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Family therapists in trauma-response teams: bringing systems thinking into interdisciplinary fieldwork

Tai J. Mendenhalla and Jerica M. Bergeb

Attention to the mental health facets of disaster-preparedness and trauma-response teams has increased considerably over the past decade. As family therapists take part in these efforts, they bring with them a worldview that adds valuable contributions to the nature in which field- work is conducted and the manners in which interdisciplinary teams function on the ground. In this article, we present how systems thinking sensitizes trauma workers to a variety of clinical presentations and biopsychosocial complexities inherent in this work. We describe common clinical- and practice-related challenges, alongside practical strategies for effectively dealing with these challenges. We draw upon our experiences as family therapists trained in the field of trauma, and our work as field responders, supervisors and team leaders across a variety of local and large-scale disaster events and contexts.

Keywords: trauma; trauma-response teams; disaster; disaster relief; disaster response; family therapy; family therapy in trauma; mental health in fieldwork.

Introduction

Attention to the mental health facets of disaster-preparedness and trauma-response teams has increased considerably over the past decade. Mental health workers representing a variety of disciplinary backgrounds and training are coordinating their efforts now more than ever before with medical providers and other team members in responding to local, large-scale, natural and man-made disasters. The

Journal of Family Therapy (2010) 32: 43–57 0163-4445 (print); 1467-6427 (online)

Address for correspondence: Tai J. Mendenhall, Ph.D., University of Minnesota Medical School, Department of Family Medicine and Community Health, Minneapolis, MN 55414, USA. E-mail: [email protected].

a Assistant Professor at University of Minnesota Medical School, Department of Family Medicine and Community Health, Minneapolis, USA.

b Assistant Professor at University of Minnesota Medical School, Department of Family Medicine and Community Health, Minneapolis, USA.

r 2010 The Authors. Journal compilation r 2010 The Association for Family Therapy and Systemic Practice. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

mailto:[email protected]

acute nature of this work – its fast pace and intensity, chaotic and unpredictable structure, clinical content, and simultaneous involve- ment of professionals and non-professionals – expands providers’ roles beyond that of conventional office-based clinical practices (Ba- cigalupe, 2002; Garner and Nocera, 1999; Mendenhall, 2006; Mitch- ell and Everly, 2003). Whether a psychologist, family therapist, social worker, counsellor or psychiatrist, fieldwork can push mental health providers outside of their respective disciplinary comfort zones into comparatively uncharted ways of working that extend not only to the surviving victims and families who allow us access to their most raw and painful suffering, but also to the ways in which we attend to our own psychological and physical well-being, interpersonal and inter- professional boundaries, cross-disciplinary tensions, and team struc- ture and hierarchies (Fraenkel, 2002; Reilly, 2002; Walsh, 2007).

Family therapists represent a comparatively new discipline in the larger field of traumatology, which encompasses first-emergency responses, providing psychological first aid, field supervision and team leadership (American Red Cross, 2008; Green Cross Founda- tion, 2004; International Critical Stress Incident Foundation, 2004; Reilly, 2002; Walsh, 2007; Weine et al., 2005). With family therapy comes a worldview in which therapists are comfortable with the complexities of overlapping human and relationship systems – and this worldview adds a valuable contribution to the nature in which fieldwork is conducted and the manners in which interdisciplinary teams function on the ground. In this article, we draw upon our experiences as family therapists trained in the field of trauma and our work across a variety of local (e.g. clinic shootings, daycare murders, office suicides, marathon deaths) and large-scale (e.g. the 9/11 terrorist attacks in 2001; East Asian tsunamis in 2003; Hurricanes Katrina and Rita in 2005; the Minnesota 35-W bridge collapse in 2007) disaster events and contexts. Working within the roles of field responders, clinical supervisors and team leaders has sensitized us to the ways in which family therapists can contribute to these important endeavours, and to an increased understanding and sensitivity to challenges inherent in this work.

Bringing systems thinking into trauma work

Family systems theory – or ‘systems thinking’ – represents a hall- mark of family therapy and the many clinical approaches that it encompasses. Key theoretical underpinnings – including attention to

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relational factors, interaction sequences, social and political contexts, and extra-therapeutic factors – guide everything that we do (Blow and Sprenkle, 2001; Rosenblatt, 1994; Walsh, 2007; Whitchurch and Constantine, 1993; Woodcock, 2001). Moving beyond primarily individual-oriented intervention strategies (and those focused on groups of individuals) in conventional approaches to psychological first aid and trauma responding, family therapy commands explicit attention to individual, relational and family systems as bounded sets of interrelated elements. Family therapists bring an overt sensitivity to inter-member processes that are related to increased stress in the contexts of disaster (e.g. family conflict, over-functioning/under- functioning patterns) and trauma work, as well as opportunities to foster and push positive relational and family dynamics in both acute and long-term phases of support.

Biopsychosocial systems

Family therapists in fieldwork readily conceptualize ‘systems’ in accord with the biopsychosocial family systems model, which pushes marriage therapy, family therapy, medical family therapy and many other arenas in collaborative family healthcare to consider multiple and interconnected systems, including patients’ anatomical and phy- siological make-up (e.g. brain structure, somatic symptoms), psycho- logical functioning (e.g. PTSD, depression, anger, sense of hope and/ or hopelessness), relational and family systems (e.g. attachment, communication, boundaries, cohesion, adaptability), and larger social and ecosystemic structures (e.g. supportive peer and friendship net- works, contemporary political milieux, neighbourhood wealth/pov- erty) (Bremmer, 2002; de Zulueta, 2006; Engel, 1977; Doherty et al., 1987; Flaskas, 2007; McDaniel et al., 1992; Woodcock, 2001). As we work with surviving victims and families in response to any kind of disaster or trauma, we must honour the complexities of these multiple and interconnected systems, as they are all relevant and influence each other. Embracing this complexity is a driving element of the multidisciplinary nature in which fieldwork is conducted, and often forces us to challenge – and sometimes extend beyond – our conven- tional scope(s) of practice (Fraenkel, 2002; Reilly, 2002; Walsh, 2007). For example, Woodcock (2001) described how integrating psycho- analytic ideas with systemic practices can contextualize individuals’ respective functioning within families – and thereby synthesize com- peting perspectives in healing and growth. Felicity de Zulueta (2006)

Family therapists in trauma-response teams 45

similarly argues for integrating such approaches, highlighting how attention to family members’ unique attachment histories influences the manners in which they experience trauma – thereby informing therapists’ effective intervening and care. Many other examples of multisystemic approaches for working with families and communities after traumatic loss and disasters are reported in the literature (see Walsh (2006, 2007); Landau and Saul (2004) for a comprehensive review).

Roles and boundaries

Finally, systems thinking commands that we recognize and honour our own roles in the process of helping. For example, attention to our personal emotional processes, self-care, and preventing burnout and compassion fatigue are not only important for our own and other team members’ sake, but for the safety and well-being of the people and families we serve (Figley, 1995; Lum, 2002; Marriage and Marriage, 2005; Skovholt, 2000; Timm and Blow, 1999). Attention to the overlapping and unique areas of expertise that we bring to fieldwork by the nature of our professional backgrounds and training is also important to consider, because everyday divisions of scope of practice and professional collaboration are often different in the field. Further attention to, and examples of, these challenges are described below.

Responding to inherent challenges in interdisciplinary fieldwork

The nature of fieldwork brings with it a variety of challenges that are considerably different from work that is conducted in conventional office, clinic and hospital contexts. Clinical and practice-related foci represent common interdisciplinary fieldwork challenges widespread in trauma work for which family therapists are trained and well positioned to inform. Throughout this section we use examples from our trauma work to highlight systemic ways of managing these challenges.

Clinical challenges

Clinical challenges (i.e. those faced by surviving victims and their families) in fieldwork present in numerous and diverse ways. From the raw intensity of being in-the-moment with individuals and families

46 T. J. Mendenhall and J. M. Berge

to their long-term grieving and efforts in recovery, the content of what is experienced in trauma is something that includes both common themes and unique experiences that are not easily imagined before- hand or repeated afterwards.

Meaning-making. As systems thinking promotes sensitivity to the com- plexities inherent in care that encompass multiple and interconnected persons, it also promotes ready appreciation for respective family members’ individual and co-created perceptions of meaning (Freed- man and Combs, 1996; Hill, 1949; McCubbin and Patterson, 1982; White and Epston, 1990). For example, ‘Why did this happen?’ is one of the most common questions and difficulties that individuals and families struggle with, and the co-creation of some kind of answer to this query is often a first step for surviving victims en route to recovery (Boss, 2002a; Frankl, 1984; Pocock, 1997). As mental health profes- sionals working with victims of trauma in the field, it is important to sit with people’s pain as they struggle with this meaning-making. Bear- ing witness to people’s stories – listening compassionately – is often more important (and indicated) than suggesting to people our versions of ‘why’ something has happened or what they should get out of it. This wisdom is important as we create space for surviving victims to process what many experts refer to as ‘shattered assump- tions’ (e.g. realizing that the world is not a safe or fair place) (Catherall, 2002; Janoff-Bulman, 1992; Shapiro, 2002; Walsh, 2007) and create new meanings and interpretations about events on their own and with their loved ones (Blackwell, 1997; Herman, 1997; Reilly, 2002; Weingarten, 2004).

For example, a child with whom we worked in New York City was able to move forward in her grief as she constructed a personal narrative with others about her father’s death that framed his familiarity with the World Trade Center towers as having enabled him to save the lives of more than a thousand people who would have otherwise perished (Boss et al., 2003). An elderly parent who had not spoken with his eldest son for over twenty years framed the 2005 hurricanes (Katrina and Rita) as a gift from God that ultimately reconnected them in a loving journey of forgiveness. A man in his mid-thirties who lost his mother in the Minnesota 35-W bridge collapse maintained that only afterwards was he able to truly appreci- ate the people in his life (a message that she had often tried to relay to him), and made considerable changes in the ways in which he func- tioned within his remaining relationships. He began saying ‘I love

Family therapists in trauma-response teams 47

you’ to his wife spontaneously and every day, instead of only as he left the house or as he signed a birthday card. He quit his second job so that he could attend his son’s sporting events. A 25-year-old woman who lost her colleague to suicide stated that she will tell her other colleagues daily what she appreciates about them so that they never feel unappreciated and lonely.

Ambiguous loss. When there is a mismatch between a loved one’s physical and psychological presence, family members are faced with a type of loss for which conventional means and mores regarding grieving and reaching ‘closure’ are not readily effective (Boss, 1999, 2002b, 2006). Across world cultures and religions, for example, saying goodbye to those who we have lost through death generally includes ceremonies and funeral sequences in which the presence of a deceased body confirms that the loved one is deceased. However, if the person is missing – as so many people were following the 9/11 and East Asian tsunami disasters, for example – objective confirmations of death are often not possible. This ambiguous loss can evolve into a state of ‘frozen grief ’, wherein individuals and family members are not able to reach closure through conventional means of saying goodbye – or even believe without doubt that the loved one in question is, indeed, dead (Boss, 1999; Boss et al., 2003). And systemically, individual members of the same family frequently espouse different viewpoints regarding the missing person’s status as a person who is alive or a person who is dead (Boss et al., 2003; Mendenhall, 2005). Attending to the simultaneous experiences of hope and hopelessness within individuals and families represents a considerable challenge in therapy, but an essential one in honouring respective members’ viewpoints in relation to each other (Boss, 2006; Flaskas, 2007)

In New York City, for example, many family members maintained that they believed their loved one(s) was still alive under the rubble, and that it was their hope and love that was keeping them alive until rescuers finally found them. As other family members let go, painfully, of this hope, conflict with those who continued to hold on to it would frequently manifest. Similar sequences were common following the East Asian tsunami and Hurricanes Katrina and Rita. It was very important to elicit, and listen to, family members’ differing viewpoints insofar as their primary sources of support – each other – are often either not available or in outward conflict as respective members processed and dealt with the ambiguous loss in different ways.

48 T. J. Mendenhall and J. M. Berge

Creating space for and normalizing disagreements is important in healing and growth – and represents a key contribution from the field of family therapy (generally) and ambiguous loss (specifically).

Across our own experiences in fieldwork, this takes the form of various interventions – from agreeing to disagree, creating new meanings together to achieve closure without conventional funeral sequences, to allowing people to change their opinion daily regarding whether their loved one was dead or alive (i.e. accepting the dialectic; Boss, 1999; Boss et al., 2003). For example, some families we worked with in New York City chose together to believe that ashes that they were given from the Ground Zero site contained ‘some’ of their loved ones – and then went on to have a funeral with these ashes. Families we worked with in Sri Lanka would walk along the beaches at low tide searching for shoes, clothes or other articles that they knew or believed to have belonged to their loved ones – and then were able to agree together that while the Ocean had taken their loved ones away, it had then returned something so that they could have a funeral and say goodbye.

Increased appreciation for loved ones. We have found that the experience of disaster and trauma pushes people to reflect on the people and things in their lives that they have heretofore taken for granted. Realizing – or being reminded of – how our lives are blessed by our loved ones is very painful when these epiphanies occur in the context(s) of losing these people through death. Many people we have worked with, for example, have struggled with the fact that the last interaction they had with a disaster victim was a negative one. A teenager who stormed out of the house on the morning of 9/11, arguing with this mother because she would not allow him access to the family car, will always remember this moment as the last time he ever spoke to her. A wife who did not say ‘I love you, too’ to her husband on the morning of the tsunamis because she was giving him the ‘silent treatment’ for an argument that had occurred the previous evening will always regret not answering him – now that she under- stands he will never come home. A colleague of a man killed in a parking lot of their workplace’s clinic will always lament the encounter she had with him that morning about switching ‘fatal’ shifts so that she could go home early that day.

Family therapists are readily able to facilitate family and group meetings in which surviving victims of trauma review their lives and begin to appreciate the people they have not previously or wholly

Family therapists in trauma-response teams 49

appreciated (Lacerva et al., 2002; Shapiro, 2002; Walsh, 2007; Weine et al., 2005). In New York City we assisted family members in communicating the warmth and appreciation they felt for each other within the contexts of disagreements about a missing loved one’s status – and this was helpful in reducing interpersonal conflict exacerbating commonly felt loss and pain. After a local school bus accident involving multiple fatalities of young children, and after the murder-death of a child in a local nursery, we worked with family members as they expressed grief over the dead and relief for the living. After the hurricanes, we assisted an elderly woman to connect with her sister (who lived in the Northeast) from whom she had been estranged since childhood. She acted with a newfound realization that we only have a limited time on Earth to rebuild bridges and commu- nicate love.

Practice-related challenges

Practice challenges (i.e. those faced by providers) in fieldwork are diverse, ranging from individual practitioners’ self-care to interactions between providers and the respective fields they represent.

Scope of practice. Having been taught well in graduate school not to venture beyond the parameters of their baseline training, many mental health professionals who are new to trauma fieldwork are quickly presented with situations and questions that can feel uncomfortable. For example, is it all right to assist medical providers with cleaning wounds, drawing up vaccinations or prepar- ing a sterile field? Similarly, should a physician provide a mental health intervention if there is another member on the team who is a therapist? Can a psychologist help a mother look for her children through pictures of tsunami victims buried in mass graves? Can he cry with her when she finds the pictures and ultimately confirms that they are dead?

Consistent with emerging literature regarding medical family ther- apy and transdisciplinary teamwork in healthcare (e.g. Blount, 2002; Kilgo et al., 2003; Kuhlmann, 2005; Mostrom, 1999; Rolland and Walsh, 2005), members of trauma teams must work together to identify and negotiate areas of cross-disciplinary flexibility and over- lap in roles. While some situations call for a distinct skill set (e.g. a physician to perform an emergency surgical procedure), many of the roles assumed by trauma team members do not. As family therapists,

50 T. J. Mendenhall and J. M. Berge

we have helped stock emergency supplies and distribute food, warded off media, prepared vaccinations and cleaned wounds. We have moved rubble and raised tents where families’ homes used to be. We have walked along beaches looking with family members for something – anything – that belonged to a loved one who is missing. We have looked through pictures – at mass grave sites and on hospital walls – for confirmations of deaths. Physicians, social workers and lay community members with whom we have worked have all done these things as well.

Cross-disciplinary tensions. Many people who are not familiar with field- work presume that trauma-response teams can present a fertile ground for cross-disciplinary tensions, competition or conflict – given that so many providers are working together under such fast-paced and often uncomfortable conditions. This perception is especially strong in contexts where mental health providers are not dual-trained (e.g. in nursing, social care, justice or education), or wherein sibling disciplines (e.g. family therapy, psychology, social work) are posi- tioned together – the latter being a reflection of single-discipline providers having been taught that their respective discipline is ‘better’ than others (Mendenhall, 2006; Pocock, 1997).

Approaching multidisciplinary care through a biopsychosocial lens, it is easy to see and value the respective roles and contributions of other disciplines (Fraenkel, 2002; Walsh, 2007). While on the one hand being flexible regarding our scope of practice (as described above), it is also important to recognize the unique contributions and expertise of other professionals. Ultimately – to use a classic ‘systems’ adage – the whole is more than the sum of its parts. We have thereby found cross-disciplinary tensions to be considerably less visible in trauma teams than many who are not familiar with this work first expect. Not only do providers see and appreciate each other’s unique contributions to the whole, they are reminded that the families we serve do not generally care what our disciplinary backgrounds are, how many letters there are at the end of our names, how many papers or books we have published, or how well-known we are in our chosen field(s). What they care about is whether – and how – we care. Regardless of what discipline ultimately brought us to it, providers in mental health entered this business to ease the suffering of those who are hurting, and to empower their growth and resolve in the face of hardship. We can do this from a variety of professional platforms, in collaboration and synchrony with each other (Boss et al., 2003;

Family therapists in trauma-response teams 51

Fraenkel, 2002; Lomas and Goodall, 1994; Mendenhall, 2005; North et al., 2001).

Interpersonal boundaries and dual relationships. Fieldwork frequently pre- sents situations that challenge our abilities to maintain appropriate professional boundaries. For example, supervisors and supervisees often have to bathe in the same locker-room facilities with communal showers, sleep in the same crowded tents or small hotel rooms, and participate in the same debriefing groups in which personal reactivity and emotional responses to trauma work are disclosed and processed. Team members who have become friends (or who were friends beforehand) struggle with whether it is appropriate to administer medications to each other for commonplace difficulties with sleep, headaches or other somatic complaints. They wonder where ‘the line’ is between performing therapy and simply being supportive in response to what are normal reactions to the intensity of fieldwork’s content and processes.

Interpersonal boundaries and dual relationships have recently been highlighted as important to consider in fieldwork (Mendenhall, 2006). Common systems themes such as appropriate hierarchies (e.g. executive power), subsystems (e.g. parents, children/siblings), and interpersonal boundaries (e.g. as they relate to sexual behaviour or self-disclosure) are valuable concepts with which to inform teams’ decision-making processes, overall structure and ongoing functioning (Minuchin, 1974; Piercy et al., 1996). In our own work, we have learned to address these challenges through straightforward and frank conversations with colleagues, supervisors and students – and maintain that these challenges call for consistent attention and diligence so that the safety of all team members is ensured and that ethical violations are not committed. For example, in responding to the 9/11 terrorist attacks, we arranged team members’ living quarters in a local hotel by professional rank and sex. In Louisiana following Hurricanes Katrina and Rita, our entire team (of seventy) had to sleep on cots arranged in a single room; we hung a large curtain to divide men and women, and team members arranged themselves so that supervisors and supervisees slept in separate areas. Locker rooms were made available around-the-clock so that team members could bathe at any time if they felt uncomfortable in the immediate presence of others.

Across all of our deployments (local and large-scale), we discuss with our team members the boundaries regarding normal support versus providing therapy to each other. We take active efforts to identify those

52 T. J. Mendenhall and J. M. Berge

who are ‘breaking down’ beyond what can be effectively addressed through standard debriefings, remove them from the field, and connect them with immediate professional mental health services as indicated. Nobody prescribes or administers medications to other team members with whom friendships were extant; team members help to connect their friends to supervisors who can either offer assistance objectively or triage as appropriate.

Compassion fatigue. Compassion fatigue refers to a gradual decline in a provider’s capacity for compassion, and is a relatively common phenomenon among those who work directly with surviving victims of disaster and trauma. It encompasses a breaking down of our physical, psychological and even spiritual resources. Physically, those experiencing compassion fatigue often struggle with a chronic sense of exhaustion and fatigue, insomnia, headaches, stomach aches, and frequent bouts of sickness (e.g. colds, sore throats). Psychologically, they may feel irritable or overwhelmed. Their baseline capacities for empathy dissolve into numbness to others’ pain, and they can become cynical regarding surviving victims’ ability to change and/or even perceive them as being responsible for many of their problems. Responders experiencing compassion fatigue often report a sense of feeling scattered and being unable to meet their professional (e.g. paperwork) and personal (e.g. calling home) obligations (Everly and Mitchell, 2003; Figley, 1995, 2002; Sabin-Farrell and Turpin, 2003; Wright, 2004).

Systems thinking requires that we, as providers, understand our role(s) with the patient and family systems with whom we work. Our own personal health (psychological and physical) is as important to attend to as those we serve (Figley, 2002; Weine et al., 2002). This is an extremely important facet in fieldwork because it is a ripe environ- ment for ‘burnout’ secondary to its fast-paced, chaotic and exhausting nature. Fieldwork supervisors work hard to coordinate their teams in a manner whereby compassion fatigue is averted and/or effectively dealt with. Deployments are generally no longer than two weeks in duration, and sequential teams usually overlap by one to three days to effectively and smoothly transition one team to another. While in the field, team members generally work for only three to five consecutive days, followed by one to two days of rest. Even in the contexts of working long hours, we encourage our team members to think about and take care of their own mental and physical health. Throughout their deployments, we watch team members closely and – as outlined

Family therapists in trauma-response teams 53

above – work to connect those who require more intensive help with appropriate providers (either locally or at team members’ home- towns). During the 9/11 terrorist attacks in New York City, for example, there was a room set up specifically for compassion fatigue prevention. We were not allowed to work longer than a three-hour shift without refuelling with food and water, processing our experi- ences with a compassion fatigue specialist, and addressing any needs that had arisen since our last break.

Conclusion

Family therapists represent a comparatively new discipline to join the larger field of traumatology. They bring with them a worldview that is comfortable with the biopsychosocial complexities of human and relationship systems. They add a valuable contribution to the nature whereby fieldwork is conducted and the manners in which interdisci- plinary teams function on the ground (Blow and Sprenkle, 2001; Mendenhall, 2006; Rosenblatt, 1994; Whitchurch and Constantine, 1993). Systems thinking brings an overt sensitivity to both intraper- sonal and interpersonal family processes that are related to increased stress in the contexts of disaster and trauma, and this fosters and elicits positive individual, relational and family growth in both acute and long-term phases of support. It promotes an appreciation for respec- tive family members’ unique perceptions of meaning, and facilitates members’ co-creation of new meanings in the evolution of healing and post-trauma growth. It pushes us to consider our own role in the helping process and how the contribution of our training and back- ground fits within the larger efforts of our team’s mission. Finally, systems thinking commands attention to our own functioning, and highlights our obligation to self-care.

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