Maintaining Mental Health in the Face of Crisis: Dealing with Anxiety Disorders, by G.M., RN, MSN, CNL

Many of us have considered how we would provide for our family’s physical needs, including medical care, during a prolonged crisis.  Indeed, it would seem foolish to be unprepared for trauma related to accidents, violence, fire, etc., when professional medical care might not be available for weeks, months, or more.  What most of us don’t think about, however, is the toll a long term crisis could take on our mental health.  This may seem to be a low-priority concern, next to food, shelter and security, but depression and anxiety related to traumatic events can have lasting and highly detrimental effects, ranging from loss of productivity, to violence and suicide. 

We may feel that we are tough and hardened to the rigors of even the worst scenarios we can imagine.  Many soldiers have felt the same way before entering combat and yet have still developed anxiety, depression and Post Traumatic Stress Disorder (PTSD).  Anxiety disorders such as PTSD are common in those who face extreme mental stress, as they are related to increased activation in the fear center of the brain. These disorders are not a sign of mental weakness, but simply the result of facing extremely traumatic events and/or prolonged high-level stress.  Typical signs to look for are hyper-vigilance (jumpiness, loss of sleep, increased hostility), intrusive thoughts (inability to stop thinking about traumatic experiences), recurring nightmares, emotional detachment and depression.  Together, these symptoms can lead to suicidal thoughts and increase the risk of violent and abusive behaviors.
Accident survivors and victims of violent crime (especially rape) are commonly diagnosed with anxiety disorders such as PTSD, so it’s not just soldiers who are at risk.  It’s not absurd to think that our family members, our friends, and even we might succumb to these problems if things turn out to be as bad as some predict.   In a changed world where much of what we’ve taken for granted is gone, even the strongest and most resilient of us could have a tough time coping.  This is especially true for children, since they usually don’t deal with change and upheaval as well as adults.  In a TEOTWAWKI scenario, or even in a prolonged crisis, maintaining mental well-being may be as much of a challenge as maintaining good physical health.
Fortunately, early action can be very effective in reducing the fear and anxiety caused by traumatic events, helping those affected to cope with their situation and return to normal functioning.  Scores of books and manuals have been written on treatment methods for anxiety disorders, more than we have time to go into here.  This essay attempts to present a plan that is both easy to follow and easy to implement, and which can provide help to those suffering from anxiety when no professional medical care is available. The plan is based in Cognitive Behavior Therapy (CBT), which stresses short-term treatment to change thoughts and behaviors, thereby reducing fear and stress.  To keep it simple, the plan focuses on two specific areas: exposure therapy and group support.

You’ve probably heard the term, ‘you have to face your fears in order to beat them’.  This is the basis of exposure therapy, to desensitize a person to traumatic events by leading them to face their fears.  One of the methods commonly used is journaling, simply writing out the bad experiences that caused the anxiety in the first place.  Writing out a detailed account of traumatic experiences has been proven to lessen their effect, reducing their power to prolong fear and anxiety.   The same idea works for recurring nightmares, but with a twist.  With bad dreams, the key is to write the dream out, but change the ending to how you would like it to end.  Don’t be nice or polite when doing this, but think at a ‘caveman’ level.  If someone attacks you in the dream, write out how you would destroy them.  Then read this ‘corrected’ dream each night before going to bed.  This idea comes from Navy psychiatrist Beverly Ann Dexter, and it’s been proven to work.  Journaling of both experiences and dreams is an important aspect of CBT, and provides a homework-like structure.  It is important that journaling be done every day, even if you’re writing the same ideas over again.  The repetition helps to lessen the effect of intrusive and recurrent thoughts and dreams, and reduces anxiety.  It sounds simple, but it works.

In addition to journaling, group meetings help in two ways.  First, they provide a context for the journal writings. The group setting provides a comfortable place for people to read their journal work aloud; the final step in the weekly homework process.  The writing and reading of journal work together help to promote desensitization to the initial trauma, and also help to instill resilience to future trauma. Secondly, group meetings provide peer support by allowing people to work through their own problems alongside others who share similar issues.  Group discussions help people better understand and cope with their own experiences, and listening to the experiences of others contributes to the exposure therapy aspect of the plan.

In group sessions it is important to have a moderator who oversees the process, allowing everyone time to share their thoughts and journals, while keeping comments from others in line with what is helpful.  Statements such as, “You should have…”, or, “I would have done…” don’t have a place in this process, nor does any hurtful or derogatory commentary.  Everyone should be focused on helping the rest of the group, even if their approach to problems is different.  Some people will be talkative, some shy, and if some don’t want to share at first that’s all right.  Take time to allow people to read their journal writings, and allow discussion to flow from the topics that come up.  Discussion helps to provide support, and shows group members they aren’t alone in what they’re going through.

An open (or public) group will do the most to help the greatest number of people, and it will take the least amount of time and effort to organize.  Open groups also help to reduce the stigma commonly associated with mental health problems, leading more people to seek help.  Groups should meet once a week, for an hour to an hour and a half, but meetings can be held more often if needed.  A group size of six to twelve often works best, but whatever suits your own purposes is fine.  Even if you work one on one with a family member, you can still get results, but you will be missing out on the benefits of group support.

What you will need: pads of paper and pens or pencils (not bad things to have anyway), a place to meet, and a mediator.  Meeting places should be safe and non-threatening, and meetings should be held during a quiet part of the day.  Mediators should have an even temperament and a fair amount of patience.  It also helps If they have some affinity with the group (for example a teenager or young adult would work best with a group of children), but the best quality is simply the desire to help others get through a tough time.  The average CBT session is time- limited, usually lasting about eight weeks or so.  Shoot for a six to eight week run of group sessions and see how people progress.  You should see good results in this amount of time.  If anyone still needs help after the group session has run its course, encourage them to take part in future groups.  Preparing to run several group sessions consecutively can help those who may need more time, and allow people who were initially reticent to seek help another opportunity to participate.

This is a rough overview which only highlights a few of the tools used to deal with anxiety disorders, but it does provide a framework for those who would be without any help during a long term crisis. Doing something is always better than doing nothing, and this is doubly true for anxiety disorders. They are more easily treated when discovered early on, but if left unattended they will often get worse over time.  Look for withdrawal, depression, hyper-vigilance and intrusive thoughts or nightmares, and remember that these signs can manifest several months after the original trauma.   

As we’ve seen with the generations of vets who have come home with PTSD, the consequences of non-treatment can be devastating.  Doing what we can to intervene at the early stages of an anxiety disorder can make all the difference, for us, our loved ones, and our community.