Best Practices for Psychotherapists
in Disaster Stricken Communities
In their own words, the mental health professionals from New Orleans describe the measures they took personally and professionally to get their lives and their work back on track after the near-destruction of their city. The clinicians interviewed for this project thought over what had been, or would have been, helpful to them in the chaos immediately after the storm, and – sometimes – what wasn't helpful at all. These tips represent a broad range of experiences.
Keep important names, numbers and email
addresses of clients and colleagues with you
Iwill never again evacuate without a computer or cell phone with an internet connection. Of course, in 2005 there were fewer smart phones. Today texting is a vital function when cell phones don’t work, which they often didn’t after Katrina, and since we didn’t know where people were, landlines weren’t much use either.
Add practice insurance to your
professional malpractice policy
1 of 2 quotesHaving practice insurance was a godsend. It meant I
could take my time returning to work and return when
I was ready, not because I had to keep making money.
2 of 2 quotesI remember I did not want to go back…I cried when I knew I had to go back to work. I cried that first month, but I needed the money.
Draw up a practice will
Download a professional will template here.
Your basic needs come first
1 of 2It seems so obvious that we need to take care of ourselves first, it is often not my nature to do so, but this time I knew I had to do that.
2 of 2I had a house to rebuild, my husband needed my help with his business, I just couldn’t think about work right then. I kept in touch with my patients by phone or text, but I didn’t start to work until I had a handle on everything that had to be done for us.
Volunteer
Many respondents found it helpful to volunteer, performing psychological first aid, assessing immediate physical and material needs, making sure survivors had shelter, helping families re-connect.
1 of 4We felt like if the first responders were going to be able to function in their jobs as well as they could, we needed to help them create some sense of normalcy in their lives. And one way to create a sense of normalcy in a totally abnormal environment was to bring families together.
2 of 4I worked in a crisis counseling program run by FEMA with people who were homeless; everybody needed services, food, and clothing. The work was so difficult.
3 of 4You hold on to the few success stories, getting someone to process their hurricane story, you can't see them more than five times; sometimes I would see them far longer.
4 of 4What was good for me was going into the volunteer center every day even if I was fairly unproductive. Each day I got a little more myself. Eventually I discovered that I could put on makeup and wear earrings again. That was like a big step.
Others felt they were not ready to do so.
1 of 2I struggled with some guilt over not doing anything to help others immediately after Katrina. Several colleagues urged me to go back to work as soon as possible. This was not helpful. As therapists we are so geared toward taking care of others that it is hard when you cannot.
2 of 2I was relieved when I did go back to work to feel that I had been able to do what I needed for me first. If I had volunteered I think I would have still been very on edge.
Get in touch with colleagues as soon as possible
1 of 4Networking is the most important thing, having a
network set up… It started with my mailing list but expanded exponentially.
2 of 4At a certain point, a local psychologist set up a website which contained information such as offers of jobs and places to live all around the country.
3 of 4Our Center President set up a system via the internet enabling our members to contact one another. This communication became a lifeline, a link to the familiar, the ability to share our stories and to find humor in our struggles.
4 of 4Colleagues, where they were, what they were doing, what they were thinking. It was just nice to have – I think belonging to any kind of group like that, both with a local nexus and larger – it was really helpful, it would have been much worse had I not.
First contacts with clients after the disaster
Many respondents found themselves initiating contact with patients, rather than waiting for patients to reach out to them.
Contacting patients did not require an internal dialogue. It was a way to take charge, to do what I had been doing for 33 years, listen to people who came to me so that I could be of help, to provide some relief, some comfort. And, as I look back at my decision, I needed to know how these people who had inhabited my life for months or years were doing, I needed to hear them.
When they did talk to their patients, they answered their questions openly.
1 of 2I usually don't tell people anything about where I am etc. But in this instance I think it's necessary to disclose exactly in concrete terms where I am, how long I'll be there, where I'll be next.
2 of 2Maybe at those times when everything is threatened we all need to hold onto something concrete to help maintain psychic grounding.
These early contacts with patients took ingenuity and flexibility.
1 of 3It is so important to be able to show flexibility. Changing techniques, helping patients identify self care activities, changing schedules if necessary, giving advice.
2 of 3Phone sessions became the norm, even though I had never agreed to hold sessions on the phone before.
3 of 3We met in my son's apartment and in coffee shops. That didn't work well. Eventually I was able to sublet an office. Sometimes I had to see people seven days a week.
This is when the hard work really begins...
take time out for yourself
1 of 4In order to take care of patients I've had to take care of myself first, and even then it's a struggle. But that's not selfish.
2 of 4Paying attention to myself, I noticed about every six weeks, it was important for me to just close things down for four days.
3 of 4I started running and joined a running club, something I'd never done before.
4 of 4I became a homebody. I took pleasure and relief in cooking large pots of comfort food to share with neighbors, family, and friends. We made great, politically inspired costumes for the first Mardi Gras after the storm.
Personal therapy
1 of 2The biggest thing which I found missing in the post Katrina experience was having the opportunity to get professional help myself. Friends and family were great but when everyone you know is going through the same thing, you don't want to burden them with your thoughts.
2 of 2The most helpful thing to me was getting into analysis—my own therapy. I wanted to be sure I was processing all my losses so that they wouldn't come back and haunt me. I needed someone to help me sort out everything that was happening to me.
Stay connected
Professional organizations.
We were able to meet in person at the Center Christmas Party. I felt as if I had returned home from a journey that I had not planned to take.
Informal professional groups.
My professional reading group became crucial. This group of six peers began meeting in 2000. This became a safe place where I could talk about my confusion in our work; where I could question myself; where I could use my imagination and stretch myself in terms of responding to the unfamiliar demands in psychotherapy. We were not merely mutually supportive, but rather mutually cognizant of the demands in this uncharted endeavor.
I just organized a workshop and hopefully there will be a training.
Friends and family.
As I sat and listened to the despair, the losses suffered, the anguish experienced I became more and more aware of my needs to be with friends, colleagues, and family.
When to return to work
Some clinicians found it helpful to start seeing their regular patients as soon as they could locate office space, others felt they did not have emotional resources to share with their patients. In the best of all possible worlds, this should be a personal decision.
1 of 5I needed to work because my grief was so profound. Sitting and not doing anything doesn't make it any better for me at all. I would much rather throw myself into focusing on someone else for a while.
2 of 5When I got back to New Orleans working was one of the most stabilizing things – getting my professional life back on track. That was familiar when nothing else was.
3 of 5I didn't think I could sit and talk with another person without needing support more than they would, and I just couldn't do it…It was the first time in my life that I ever felt incapacitated to work.
I don't want to listen, but I have to it's my job, my livelihood, my identity.4 of 5
5 of 5I somehow knew I shouldn't take on new patients and listen to their stories. It wouldn't be good for me. I needed time to recuperate.
Emergence of symptoms
Preoccupied with the physical job of recovery, adults often are not aware of the price they have paid psychologically for their survival after a disaster that has threatened their lives and/or laid waste to their community. It is not unusual for the consequences of an adult onset trauma to take a month, or a year, or even several years to present themselves.
1 of 3I feel like people have to get their basic needs met and then feel when they're in a space where they could call. And for some of my patients that does not happen right away.
2 of 3A lot of people felt worse six months or a year after.
3 of 3This is trauma's slow burn. It takes a while to realize what's happened to you.
Psychotherapy under the conditions of shared trauma
Many short term treatments focus on symptom alleviation after a traumatic experience: EMDR, CBT, somatic experiencing, systematic desensitization, hypnosis. However, many clinical respondents found that even after a course of one of these treatments, they and their patients were left feeling isolated and uneasy.
These are some of the questions that people
had about their clinical work after Katrina:
Am I making things worse for my patients?
The usual therapeutic boundaries are topsy-turvy –
what can I let my patients know about my experience?
Do I want them to know it?
What if they are doing better than me?
As a therapist I'm supposed to be OK. Am I OK?
Am I recovering from the storm or just pretending?
What am I bringing into treatment sessions
from my own life?
Does anyone else feel this way?
In thinking about these questions, we have learned a lot about the difficulties and occasional rewards of doing treatment under these conditions.
Technique
1 of 4Just the concrete presence is so important. Enduring persisting holding onto sameness, that we can continue to talk regardless of where we are and what has transpired.
2 of 4It is not business as usual anymore.
3 of 4Some of the things I was doing during a therapy hour did not resemble the therapy I was accustomed to doing. The usual therapeutic stance was abandoned and familiar boundaries seemed insignificant. It was not uncommon to share information about community resources or activities.
4 of 4Only two years later could I start thinking about what was happening with my patients in a metapsychological way.
Boundaries
Where you saw your patients, when you saw your patients, whether you kept in touch with regular sessions by phone or exchanged emails, nothing was the same. It was impossible not to break the rules you had learned during your training.
The rules of therapy and the boundaries of therapy changed for some time afterward. This did not bother me
at the time and I had little or no conflict about it, but the
fact that this type of thing will happen may be useful for other therapists to know.
Self disclosure
All mental health disciplines share an understanding that the clinician is there to learn about the patient's circumstances not vice versa. But after the storm some disclosure was inevitable.
1 of 5Patients asked the questions that frequently they dare
not ask: What happened to your house? Any damage? Insurance? Everyone ok? We knew that we had shared something that linked us together in a way that had not existed before. It could not be denied.
2 of 5I had some sense that most everyone did self-disclosure. It was unrealistic not to.
3 of 5It would be inhuman not to give some details.
4 of 5When I find myself talking too much about me I know it's time to go back to my own therapy.
5 of 5There was a constant diligence about what is going on in my own life and what am I bringing in. That's always a part of what we do but when we are both in it together it's just on such a higher level.
Handling Patients' Feelings
Empathizing with patients' experiences when they are so reminiscent of your own is constantly challenged after a shared trauma. Many clinicians found at first that they were overwhelmed, crying in sessions or after sessions. Having colleagues or supervisors with whom to debrief was crucial. Knowing when not to take on particular patients was an important skill. Over time hearing about patients' experiences became less destabilizing.
1 of 3My feelings were thinly veiled, as I was effusive with
my encouragement and unable to disguise my tears and sadness on occasion.
2 of 3I finally understood that being present had nothing to do with the similarities or differences in the facts of my experiences as compared with the facts of the stories of my patients; it had everything to do with the emotional resonance.
3 of 3This shared disaster brought a new dimension to our work. This was no longer about taking in or sheltering myself from my patient's experiences, this was about knowing, first hand, what my patients were speaking of.
Validation
Those therapists who had come to terms with their own storm related experiences were in a better position to listen to and to acknowledge their patients' experiences. When treatment becomes an avoidance of the therapist's pain rather than an exploration of the patient's, it promotes further dissociation.
1 of 2It was very hard for me when my therapist didn't want
me to be traumatized and told me how well I was doing.
I felt that he couldn't understand what I'd been through,
he didn't understand because he didn't want to.
2 of 2From a patient's letter: I understood that I had censored my experience [when I was talking to my therapist] … But I needed her to acknowledge it. I finally called her back and made her listen to a real account of what happened. She was quick to say what was happening; that she hadn't wanted to hear I'd been traumatized. It made me feel much better. That may seem to be a small thing.
1 of 5Ithink by now, three years after Katrina, our work is going back to the way it was, but things will never be the same.
2 of 5I'm feeling kind of a renewed joy in my work and I feel that comes across to patients. We're back on track now.
3 of 5I'm a lot more real, more present, more connected to my patients.
4 of 5I have at once been humbled and enriched by this experience. I think that I appreciate the complexities, the texture of life's experiences differently than I have before now. Having shared the intimate experience of trauma with so many people makes room for a kind of connection I had only sampled and not quite captured before Katrina.
5 of 5I am aware of being different, personally and professionally. I am not uncomfortable in this new situation; I believe that it was through sharing this experience that my patients and I grew and came to understand the human factor that we all share.
For an in-depth discussion of the dynamics of shared trauma see Boulanger, forthcoming, Fearful Symmetry: Shared Trauma in New Orleans after Hurricane Karina.
Are you ready to think about the long-term effects of this disaster on yourself and your professional community?
It's really helpful having outside mental health professionals come in and provide various types of training and support and encouragement.
Determine whether you could use an outside group to come in monthly to provide consistent professional debriefing and support. You can get in touch with therapistspostdisaster@gmail.com in order to learn more about the outside help available.
Be prepared to step in where needed.
Support local clinicians in their individual work where necessary.
1 of 3People have mixed feelings about people who come from the outside. If outsiders come making assumptions about us, it doesn't work. They need to be interested in us, not just the storm; they need to understand our context and our history.
2 of 3The Red Cross wanted us to volunteer in their shelters. But they didn't give us enough to do; I was just kind of sitting there. The things they gave me to do were not particularly helpful.
3 of 3I think using the local people for concrete activities that didn't really involve our high level skills could have been helpful. We were so overwhelmed with anxiety. We weren't capable of doing any more.
Offer resources depending on requirements.
1 of 3They asked us what we needed, they came back several times. They did EMDR with us, and then they trained a group of us to do EMDR. It was a wonderful training opportunity.
2 of 3Not long after the storm one man came to talk about PTSD. Almost as soon as he started to speak, people raised their hands to comment. After a few minutes of that, he put aside his lecture and said, 'It's clear you all have a lot to tell me, so why don't I listen to you instead.' That was very helpful.
3 of 3A group of outsiders came to run a support group for the school children who had been evacuated to Baton Rouge. I'm the school counselor but they wouldn't let me be part of those groups because they said they had to keep their boundaries. I thought that was very disrespectful to me. The kids needed the continuity I could provide, I needed them to know I was there for them.
