From January 2002 NASW NEWS
Copyright ©2002, National Association of Social Workers, Inc.

Practitioners Adapt Skills to Post-Sept. 11 World

Coping With the Fear-Filled New Reality

Many use relaxation techniques and EMDR to lessen generalized fear.

By John V. O'Neill, MSW, NEWS Staff

The intense, generalized fear of terrorist attacks is so raw and new to America that social workers are thinking about how they will adapt their old skills to help themselves, the public and their clients cope with the new realities.

Whether it's fear of flying, chemical and biological weapons like anthrax, generalized government warnings, alerts about bridges or shock from a jetliner plunging to earth because of mechanical problems, there is a "blanket of fear," said Tom Golden, a Gaithersburg, Md., clinical social worker. "I suspect it's deeper on the East Coast than the West Coast, but we're all surrounded by it. It's not like a bruise that's going away."

Most social workers dealing with fearful clients use cognitive techniques. "I'm not an expert on the psychology of fear, but from what I have learned from reading and talking to others, cognitive types of therapy in which people are taught to think rationally about dangers are helpful," said Suzanne Adelman, who is crisis program coordinator for the Jewish Social Services Agency of Metropolitan Washington, D.C.

"If people can learn the facts about the actual scale of the threat, they may be able to diminish their fears, especially if they learn statistically that the chances of something happening to them and their loved ones is small," said Adelman.

Fear escalated in New York City when one hospital worker died from anthrax and nobody could determine how she was exposed, said Michael Cronin, a social worker at St. Luke's Roosevelt Hospital Center in New York and crisis intervention volunteer with the American Red Cross. But there are eight million people in New York City, he said. "When it is put in that perspective, there is a high probability that it's not going to happen to me."

Getting the facts helps "partialize" fear, said Cronin. Instead of a generalized fear, we know what it is we're afraid of, he said. "Now we can attack each reason for fear. There is no way to get rid of it all, but [there is] a way to make sense of it."

A second technique in mitigating fear is for people to take some measure of control they feel comfortable with, said Adelman. Some develop personal guidelines of how they will handle the mail every day. They may open it outside or in the garage. Some avoided bridges in California after the governor's warning there; others didn't. "People have different levels of risk they are comfortable living with," Adelman said.

"Another thing we are all learning is disaster preparedness," said Cronin. "We are sitting down with our families and saying, 'If this happens, what will we do? If we get separated, how will we find each other?' These concrete steps help alleviate generalized fear."

Another technique Adelman recommends is to limit exposure to repeated news accounts. "People need to stay informed, but not to listen to the same news over and over again," she said. She also suggests that people maintain their normal routines and use humor or read or watch something humorous on television to lighten the anxiety.

It helps if people remind themselves that they have been through tough times before in their lives when they worried a lot, and they got through it. They might also remind themselves that in other parts of the world, people have lived with threats of terrorism for a long time, and they have developed a level of vigilance that works for them.

Adelman especially recommends that people do things that are creative and meaningful as ways to engage energies rather than worrying all the time. These include all the things that normally help people with stress, like exercise and talking, or creative activities like music, art, writing, cooking, gardening or many others.

Everybody has a different way of dealing with fear, said Golden. "What is so remarkable about human nature is that we have so many different ways to heal." For years, he said, we assumed everybody healed in a certain way: by talking about a problem and crying. "But that is just one tiny path among thousands of ways." Some people are helped by listening to others, some by a walk in the woods, and some by getting active and giving blood or volunteering at the site of the World Trade Center.

Fear is stifling and chaotic and throws people out of their normal worldview, said Golden. "The closer people get to New York City and the Pentagon, the more they are immersed in chaos and fear."

There are two essentials for dealing with fear and healing, Golden said. The first is to find a safe place, and the second is submission, or finding a way to touch the pain.

It is important to hear people out with an "open and loving heart. When people feel they've been heard, it gives them a safe place," he said.

Then it is important to teach people skills to move through the world in a calm manner. "The technology is out there: relaxation techniques, biofeedback, EMDR [eye movement desensitization and reprocessing]," Golden said. "It is very simple to teach people different ways of breathing that will help them calm down. The research is clear: if we take 15 minutes a day and lower our stress, the body and the immune system get better, and we get better."

"People are surprised that they have a lot more control than they thought. If you are extremely calm, fear is almost nonexistent," he said.

Almost all the therapists in the two peer-supervision groups Golden is involved with in suburban Washington, D.C., use relaxation techniques like EMDR, meditation and breathing exercises, he said. "The great thing about relaxation [is], it automatically creates a safe place."

Clinicians used to talk about people being resistant to therapy, said Golden. "Now we talk about how we can adjust therapy to fit the client. If they can't process the problem, then we need to work on creating a safe place."

Speaking at the NASW-sponsored meeting of the social work community in New York City in October [see story in this News], Sandy Bloom, a psychiatrist and trauma expert, also emphasized the need for safety for recovery, and encouraged social workers to look for healing in community groups.

"It is impossible to recover from traumatic experience as long as you are still unsafe," Bloom said. "And we are still all unsafe; it is not over yet."

Trauma keeps people stuck in time, "slowly sinking in quicksand. Our job is to keep as many people from getting stuck in the goo as possible."

Humans are an astonishingly adaptive, responsive and resilient species, said Bloom. "As helpers, our job is to support coping and minimize harm. The challenge comes when someone's coping skills don't agree with our own. . . . You must support coping and the continuation of functioning whether you agree or not with the other person's coping skills. Some people need their anger; others need to march for peace. Some go numb; others become hysterical. As long as they are functioning and not becoming destructive to themselves or others, congratulate them and offer them some simple tools, education and encouragement."

Bloom strongly recommended mobilizing communities to combat fear and inaction. "Social workers are geared to making the most out of community resources and tend to avoid pathologizing people. That is good, because we want to pay attention, now more than ever, to strengths that are available for mobilization, strengths that exist in even the most injured person," she said.

"Maximize the community in response to this disaster. Emphasize those skills you already have. Reconnect people to community supports. People need to be a part of something, and this connecting thing is a natural way for social workers. Help everyone in the family, not just the identified patient. Look for the leverage points. Develop an extended network and support system. Be a therapist to the system. Emphasize group interventions. There are simply too many victims for individual work; it is not the answer, except for the most injured people. Get everyone into some kind of a group; run groups yourself," said Bloom.

"Create therapeutic community in any way you can think of — it is an antidote to trauma. Work with culture and cultural diversity. Look for the inherent strengths and resources in every cultural group. Get the clergy involved, as well as educators and employers. Create networks of support for the most injured people. Be the facilitators for networks of natural support. Don't try to do it all yourself," she said.

New York City social worker Sue Matorin, a treatment coordinator at New York Presbyterian Hospital, would like more professional discussion about whether special training in trauma and bereavement is necessary to deal with fear and grief from terrorist actions. "We are doing what we always do with bereavement with any client," she said. "What is different about this is our own level of not feeling safe."

"In the beginning [after Sept. 11], some social workers felt themselves more inadequate than they needed to," Matorin said. Social workers have much training with cancer patients and suicidal clients, have worked in emergency rooms and with people who were raped and whose children died, and have worked with friends and family who were traumatized and fearful. "Not all that goes out the window because we don't have specialty trauma training." She said she would like to see a panel discussion on skills actually used in dealing with trauma and fear.

Matorin is working for change at the systems level, advocating mental health parity, as one way she deals with the after-effects of the terrorist actions. The World Trade Center tragedy ushered in a better understanding of the crippling symptoms of post-traumatic stress disorder and depression and highlighted the urgent need for access to quality mental health clinicians, she wrote in a letter to The New York Times in November. Such overdue recognition has backfired and mobilized insurance industry opposition to mental health parity, which would broaden access to service, she said.

"The opposition to parity defies our surgeon general, who has advocated for more diagnosis and treatment, and the economics that have demonstrated that any modest cost is offset by increased productivity and decreased absenteeism," Matorin wrote.

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