CAMFT's Professional Exchange

The Therapist - May/June 2008
The scene: Complete and total chaos at the Houston Astrodome. I am raw, saturated with stories. I am hearing and holding the horror of Hurricane Katrina: the ominous approach of the storm, the sickly green color of the sky, the hurricane hitting New Orleans and the entire Gulf coast. Survivors tell me how quickly the floodwaters rose to the roofs of the houses when the levees broke, and they tell me of shooting and looting in the streets. The terror at the Superdome continues to shock; I hear of people dying, of sexual assaults and murders, there is filth, and fear. Tears come with the stories of the chaos of evacuation, with the cry, “I don’t know where my family is. I don’t know if they are dead or alive.” These stories are from the adults and adolescents; the younger children don’t have any words for what they went through.

The children at the Astrodome are deeply traumatized—they are in shock, whimpering, crying, clinging, frozen, and acting out. Each child will express loss, grief, and shock in a manner particular to him or herself, mediated by age, developmental level, culture, family, personal history, proximity to “Ground Zero” of the disaster, how much loss he or she experienced, and how the caretakers are holding up. Each child brings his or her whole personal, familial, and cultural history to a trauma.

As disaster mental health workers, we have little, if any, time for assessment. There are no intake forms at a shelter, no history, no knowledge of the age little Sally started to walk, or how she is doing in school, if she has been living with her parents or in foster care, or is she has had any prior traumas. Nothing. All we know is that there is a child in front of us who is in a world of pain. How did we get here? What do we do now? There are three parts to this answer:

1. Get trained – take courses like “Eye of the Storm,” the American Red Cross Disaster Mental Health courses, and Critical Incident Stress Management: Group Crisis Intervention.

2. Wait to get deployed. Don’t show up at a disaster uninvited, as you will be part of the problem, not part of the solution, burdening the fragile infrastructure of disaster response.

3. Once you have been deployed, then the only thing you can do is show up, be as authentically human as you can be, and be with an open heart. Your job is to create as safe a space as possible - for the time you are with the child. We bear witness, with the greatest respect for the defenses of the child, and the resiliency he or she has shown, that he/she survived. We can’t “fix” anything, can’t undo the hurricane, or fire, or flood, or tsunami. We don’t have toys, or a sandtray. I do bring a few puppets with me, and stickers, things I can pull out of the pockets of my Red Cross vest.

One boy, who I will call Paul had not spoken to anyone and the other volunteers were very concerned. He had been dropped off when the children’s play area opened in the Astrodome. By whom—his mother? a relative? another volunteer? We didn’t know. What had happened to him? Had he been in the Superdome? Had he stayed in his house as the waters rose? We knew nothing and he wasn’t telling anybody anything.

Paul was racing around on a donated big wheel bike, bashing into tables, full of energy. He was disrupting the other children, who were trying to draw. He seemed about seven or eight years old. He had not said a word to anybody the entire day. He rammed into me with the bike. I said, “Ouch!” He looked at me. I repeated, “Ouch, that hurt!”, making eye contact. I wanted him to sense that I understood that he, too, was hurting. He furiously drove off. He roared back, coming close to crashing into me again, but he stopped short of contact. I said, “Hi,” but he roared away. Finally, I took out my trusty assistant, Bear, a brown teddy bear puppet that wears a Band-Aid over his heart. Bear goes to every disaster with me.

I sat on the chair, and the next time Paul swung by, Bear popped up his head. Bear didn’t say anything. Paul kept on circling Bear, and Bear kept playing silent “peek-aboo” with Paul each time he raced by.

After several passes, Paul reached out and grabbed Bear from me. He raced around on the bike, having Bear play “peek-a-boo” with me. I pulled another puppet out of the pocket of my Red Cross smock. Elli is a very old, very ratty elephant, who has been through the wars (literally) and the wash, and only has one eye. Many children have responded to this woebegone and injured puppet. Bear and Elli also have been known to comfort me on a disaster assignment, along with pictures of my family and my favorite music on my iPod. Remember that we can’t take care of others if we don’t take care of ourselves.

Paul’s bear and Elli played “peek a-boo” then Elli said, “Hi” to Bear. As I held my breath, Bear said “Hi” back. Then Bear started to talk. Bear told Paul’s story, and as Bear talked, the narration moved from third person (he) to fi rst person (I).

“He was in the apartment with his mother and sister, and the water came. It was rising high. He and his mom and sister, Precious, tried to escape, and went outside. There was shooting, guns shooting. It was scary. One bullet went real near my head. My mama pushed me and Precious under water, so we wouldn’t get shot. But the water was deep, and it was scary. I was scared. My little sister, Precious, she slipped away and drowned.”

I sat, I was sad, and I was silent. I learned to do this from years of therapy, fi rst as a client, then for over 25 years as a therapist. So, my puppet listened to Paul’s puppet, bearing witness to his story, his loss, his pain. Neither Paul nor I spoke, but our puppets did. My hands, in my puppet, mirrored his hands, in his puppet.

When Bear was done talking, Paul was still for the fi rst time since he had arrived at the shelter. His frenetic energy was gone. Paul got off the big wheel bike and continued to tell about the rescue and evacuation. He gave voice to what had happened to him. Paul began to draw a picture, showing me what he had been through.

Deepak Chopra said, “In the midst of movement and chaos, keep stillness inside of you.” I can’t think of any better advice to take to a disaster, other than the usual caveats to remember to “breathe” and “drink lots of water.” We must try to keep our hearts open! Using all of our clinical skills, treating everyone with respect and dignity, and listening and being present, can make a tremendous difference.

And we go because we, as humans, want to do something for other humans who are suffering. Bear in mind that no technique will work if basic needs are not met: if the child is still in danger, hungry, or without shelter. The fi rst step in trauma work is to establish that the danger is over, that the child is safe, for now. We must create the “free and protected space,” fi rst in the real life of the child, and then in the psyche. The last step is to leave the child with a sense of hope.

There are many techniques and trauma-specifi c protocols available: different interventions dependent upon the ages of children, the length of time post-disaster, the type of disaster (natural v. man-made), the cultural and religious orientations of the affected populations, etc. While it is important to know interventions appropriate for the children you will be seeing, please also keep in mind:

Strip away a therapist’s orientation, the journals he reads, the books on his shelves, the meetings he attends—the cognitive framework his rational mind demands—and what is left to defi ne the psychotherapy he conducts? Himself. The person of the therapist is the converting catalyst, not his order or credo, not his spatial location in the room, not his exquisitely chosen words nor denomina tional silences. So long as the rules of a therapeutic system do not hinder limbic transmission—a critical caveat—they remain inconsequential, neocortical distractions. The dispensable trappings of dogma may determine what a therapist thinks he is doing, what he talks about when he talks about therapy, but the agent of change is who he is…. “ (Lewis, T., Lannon, R., & Amini, F., pp. 186- 187)

Something completely authentic happens to humans during and after a disaster; we are at our most raw, and most real. The interchanges I have had with fellow disaster volunteers, and the disaster survivors are so deep and honest that they take my breath away. Authenticity. I have seen pain, shock, and loss on the faces of the survivors—everything can change in a nanosecond. Life is precious and fragile. How do you go on when your village, your home, your family, is destroyed? Our job, regardless of technique, training, or equipment, is to show up and bear witness, so that one human being, who has been through extreme trauma, knows that another human being is there.

Kate Amatruda, LMFT, CST-T, BCETS, EMT, is a Licensed Marriage and Family Therapist, Board Certifi ed Expert in Traumatic Stress - Diplomate, American Academy of Experts in Traumatic Stress, and a teaching member of the International Society for Sandplay Therapy. She is a Disaster Service Mental Health volunteer, a Disaster Action Team member, part of the Marin Medical Reserve Corps, and of CAMFT’s Trauma Response Network. She is the Mental Health Lead for the Marin County Chapter of the American Red Cross, a member of DMAT CA-6 and a licensed EMT. She has been to the Southeast Asia Tsunami, Hurricane Katrina, Florida Tornadoes, the San Diego wildfi res, and many local disasters.

References:
Deepak Chopra. (2007, June 27). In Wikipedia, The Free Encyclopedia. Retrieved 19:42, June 27, 2007, from http://en.wikipedia.org/w/index.php?title=Deepak_Chopra&oldid=140938376
Lewis, T., Lannon, R., & Amini, F. (2001), A general theory of
love. New York: Vintage Books

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