Maintaining Mental Health in Time of Crisis

Maintaining Mental Health in Time of Crisis

The attacks on New York City and the Pentagon in September, among many other results, have played havoc with our mental and emotional life. No one knows how many people sought crisis counseling in the aftermath—or needed it and did not seek it. The list of traumatized people was very long: rescue workers, those who had lost friends, colleagues, spouses, parents and other family members, and eyewitnesses to the disasters, in reality or on TV.

As the war against terrorism goes on, anxiety about economic repercussions and bioterrorism also take their toll. Mental-health experts, testifying before the Senate in mid-September, said that an unprecedented number of Americans were at risk for depression and other disorders. Part of the federal aid package for New York City was a grant for mental-health services. Research from the aftermath of the Oklahoma City bombing in 1995 suggests that it may take a while before people work through the shock and denial phases of their reaction and come in for professional help.

Unfortunately, many people deny the need for help. To admit that a problem exists is often the first step in solving it. No form of therapy is a guaranteed cure. But the very act of seeking help may be a form of therapy in itself.

Maybe all you need is some sympathetic advice—or just somebody to listen to you and reassure you—and short-term therapy is growing in availability. Short-term counseling can help the bereaved or those with family problems. These times may also put a stress on relationships. Couples counseling is one good example of short-term therapy. One of the strongest trends of recent years has been toward a varied menu of therapies—a person may try everything from years of psychoanalysis to single sessions or self-help groups. It is important to find out how various therapists work and how you feel about the process.

Start by asking your primary-care physician for advice and a referral. Or a friend may be able to recommend a therapist. Shop around before making a commitment. Talk with several therapists, if you wish, and compare approaches. Most people will want to be sure that the therapist is comfortable with them, too—that he/she can treat a variety of problems without prejudice. Most therapists will charge for trial visits. Some may be willing to discuss their methods over the phone without charging.

Some people may opt for psychoanalysis, requiring frequent sessions and usually years of delving into the past. (Not all long-term psychotherapy is psychoanalysis, however.) Those trying to deal with grief or other crises may do just as well with other trained and qualified therapists. If you or a family member suffers from severe psychosis (such as schizophrenia or manic depression) you'll need an M.D., because hospitalization and psychotherapeutic drugs may be necessary.

Evaluating the care you get

The therapist's credentials and reputation are important, but so are your own feelings. You should ask yourself if you feel comfortable with the therapist, and if you believe this person can help you. According to guidelines issued by the National Institute of Mental Health, you should be able to express your concerns openly with your therapist, and if you don't "click" with one therapist you should consider finding another.
Be sure that both you and your therapist understand your goals—even if your goal is as vague as simply feeling less miserable. If you have doubts about the therapy or the therapist, express them to your therapist.

Paying for it

Self-help groups are free. But self-help may not answer your needs. Psychoanalysis, on the other hand, costs thousands of dollars annually. Drugs, if you require them, may be expensive and may not be covered by insurance. Short-term care is obviously less costly and may be available through employee-assistance programs. Many therapists are willing to accept what their patients can afford. But think twice before counting on your health insurance policy. Most insurance policies pay only in part for outpatient mental-health care. Some policies exclude psychiatric treatment altogether. Moreover, if you apply for reimbursement for mental-health care, this will become part of your permanent medical records, and may be a factor if you apply later for life insurance or individual health insurance.

The good news: Medicare covers up to half the cst for mental health services, and most supplemental (Medigap) policies pick up the rest—provided the therapist is willing to settle for what they allow. A bill is currently before Congress mandating higher Medicare coverage (Medicare Mental Health Modernization Act of 2001, sponsored by Senator Paul Wellstone of Minnesota and Representative Pete Stark of California).

Medicine for the mind

Antidepressants and anti-anxiety drugs have come into wide use as adjuncts to talk therapy—or replacements for it. Drugs usually work faster and cost less than therapy, so HMOs favor them, and sometimes doctors and patients do, too. Prescriptions for these drugs were the third largest category of all drug sales by 1998, written not only by psychiatrists, but also primary-care physicians.

Antidepressants: Those prescribed today are usually the SSRIs (selective serotonin reuptake inhibitors). This mouthful means that the medication helps keep the brain chemical serotonin at desirable levels—so that instead of feeling depressed, for example, you may have a sense of well-being. Prozac is the most famous of these; it is now also available as a generic (fluoxetine). Other SSRIs include Paxil (paroxetine), Celexa (citalopram), Zoloft (sertraline), and Luvox (fluvoxamine). All have been shown to be helpful for mild to moderate depression. Other antidepressants that work on different brain chemicals may also help.

Choosing the right drug and the right dose usually takes experimentation—under a physician's supervision. It takes about two to six weeks before SSRIs are fully effective. All of these drugs have side effects.

Anti-anxiety drugs: Benzodiazepines, the most commonly prescribed tranquilizers, are used for anxiety rather than depression. Examples include Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Librium (chlordiazepoxide). They can cause drowsiness—indeed, sometimes they are prescribed as sleeping pills or sedatives. But they should not be used long term, because they are habituating—that is, they lose their effectiveness over time. They can also cause disorientation and other side effects.

Antidepressants and anti-anxiety drugs should not be used with alcohol.

Dealing with traumatic stress

Post-traumatic stress disorder (PTSD) is a relatively new term for what used to be called "shell shock," the disabling anxiety disorder first noticed among soldiers who had been through battlefield horrors. (Every war produces its share of such cases.) But PTSD can affect civilians, too—people who've lived through bombardment, imprisonment, or torture; earthquake and hurricane survivors; children who witness terrible events or are subjected to abuse; and victims of rape or other forms of violence. Some survivors of the September terrorist attacks may suffer from it, particularly rescue workers and the bereaved, as well as those who witnessed events up close.

Symptoms can include intense feelings of helplessness, anger, denial coupled with numbness, grief, and possibly hatred and mistrust of everyone. Insomnia is common, along with bad dreams and nightmares. Survivor guilt ("why didn't I get killed, too?") may torment people. Many relive their experiences in flashbacks and dreams. A few think of suicide.

Still, the great majority of people recover and go on. PTSD is usually diagnosed when the symptoms continue for more than a month. Nobody can explain why some people recover from trauma and others don't. But the very young and the very old, those in frail physical or mental health to begin with, and survivors of past trauma may be more vulnerable than others.

If you or someone you care about needs help with PTSD, look for a therapist with training in treating it. Psychotherapy and medication are the two main approaches. If your symptoms are milder, you may do all right without medications. But if therapy doesn't help, medication can get you past a crisis. A therapist can teach you skills to manage your anxiety and help you challenge irrational beliefs.

A glossary of therapies and therapists

Talk therapy takes place in many settings and in many forms. It may consist of long-term therapy or short-term counseling. Individual therapy may be combined with group therapy or self-help groups. There's little to indicate that one kind of therapy is superior to another.


• One-on-one therapy: May deal with immediate or long-term problems; often tries to uncover underlying causes in the past.

• Couples and/or family therapy: Discussions with a psychiatrist, psychologist, marriage and family therapist, or other trained and licensed mental-health professional. Focuses on psychological dynamics between spouses, partners, lovers, and friends, and among family members and even co-workers.

• Self-help groups: Informal groups that discuss shared problems, such as a mental or physical illness, addictions, and personal crises and life changes. Alcoholics Anonymous is the oldest and best known.

• Psychologists: Clinical psychologists usually treat single patients; may work as counselors in businesses, schools, mental-health centers, and hospitals. Usually have a doctorate plus postdoctoral training.

• Psychiatrists: M.D.s with several years of postgraduate training. Can prescribe medicines and hospitalize patients. May treat a range of problems, from severe psychoses to milder emotional disorders; may specialize in child, adolescent, or geriatric psychiatry.

• Psychoanalysts: Usually M.D.s with additional psycho-analytic training. Only those who are M.D.s can prescribe drugs and hospitalize patients. Members of the American Psychoanalytic Association have received rigorous training in institutes approved by the Association. However, other schools also train analysts, and almost anybody can legally call himself a "psychoanalyst."

• Psychiatric social workers: May direct clinics or have private practices, and are often active in community programs, such as drug-abuse treatment. Must be licensed.

• Psychotherapist, psychiatric counselor: If you choose someone who practices under such a catchall title, ask about his/her training and background. In particular, marriage and family therapists and clinical social workers often call themselves psychotherapists. But people can set themselves up as "psychotherapists" without being trained or licensed.

Resources

Your primary-care physician, teaching hospitals, university departments of psychology and social work, and local self-help groups are potential sources of referrals. Many employee-assistance programs also offer confidential counseling and referrals. Your local library, and even the Yellow Pages, are other good places to start. Here's a partial listing:

• The Knowledge Exchange Network (KEN) of the Center for Mental Health Services can direct you to organizations and offers many publications.
KEN, P.O. Box 42490
Washington, DC 20015
800-789-2647


• The National Mental Health Association (NMHA) provides brochures and referrals.
NMHA, 1021 Prince Street
Alexandria, VA 22314
800-969-NMHA (6642) or 703-684-7722


• The National Mental Health Consumers Self-Help Clearinghouse can help you connect with self-help groups.
1211 Chestnut Street, Suite 1207
Philadelphia PA 19107
800-553-4539 or 215-751-1810


• The American Psychiatric Association offers free pamphlets on mental disorders, substance abuse, and choosing a psychiatrist.
APA Division of Public Affairs
1400 K Street NW, Washington, DC 20005
888-357-7924


• The American Psychological Association publishes pamphlets on mental health problems, as well as lists of psychological associations in your area.
750 First Street NE
Washington, D.C. 20002-4242
800-964-2000


• The National Association of Social Workers (NASW) provides lists of credentialed members.
750 First Street NE, Suite 700
Washington DC 20002-4241
800-638-8799 or 202-408-8600


• The American Association for Marriage and Family Therapy provides tapes, brochures, and lists of licensed counselors.
1133 15th Street NW, Suite 300,
Washington DC 20005-2710
202-452-0109