If the individual is reporting anxiety symptoms that are interfering with daily functioning
If the individual is requesting assistance in managing anxiety symptoms
If the individual’s score on the Anxiety subscale of the DASS-21 is 4 or above (using the 0-1-2-3 rating for questions)
Provide psychoeducation about the nature of anxiety in the aftermath of disaster
Implement thought monitoring to increase awareness of the experience of anxiety, and in particular worry and rumination
Provide behavioural interventions: control short-term hyperarousal via breathing retraining, here-and-now calming strategies, as well as the regular scheduling of progressive muscular relaxation and other relaxing activities for longer-term regulation of the autonomic nervous system
Consider cognitive interventions: reducing worry and rumination with the use of cognitive techniques
Administer Depression Anxiety Stress Scale (DASS-21)
Assess the following:
Recommend anxiety monitoring with the use of the monitoring form here. Increased awareness of the experience of anxiety, and the particular symptoms most prominent for each individual, provides direction regarding the interventions most likely to assist. For example, many disaster-impacted individuals are not aware of the role of worry and rumination in contributing to their distress. Highlighting the issue may provide an impetus for using worry and rumination management strategies. Monitor for at least a week prior to commencing using the strategies to provide a baseline against which to gauge the effectiveness of the interventions. Continue monitoring throughout the intervention period to gauge success or otherwise. Adjust interventions if improvement does not occur.
1. Provide psycho-education about anxiety, worry and rumination
Disaster-impacted individuals may find it useful to understand the role of the flight-fight response in anxiety. Read this Flight and response handout. This flight and response handout can form the basis for a conversation between health practitioner and the disaster-impacted person.
It is also important for people to recognise when they are worrying or ruminating, and to note the impact on their mood. Worry is thinking about the bad things that might occur in the future, the ‘what if’s’. These thoughts are associated with anxiety and tension. Rumination involves dwelling on things that occurred in the past, and can lead to sadness, hopelessness and depression. Worry and rumination are common following the experience of disaster, and many people will engage in both without actually noticing they are doing so. Some degree of reflection on the past, and anticipation of future events, with a problem-solving focus, is helpful. However, the balance is tipped when a spiral of worry or rumination occurs that the individual cannot easily extract themselves from.
If relevant, it may also be helpful to challenge a particular myth around worry and rumination. That is, some people believe that worry and rumination are effective ways of solving problems. They are not. They often cause levels of distress that actually make it less likely the individual can think rationally and arrive at effective solutions. Furthermore, worrying about what might be in the future will not change the likelihood of something bad happening and rumination does not change events of the past. Essentially, when people worry and ruminate, they are often thinking about things that they cannot change.
However, in challenging worry and rumination, the health practitioner should be careful not to sound as if they are minimising the person’s experiences. The experience of disaster can be highly stressful, and sometimes traumatic. Additionally, ‘negative thinking’ may, at least partly, be true, for example, “I’ll never be the same”, and “What’s the point, this could happen again”. In the aftermath of a disaster, it is important that people have time to think about and process what has happened. The goal is to adjust the thinking in such a way that it moves them forward, even slightly, rather than keeping them stuck in patterns that perpetuate anxiety or sadness. For instance, the often unacknowledged background to these types of thoughts is “…and I won’t be able to handle it.” This may be able to be shifted in a more constructive direction, such as: “This could happen again, but I now have some people and strategies that I can turn to if it does.” See: Worry and Rumination handout.
2. Introduce calming skills
Acute episodes of stress, and in particular, the experience of chronic stress, can change breathing patterns. With chronic stress, breathing patterns can become shallower, more rapid and unbalanced. These changes can result in physiological responses that mimic feelings of fear and anxiety, in particular the aspects of those emotions that are experienced physically, e.g., increased heart rate, sweaty hands, and muscle tension. A powerful way to deal with distressing emotions, and counteract tense breathing and associated physical reactions, is to use controlled breathing techniques. Controlled breathing techniques prioritise slower, deeper breathing that balances inhalation and exhalation. Controlled, slow and balanced breathing underpins many effective relaxation and meditation techniques.
Post-disaster anxiety, worry and rumination may also be addressed with the regular use of Progressive Muscular Relaxation. Consider reviewing the module that explores self-help techniques designed to reduce distress. Daily practice and use of these techniques can also enhance the individual’s sense of self-control. Encourage individuals to consider using a range of free-to-download apps for smartphones designed to assist with relaxation and sleep. Other useful apps are available but may involve a fee. A Progressive muscular relaxation script is available and disaster-impacted individuals may benefit from recording themselves talking through the script, to be listened to at a later time as necessary.
3. Introduce worry and rumination management strategies
Distraction techniques aims to act as circuit breakers in the cycle of worry and rumination. Introduce the idea that genuine worries, matters or concerns that need to be solved are not being avoided, but rather unproductive worry and rumination processes are being interrupted, with the goal of replacing them with more productive processes and activities.
Some distraction techniques include useful activities such as cooking or cleaning, pleasant activities such as reading a book or listening to music, physical activities like exercise or dance, socialising, or engaging in absorbing mental activities such as a crossword. All distraction activities must be absorbing as a counterbalance to the ‘weightiness’ or degree to which memories of disaster or fears for the future can absorb attention. This is best achieved with the use of activities that require focus and concentration. Sometimes, when distraction acts effectively as a circuit breaker to worry and rumination, the person finds sufficient mental ‘space’ and clarity to move on to engage with more effective problem-solving.
Here-and-now grounding techniques
Grounding techniques can be particularly useful when a person is overwhelmed by worry and rumination. Grounding techniques pull attention from the past and future by focussing attention on the sensory details of the immediate environment, here and now. In this way, they can act as an effective ‘circuit breaker’, the use of which may then be followed by other activities such as more effective problem-solving strategies. One example is the 5, 4, 3, 2, 1 exercise. For this exercise disaster impacted individuals are asked to notice and think about things they can experience with your senses. For example, they are asked to think about ….
… 5 things they can see
… 4 things they can hear
… 3 things they can feel or touch
… 2 things they can smell or like the smell of, and
… 1 thing they like about where they are.
This technique can be repeated until the individual feels calmer. It is easily taught and easily acquired, and can be used anywhere and anytime the disaster impacted individual needs to interrupt worry and rumination. View our Here and now exercises.
Scheduling worry and rumination time
Many people believe worry and rumination are helpful strategies to engage in, and it may be difficult to persuade them otherwise. Some people appreciate strategies that ‘contain’ or limit the amount of time they spend worrying or ruminating. Where this is the case, negotiate with the person to set times when they are ‘permitted’ to worry and ruminate, but preferably not when they are trying to work or sleep. Set a limit of time to worry, e.g., 15 minutes daily, and encourage the setting of an alarm so that limits are adhered to. They should find a time of the day that does not impact on activities such as sleep. Emphasise that by scheduling time to worry and ruminate, when worrisome thoughts begin, the person can take note of the thought and tell themselves they will postpone the process until later, thereby learning that worry and rumination are controllable. Noting those thoughts in writing can assist the person in the knowledge that they can come back to the thoughts at a later time.
During worry and rumination time, encourage the person to ask themselves if the issue they are thinking about is something that can be solved – can they change the situation or not. If the situation can be changed, encourage them to think of practical, concrete ways that change may occur and to write them down. If the situation cannot be changed because it has already occurred, or because it involves a future event over which there is no control, encourage a shift towards acceptance. Accepting it will not change the situation or diminish the ‘badness’ of the event happening (because nothing will), but it will limit the effect that the situation has on the person’s emotions and behaviour in the present. Help them to formulate and record an acceptance self-statement for the situation that they are ruminating or worrying about. The Worry management sheet may be useful.
Establish realistic expectations for change. Worry and rumination can be difficult thought processes to shift. Ongoing monitoring may allow the individual to note continued engagement in worry and rumination, and the impact on their mood. As disaster impacted individuals become more adept at noticing engagement in worry and rumination they can become more skilled at interrupting those thought cycles with circuit breaking distraction strategies. General anxiety monitoring also highlights small reductions in the process and associated improvements in mood that might otherwise be overlooked. View this anxiety monitoring form. Continue to encourage the person to complete the various anxiety management strategies in order to monitor their effectiveness.
Recommended reading list
Dai, W., Kaminga, A. C., Tan, H., Wang, J., Lai, Z., Wu, X., … & Liu, A. (2017). Comorbidity of post-traumatic stress disorder and anxiety in flood survivors: prevalence and shared risk factors. Medicine, 96(36). doi.org/10.1097/MD.0000000000007994
Pfefferbaum, B., Nitiéma, P., & Newman, E. (2019). A meta-analysis of intervention effects on depression and/or anxiety in youth exposed to political violence or natural disasters. In Child & Youth Care Forum (pp. 1-29). Springer US. doi.org/10.1007/s10566-019-09494-9
Smith RP, Katz CL, Charney DS, & Southwick SM. (2007). Neurobiology of fear, anxiety, trauma, disaster exposure: and resilience. In Ursano RJ et al (Eds). Textbook of Disaster Psychiatry. Cambridge University Press. doi.org/10.1017/CBO9780511544415.006