curran have any advice for others who are afraid?
“Nothing helps,” he said. “It’s awful. From someone with the same phobia, it sucks. Nothing helps. Just do it.”
This story originally appeared in the Los Angeles Times.