In part 1 of this blog, I explored how my colleagues and I have been personally coping with the elevated risk of terrorism and violence. In part 2 I’ll focus on how the uptick in events and threats has affected our work with patients and with the professionals whom we train.
Working in the area of military psychology, we are constantly addressing concerns about safety and preparedness. As part of the normal readjustment to civilian life, our patients may struggle with how to “turn down” their alert system and adjust to realistic threats in their environment. At the more extreme end of the spectrum, our patients may struggle with significant safety-related worry due to PTSD and other anxiety disorders or hopelessness related to depression. Five years ago I felt much better prepared to challenge what I considered to be patients’ misperceptions about safety at home and pessimism about the future. But the line between realistic and unrealistic fear has become blurred.
Again, I’m not the only clinician struggling with this issue. The same question has come up at almost every Cognitive Processing Therapy (CPT) training that I’ve led over the past year: How do we work with patients’ hypervigilance and safety-related concerns when there is real danger in the civilian world? Interestingly, whereas my colleagues and I offered very similar responses to how we coped in our personal lives, we are much more varied on how we address this in professional life. Our approaches differ based on our individual styles and the subset of patients whom we each treat or consult about.
Calculating the probability: At some point, we’ve all encouraged our patients to investigate the real probabilities of their fears coming true. Many of our patients who’ve returned from a combat deployment live with a fear of another IED explosion, a sniper on an overpass, or a gunship overhead. For these types of concerns, it’s still helpful to compare the combat setting with the current setting and calculate the probability of these events happening again. How many IEDs have gone off in the United States? How many helicopters overhead have turned out to be gunships? Are you living life in line with these statistics, or are you overestimating the likelihood of danger?
Testing the hypothesis: Following naturally from probability calculations, I have often asked patients to conduct an experiment to test their hypotheses. If their assumption is that they will “freak out” in a crowded grocery store, how can we test this out? I’ve worked with patients to test hypotheses ranging from “I can’t come to my appointment without taking my Xanax” to “I can’t eat in a Vietnamese restaurant.” It can be fun to operationalize each hypothesis, develop an experiment to test it, and then interpret the “results.”
These are still some of my favorite therapeutic techniques. They tend to work well when a patient’s past experiences are very different from their current experiences. And patients often feel a greater sense of control over their therapy when they are invited to collaborate as a fellow scientist. These techniques are less helpful, however, when the fear is more substantiated. While school shootings are thankfully infrequent, each has the power to devastate whole communities and strike the most primal fears in parents everywhere. Calculating probabilities does little to allay this. Mental health professionals are using a different set of tools for these concerns:
Normalize anxiety and grief: At a basic level, every good clinician empathizes with a patient’s concerns and normalizes how certain emotions have developed over time. We also challenge underlying cognitions when patients’ fears appear irrational, but we’re better off stopping at step one if their fears are founded. Frankly, it’s healthy to feel sadness or worry when an attack takes place. We would be more concerned if our patients felt numb or content. So focus should move away from changing or shifting the emotion to accepting it and finding healthy ways to cope with it. My colleague noted eloquently: “Can you really convince your patient that their child won’t be a victim of a school shooting? Even if you could, should you?”
Respond genuinely: One opinion that we all share is that we should not pretend to have all the answers nor claim to be unfettered by the news. Of course, that doesn’t mean we should reveal our deepest fears or share blueprints for an underground shelter with our patients. But being disingenuous about our own humanity could be harmful. At best, patients may sense that we are being insincere, which can have significant effects on the therapeutic relationship. At worst, they might (rightly so) question our judgment and reality testing. Somehow we need to strike a balance between foolish stoicism and emotional dysregulation and then model that response for our patients. We can acknowledge having similar fears and then discuss what aspects are within our control and which are not. Or discuss how we’ve chosen to live in line with our values despite this fear. Or even the costs of ruminating on that fear. Any of these techniques are more likely to be effective if we are honest about the challenge.
Limit media exposure. We try not to forget about the most obvious intervention. There is evidence that watching hours of media coverage of tragic events is bad for your mental health. Based on studies about coverage of the events of 9/11 and the Boston marathon bombing, this is especially true for individuals who have previous trauma exposure or have struggled with mental health issues in the past. Remembering that appealing to your fears is an effective way of boosting ratings (“Are you being poisoned right now without realizing it? Tune in at 11 to find out!”), sometimes we just need to shut off the TV and close the browser window in order to preserve mental health.
Compartmentalization. Finally, we clinicians have to find a way to manage our own emotional reactions while serving our patients. Using this common psychological defense mechanism, we can separate conflicting ideas or emotions from one another so that we can function without distress. One colleague offered a powerful example of this: When she’s working with patients who are struggling with anxiety about safety, she pushes aside her own memories of her parents working at the World Trade Center on 9/11. In this way she can attend to her patient’s needs without becoming emotionally overwhelmed herself. Of course, she often finds that she is faced with her own anxiety and distress at the end of the workday, when compartmentalization is no longer sustainable. Then she has to be more vigilant about following her own self-care prescription.
What I found most interesting about this discussion is that we seem to be relying more on our non-specific therapy skills to address these issues. In general, my CDP colleagues and I are adamant about using evidence-based psychotherapy, (EBPs). For your own sanity, you really don’t want to get any of us started on talking about randomized control trials, maintaining fidelity to a treatment protocol, or the never-ending debate over cognitive vs. behavioral interventions. But when it comes to these shared experiences and anxieties, we tend to focus on the more humanistic aspects of clinical work, including expression of empathy and taking care to not pathologize normal reactions.
My sincerest appreciation to my colleagues who contributed to this blog by sharing their own incredible experiences. I am humbled by your strength and compassion.