George Santos is no stranger to natural disasters. Currently the chief medical officer at the Houston Behavioral Healthcare Hospital, he still remembers the successes—and failures—of disaster response after Hurricane Katrina struck, nearly 12 years ago. Back then, he managed a New Orleans–based team of clinicians who struggled under the duress of crowded shelters like the Superdome, breeding ground for not only despair, but violence, theft, and sexual assault. Santos anticipated that the scope of devastation from August’s Hurricane Harvey might’ve been comparable, but this time he was confident that the preparedness—and response—would be overwhelmingly different.
In the days immediately after the hurricane, Houston’s NRG Stadium became a de facto shelter, housing nearly 3,000 displaced residents assigned to cots surrounded by whatever valuables they’d been able to salvage. Creating order to avoid another Superdome-esque nightmare became paramount. There were separate rooms for single males, single females, and families, each well-guarded by checkpoints. Meanwhile, Santos and his four teams of roving psychologists and psychiatrists, equipped with reading materials and first-aid kits, combed the long hallways, using a model based on the Veteran Administration’s Field Operations Guide. Their plan: to meet with families to educate them on the psychological impact of the hurricane, recognizing that children were particularly susceptible to the traumatic effects of natural disasters. Santos sums up his guiding principle in a few words: “You don’t wait for people to come to you,” he says. “You go to them.”
Disaster work is anything but therapy as usual. From conducting an impromptu session in a stadium bathroom with a man weeping at his son’s recent arrest, to treating a revolving door of people at a walk-in clinic—up to 90 residents per day—the medical model of traditional therapy as most know it becomes irrelevant. No longer are clinicians bound by 45-minute sessions between a therapist and client in a quiet office setting. “Immediately,” Santos says, “I knew this wasn’t going to be like the old process, where I do a psychological debriefing and get into this intensive decompression talk about a traumatic event.” Instead, he says the strategy becomes tending to immediate needs—“making people feel like they have some control back in their lives.”
While seemingly intuitive, psychological first aid, says Santos, still needs to be learned. A common misconception about doing this work, he explains, is that the focus is going to be all about the natural disaster. But the problems that many displaced Houston residents are experiencing aren’t necessarily about the flood. “They’re about the compounding stressors,” he says. In the years since disasters like Katrina, clinicians like Santos say they’ve fine-tuned their interventions down to a few simple but important points: pursue a first-aid model based on giving practical assistance, be therapeutic without necessarily acting like a therapist, teach local residents the skills they can use to put therapeutic teachings into practice long after shelters and the therapeutic staff are gone, and enlist community resources even before disaster strikes.
Knowing that children are among those most affected by natural disasters, and using Katrina as a reference point, the Houston Independent School District, for instance, recently put in place a “mental health recovery plan,” which included clinician-led training programs to educate schoolteachers about therapeutic playtime activities. With more than 200,000 Houston students displaced by Harvey, teachers became de-facto counselors—the most efficient way, the organization says, to stave off post-traumatic stress in young populations.
The Community Mobilizes
One of the people leading such training programs is Janet Pozmantier, a clinical social worker and director of the Center for School Behavioral Health at Mental Health America’s (MHA) Houston chapter. In the days after the storm began, she watched as her own backyard flooded with water and her neighbors and their children sought higher ground. “After just a few days,” she says, “I could see that these kids were becoming withdrawn and anxious. They had headaches and stomachaches. Many even blamed their parents for failing to protect them.” In response, she spearheaded an initiative through MHA Houston to get 50 licensed therapists to visit area schools and train two teachers per location on how to spot early signs of trauma, conduct grief counseling, and lead mindfulness exercises. To date, more than 700 teachers in 23 independent school districts have been trained under this program. “More than anything,” Pozmantier says, “healing is coming from just being there with people and holding their hands.”
Other Houston residents, like Jennifer Townsend, a board-certified music therapist and program manager of Music Therapy at Houston Methodist Hospital, agree that simply offering an immediate sense of comfort and support can work wonders. After the hurricane struck, Townsend set up a makeshift daycare in the hospital conference room—“not exactly a normal space,” she recalls—for their overworked staff’s families. About 50 children between the ages of 18 months and 11 years old attended, many of whom Townsend knew were at risk of traumatization after being forced to leave their homes. One young boy, whose family was forced to move to a hotel, isolated himself from group activities, curled into a ball, and cried anytime another child encouraged him to join in. And a young girl continually complained that since her living room had flooded and a portion of the rug had been removed, the exposed floor was now covered in sharp carpet tacks.
“I knew these kids had confines put on them that were disrupting their normal childhood activities and development,” Townsend says. “And while I didn’t have consent to do therapy in the traditional sense,” she adds, “I knew it was possible to give them back some of the control they’d lost.” To access the therapeutic benefit of using their bodies and voices, she asked the group to sing while using egg-shaped rattles. To normalize their experiences, she had them change the lyrics of “There Was an Old Woman Who Lived in a Shoe,” so the woman in the song lived in a hotel instead. And for the child whose living-room rug had been damaged, she came up with another exercise. “Gosh, you can only play on one area on the rug?” she asked the girl. “Well, when you go home tonight, what could that rug become? What if we turned that part of the rug into a flying carpet?” Day by day, she watched as the boy inched closer to the group sing-alongs. Within a week, he’d joined the group and even befriended the little girl, who draped her arm around him and invited him onto her magic carpet.
“What I did here wasn’t therapy,” she says. “But I could still discuss these kids’ concerns and validate them. When we sang, for instance, we could talk about what lyrics mean without going super deep, and could still touch on themes of hope and positivity. We’re looking at a 10- to-15-minute experience that’s offered a space for brief healing and getting used to new situations, one day at a time. That’s what people need right now.”
The nature of giving psychological first aid is that the therapist and the treated person don’t develop any long-term relationship, says Valerie Cole, who manages the Disaster Health Services program for the American Red Cross and has been working in Houston since the hurricane. Instead, she explains, the community eventually fills the therapeutic role. “With a little luck,” she says, “the people we treat will be leaving the shelters soon. We assume that most people are going to be resilient or be able to cope with the stresses of the disaster if they connect with their normal support network of friends and family.” Cole manages roving teams that include nurses, spiritual care specialists, case workers, and psychologists—unique, she says, in their composition and the degree of collaboration that comes with it.
Cole warns that this type of work is drastically different from typical therapy, and volunteers can work up to 12-hour days. “Things change rapidly,” she says. “If you expect things to be a certain way, you’re probably going to be wrong. We can train someone on Monday, and by the time they arrive in Houston on Wednesday, some shelters may be closed, others newly opened. Or new storms could suddenly hit. You just never know what you’ll find.”
A Self-Sustaining Model
Therapists like James Gordon, who runs the Center for Mind-Body Medicine (CMBM) in Washington, DC, find several important constants in doing this work: just making yourself available, and paying attention to self-care. These are takeaways from Gordon’s repeated interventions in disaster areas like post-Katrina New Orleans, Haiti, Syria, and the Gaza Strip. “I actually encourage therapists to call up their clients and let them know they’re available,” Gordon says about post-disaster care. It’s equally important, he adds, to reach out through established community services to other people in disaster areas who’d never normally consider seeing a therapist, or might avoid it because of stigma.
Both a boon and a detriment to doing this type of work, Gordon says, is that the problems that therapists working in disaster areas deal with hit close to home, especially if they live in the affected area. “People will say, ‘Yeah, this therapist gets what I’m going through,’” Gordon says. “But I’ve seen it time and again: when we’re in these areas, we share the people’s anxieties; we share their dreams and nightmares. Helping people is one of the most profoundly therapeutic things you can do, but it can definitely catch up to you.” Talking about what you’ve seen and heard with other professionals, Gordon says, goes a long way in preventing burnout. Even just taking a walk for a few minutes a day, he adds, can make all the difference.
In late August, the American Psychological Association released a statement warning Houston therapists against “self-deploying” to disaster areas, encouraging them instead to volunteer through the Red Cross website, which coordinates nine-day deployments. It’s a point Gordon agrees with. “Make sure there’s a place for you,” he advises, by first connecting with a university, community center, or other institution that has a volunteer program in place. “Otherwise, you’re just wandering around and might get in people’s way,” he says. And “going to the client,” he adds, doesn’t mean walking into shelters and sitting on people’s cots uninvited. Rather, clinicians should offer a gentler invitation, such as announcing to a room of displaced people who you are and offering your services, either individually or as part of a group workshop. Above all, he says, “I tell people who I am and why I’m there. I tell them I have no agenda, except to help them, should they want the help at all.”
In the nearly 26 years since CMBM was created, Gordon says he’s learned that the best psychological first aid provides basic support and education. The exercises he relies on the most for this—like deep belly breathing, guided imagery, and drawing—allow remedies to surface that wouldn’t come up with talk therapy alone. One intervention he found particularly helpful with Katrina survivors was an exercise in which he asked people to draw two pictures: one portraying them with their biggest problem, and another in which this problem was solved. Gordon says he anticipates using this technique again with Harvey survivors when he travels to Houston at the end of the year, at which point any lasting PTSD symptoms will have become evident.
Laurie Leitch, a psychotherapist and trauma specialist based in New York, also swears by body-oriented interventions like Gordon’s, which she says are ideally suited to working with populations that may have little or no experience with psychotherapy, and can be easily taught by others after just two or three hours of training. “The medicalized approach to mental health as we’ve long known it,” she says, “is an outdated concept.”
What therapists need to be doing, Leitch explains, is figure out how to use the community as a healer. “One of the ways we can do this is by teaching people what happens to the body when they feel fear or anxiety,” she says. “I tell people what to expect in the days or weeks after disasters—sleepless nights and anger, for example—and then how to access their natural capacity for resilience.” After teaching them tools to self-regulate, like breath work or drawing, they can advocate better for themselves, she adds. “These are tools more therapists need to have in their tool bags. Say we’re treating 10 people in the basement of a church. If those 10 just teach 10 other people, that’s 100 people treated at no cost. Slowly but surely, we’re going to see the community bounce back.”
In the end, many therapists say that while working in disaster areas can be gritty, unpredictable, and energy-sapping, every day is a reaffirmation of why they chose to get into the profession in the first place. George Santos says he’s buoyed by the notion that when therapeutic relief work is done well, the community rebounds quickly and, in essence, neighbors and friends become their own best therapists—to themselves and others around them. Keeping this in mind, Santos says, is the greatest takeaway from his years in the field. “As tragic as these events are, I’ve always told my staff that when something like this happens, you have to jump in and participate,” he says. “These are rare events that teach us a great deal about why we do what we do. And throughout it all, I’ve watched our professional community come together. As so many people have said, Texas has more love than water.”
Chris Lyford is the assistant editor at Psychotherapy Networker.
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