How has your practice been affected by the events on and following September 11th?
I run an entire program dealing with anxiety and traumatic stress. It's a group practice with 90 clients per week on a normal basis. I've noticed three main things since September 11th:
- Since September 11th we have had a lot of new clients, what I call "the worried well." These are people who were functioning pretty well before September 11th and still are but are experiencing things that they hadn't before, like not sleeping or eating well, feeling irritable and vigilant.
- People who usually come to our program are now feeling a little bit worse. If people were depressed before September 11th, now they feel more depressed. If they were "worriers" beforehand then they are more worried now.
- Some people who usually come to treatment are now not coming. Some may be scared to go out or may be reprioritizing and want to cocoon at home. People are off their routines. They could be out looking for gas masks instead of coming to therapy. People are also concerned about finances and don't want to spend money on therapy. Also, with all of the cutbacks they want to put on a good show at work to keep their jobs and so don't have time for therapy. Some also just want to avoid having to talk about the obvious, about how scared they are: It's the old-fashioned idea of resistance.
Have you seen a rise in outpatient intake since September 11th?
Yes, more new "worried well" people are coming in. I'm not seeing an increase in people we've treated in the past. I think that overall people are still in their emergency coping mode. I think the significant problems will emerge later.
What is "emergency coping mode"?
Trying to gather information. Trying to decide what to do. Deciding whether to buy a gas mask or Cipro or stockpile water and canned goods. All of that preparedness stuff.
There has been a surge in antidepressant and sleeping pill prescriptions. Why?
One of the first reactions to a stressful event is poor sleep so people are looking to sleep aids for help. Sleep aids are not a bad thing because people need sleep to be able to function better during the day. Unless you have a history of substance abuse, sleep aids can be a good short-term solution to a hopefully short-term difficulty. The antidepressant increase concerns me more because they don't kick in for 6 weeks. It concerns me that the medication won't relieve these symptoms immediately and that by te time it kicks in these people might not really need the medication on a long-term basis. People who should look toward medication are people who have had major depressive episodes in the past and can feel those old feelings coming back. Going on antidepressants now would be a good idea to prevent a relapse.
Are these increases unprecedented?
We don't know yet. I don't know that we've ever really monitored the blips in these pharmacological needs before. But so much of this event is unprecedented that the reaction to it is unprecedented as well.
What is a "normal" reaction?
Increased anxiety and irritability, appetite and sleep change, poor concentration at work, and poor productivity. People are preoccupied with worry. It's important for management to provide a forum to address these worries. A lot of people don't know how to react to the situation and are having a hard time making everyday decisions like whether to take the bus or wear a partcular coat. This inability to make decisions just compounds people's sense of helplessness and undermines their confidence. It makes them feel less safe. And that is what terrorism is about--psychological warfare. Terrorists don't have a lot of physical resources so they use what they can, which is a war of the mind.
How should people react in the face of this uncertainty?
People need to continue to take action and make decisions about their everyday life. Those decisions and assessments will be different for every person. Some people will feel safer if they take a bus instead of the subway. Other people will decide that they feel safer if they don't walk past bridges. And I don't think that any one of us can judge what the correct decision is. But the important point is for every person to get as much information as they can to be able to go forward feeling as safe as they can--because taking action is a way of feeling more in control of your life. We take control of our life by taking action and making decisions even when we have imperfect information--when we really don't know the severity of the anthrax threat.
What behaviors do you think are "okay" in the face of this anthrax threat?
Whatever makes you feel better. Some people will decide that they need to leave New York in order to get their system back to normal. If they are spending all day germinating catastrophic scenarios then they should just get out of town for a few days to feel safer, to regroup. It's important that people stick with their routines as much as possible because it reminds us that life goes on and that we are more safe than not. If buying a few bottles of water and canned food makes you feel better then that is fine. Whatever makes you feel better is fine as long as it isn't an action being proscribed by the authorities.
So is stockpiling Cipro okay?
No. There are things that we do know from the authorities, like the fact that you houldn't stockpile Cipro or medicate yourself. There are people out there who really need the drug for other infectious diseases. But that decision is up to the individual. If having one prescription of Cipro at their disposal makes them feel better then that's okay. For other people, not having Cipro makes them feel safer, as if the threat is not real to them. They don't even want to contemplate that possibility. I would need a crystal ball to say which route is better than the other. As a mental health provider I can only help people to function better under circumstances of uncertainty.
This anthrax scare reminds me of the old saying, "You're not paranoid if they are really after you." Yes, me too. A few months ago if someone came to me and told me that they were living in fear of anthrax, that they were terrified to open their mail, that would mean that they had a mental disturbance affecting their perception of the world. But today it's a totally different scenario. People's anthrax fears have a justification of source. There really is the possibility of anthrax in their mail! But even though these fears are somewhat based in reality we need to realize that these fears are purposeful, that these terrorists are trying to make us afraid. It might reduce people's fear to know that they are being manipulated into being afraid. Knowing that might help people to stand up to their fears, to say to themselves, "Well you can't manipulate me. I won't let you."
How do you know when you've become irrational--when you NEED professional help?
When you notice that your functioning has really decreased or when your loved ones tell you that you are behaving very differently. If you are unsure of whether you need professional help or not, it doesn't hurt to have a consultation. A professional can evaluate whether your levels of anxiety and fear are impairing. We can differentiate between "impairing" and "mildly distressing." And there are coping strateies that people can do to help themselves cope. People don't need to suffer without help.
What are some of the coping strategies?
A person can talk to another person about what they are worried about. They can figure out what activities calm them down and make them feel better. They can talk themselves through their day. They can balance their schedule so that they don't overwhelm themselves. They can work on becoming more confident, which will make them feel better, which will then make them feel less afraid. Coping strategies can help people stay focused. Being focused is an antidote to fear because fear is very disorganizing, and that disorganization compounds their feelings of incompetence. If you focus on a particular task you find that you are more in control of your life than you think you are.
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