Systemic Therapists on the Frontlines of Climate Change

Survivors of natural disasters might experience a threat to their own life and physical integrity and be exposed to other people’s death and injuries. These stressors might also lead to experiences of ambiguous loss, bereavement, social and community disruption, and ongoing difficulties (Norris, 2002; Landau, Mittal & Wieling, 2008). There is a large body of literature on post-disaster mental health. Studies have shown that survivors might experience a range of psychological and physical health problems such as depression, anxiety, post-traumatic stress disorder, sleep disturbances, somatic complaints, impaired immune function, relationship problems, financial stress, and loss of social support (Norris et al., 2002a; Norris, Friedman, & Watson, 2002b; Wieling, Utržan, Banford, Witting, & Seponski, 2020).

Scholars and researchers have underscored the importance of considering both individual trauma/personal losses and collective trauma/community destruction when working with survivors as people with no personal losses can also experience psychological and physical symptoms in the aftermath of disasters (Bolin, 1985; Norris, 2002).

There is a growing body of literature on the differential impact of weather-related disasters based on one’s social location. Social location can not only impact both one’s vulnerability to but also recovery from disasters. Research on disasters also documents the interrelationship between social and place inequalities. Marginalized and minoritized populations are often forced to live in poorly constructed housing in areas that are more vulnerable to weather-related disasters. Further, few resources are placed in these communities post disaster to help with rebuilding (Myers, Slack, & Singelmann, 2008; Zhang & Peacock, 2010). As a result, racial and ethnic minority individuals and communities with less socioeconomic privilege are severely impacted by climatological disasters. An example is resettled immigrant and refugee communities displaced as a result of war, organized violence, and persecution. These families are likely to have been exposed to multiple traumatic events and are at risk for higher rates of psychiatric disorders such as posttraumatic stress disorder (PTSD), depression, anxiety, complicated grief, psychosis, and suicide (Akinsulure-Smith & O’Hara, 2012; Fazel, Reed, Panter-Brick, & Stein, 2012; Kandula, Kersey & Lurie, 2004; Steel et al., 2009). Studies also show that women from low socioeconomic backgrounds, particularly women of color, are adversely impacted due the gender roles and expectations of caretaking during and post disasters (David & Enarson, 2012). Family structure and composition (e.g., families with children, elderly, and people with disability) are further associated with more negative disaster-related outcomes. Cultural factors also influence people’s experiences with weather-related disasters. For example, emergency warning messages might not be culturally or linguistically tailored. It is critical that cultural knowledge informs how post disaster programs are developed and provided (Norris & Algeria, 2008; Wieling, Utržan, Banford Witting, & Seponski, 2020). Addressing and preventing the direct and indirect effects of trauma exposure and displacement related to climate change is a social justice issue with broad public health implications. The mental health community also has a specific role in ameliorating and treating families in the aftermath of exposure to climatological disasters.

Clinical implications for disaster response

Disaster response efforts broadly seek to reduce the negative and collateral consequences experienced by individuals, families, and communities (Witting, Bagley, Nelson, & Lindsay, 2021). Community and household preparedness (i.e., plans and resources) remain the primary mechanism in mitigating the effects of weather-related disasters (Levac, Toal-Sullivan, & O’Sullivan, 2012; Witting et al., 2021). Research suggests that although many people fare well following a disaster, the need for immediate mental health intervention typically outweighs existing mental health infrastructure (Witting et al., 2021), especially in communities where health inequities pervade (Myers et al., 2008). In this way, mental health therapists are “front line workers” ready, willing, and able to support people during and after a disaster, as was seen during the COVID-19 global pandemic. As couple and family therapists, we are uniquely suited to conceptualize the systemic (e.g., relational, communal, economic, political, etc.) effects of a disaster, thereby facilitating a holistic intervention approach. Yet the question remains, what exactly should we do, clinically, for those reeling after a weather-related disaster? Do we conduct therapy as usual? Or something else? Here, we suggest a two-fold approach to clinical disaster response. First, we recommend providing an immediate, short-term environment of care and psychosocial support that focuses on safety, resources, and reducing the psychological and relational consequences of trauma exposure. Second, we recommend specific therapy approaches that may be best suited to address disaster-related mental health challenges in the long-term.

Short-term interventions      

Immediately following a weather-related disaster, it is imperative that physical and emotional safety, as well as basic needs, are addressed. A recent study examining the use of New York City’s 311 call center following Hurricane Sandy found that in the month following Hurricane Sandy (October to November 2012), the vast majority (i.e., 92.8%) of 311 calls were seeking information on transportation resources, school closings, food assistance, supplies, shelters, and disaster assistance for hurricane damage (Eugene, Alpert, Lieberman-Cribbin, & Taioli, 2021). Further, requests for mental health services following Hurricane Sandy did not begin until two years after the hurricane, with the highest frequency of mental health service requests occurring in 2017. So, how can therapists effectively intervene in the short-term, prior to conducting long-term traditional therapy? We recommend applying trauma-informed care and psychological first aid strategies to assess needs, provide resources, and reduce trauma activation.

Trauma informed care (TIC), first developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), is an evidenced based approach to establishing an environment of care that seeks to reduce trauma activation (Morgan, Thomas, & Brossoie, 2020; SAMHSA, 2014). In this way, TIC is not a specific treatment approach but rather a method of establishing a safe setting for those exposed to trauma and disasters. TIC is predicated on six principles: 1) Safety (i.e., physical and emotional); 2) Trustworthiness and transparency (i.e., clear and accessible procedures and practices to reduce feelings of helplessness); 3) Peer support (i.e., empathy and guidance from a person with a related experience); 4) Collaboration and mutuality (i.e., staff working together to minimize disruption); 5) Empowerment, voice, and choice (i.e., empowerment and respect to enhance a sense of autonomy); and 6) Cultural, historical, and gender issues (i.e., employing cultural humility and considering social location).  Whether someone is handing out blankets or providing resources, the tenants of TIC will aid in establishing an environment of care that is responsive to the unique effects of weather-related disasters.

Another useful intervention to employ immediately following a weather-related disaster is psychological first aid (PFA). PFA is an evidence-based approach to reduce the initial distress following traumatic events and seeks to foster short- and long-term coping (National Child Traumatic Stress Network; NCTSN, 2006). PFA is comprised of eight core actions: 1) Contact and engagement (i.e., initiate contact in a non-intrusive, compassionate, and helpful manner); 2) Safety and comfort (i.e., enhance immediate and ongoing safety through physical and emotional comfort); 3) Stabilization (i.e., calm and orient emotionally overwhelmed or disoriented people); 4) Information gathering (i.e., identify immediate needs and concerns); 5) Practical assistance (i.e., offer practical help and resources); 6) Connection with social supports (i.e., establish contacts with support persons including family, friends, and community resources); 7) Coping information (i.e., provide information about stress reactions and coping to reduce distress and promote adaptive functioning); and 8) Collaborative services (i.e., link people with available services in the short- and long-term) (NCTSN, 2006). Although slightly different, both TIC and PFA are excellent frameworks for responding to the immediate needs of disaster affected communities

Longer-term interventions

Following a weather-related disaster, it may take weeks, months, or years for someone to initiate mental health services. Although survivors of weather-related disasters may experience a wide range of psychological symptoms, or none at all, PTSD is the most commonly studied mental health issue following disasters (Norris et al., 2002b). While the projected lifetime risk for PTSD in the United States is 8.7% (American Psychiatric Association, 2013), research indicates that 30-40% of disaster survivors, and 10%-20% of rescue workers, develop PTSD (National Center for PTSD, 2019).

Women from low socioeconomic backgrounds, particularly women of color, are adversely impacted due the gender roles and expectations of caretaking during and post disasters.

Several therapy models have a strong body of evidence (i.e., clinical trials) for effective trauma symptom reduction: 1) Prolonged exposure (PE), which evokes imaginal and in-vivo exposure to process distressing trauma-related emotions and work through avoidance (Foa et al., 2005); 2) Cognitive processing therapy (CPT) which challenges and modifies maladaptive trauma-related beliefs (Resick, Nishith, Weaver, Astin, & Feuer, 2002); and 3) Eye movement desensitization and reprocessing (EMDR) which evokes imaginal exposure to memories and uses bilateral eye-movements to install a healthy cognitive reappraisal of the memories (Rothbaum, Astin, & Marstellar, 2005; Shapiro, 1989).

Specific to mass violence and disaster, treatment models with emerging evidence for trauma symptom reduction include: 1) Trauma-focused cognitive behavior therapy (TFCBT) that employs cognitive restricting, coping techniques, and development of a trauma narrative (Bryant et al., 2011) and 2) Narrative exposure therapy (NET), a manualized short-term treatment that integrates cognitive behavior therapy and testimony therapy for conducting imaginative exposure on traumatic events that occur over the life course (Schauer, Neuner & Elbert, 2011). Randomized controlled trials (RCTs) of both TFCBT and NET demonstrated higher efficacy when compared to treatment as usual and waitlist conditions, with additional reductions in depression symptoms (National Center for PTSD, 2019). Further, a growing number of meta-analysis report NET as the best-supported intervention for complex trauma in displaced communities (Nosè et al., 2017). In addition to PTSD, it is not uncommon for disaster affected individuals to experience symptoms of anxiety and depression. However, the National Center for PTSD (2019) reports that, to date, there are no RCTs examining treatment approaches for psychological presentations other than PTSD. Further, it is recommended that best clinical practice is to employ evidence-based treatments for depression and/or anxiety, accordingly (National Center for PTSD, 2019).

Most evidence-based practices for post-disaster traumatic stress, and other psychological symptoms, are individually focused. Indeed, although the psychological effects of weather-related disasters on individuals are well documented, significantly less is known about the unique effects and needs of couples and families following disasters (Witting et al., 2021). Further relational research is needed to better understand both the effects of weather-related disasters on couples and families, as well as the best relational treatments to employ long-term following disasters.

Training implications

As indicated, preparedness is a key factor in disaster response. So, how can we, as systemic therapists, and front-line healthcare workers, best prepare to serve our communities following weather-related disasters? First, it is imperative that we familiarize ourselves with short-term interventions (i.e., TIC and PFA) designed to be used immediately following a disaster. At present, there are free accessible guides available for training oneself on these approaches (see Professional Resources). For long-term therapy interventions, we recommend training and certification in one or more of the evidenced-based treatment approaches (e.g., TFCBT, NET, EMDR, etc.) that have yielded promising results for trauma symptom reduction among disaster affected individuals. Further, we encourage our couple and family therapist researchers to advance clinical research that examines both the unique needs and responsive treatment approaches to couples and families following a weather-related disaster. Finally, we implore training programs to consider integrating curriculum on short-term (i.e., TIC and PFA) and long-term (i.e., evidence-based treatment approaches) interventions following mass crises and disasters. The past year and a half have demonstrated that therapists, and in particular couple and family therapists, are essential workers in local, national, and global crises. As climate change worsens, we must be prepared to address the front-line needs of individuals, couples, families, and communities alike in response to the untold toll of increasing weather-related disasters.

Professional Resources

Trauma Informed Care: A downloadable, comprehensive, and free guide to TIC is available at: https://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/SMA14-4816

Psychological First Aid: A downloadable, comprehensive, and free guide to PFA is available at: https://www.nctsn.org/resources/psychological-first-aid-pfa-field-operations-guide-2nd-edition

SAMHSA Resources by Disaster Type: https://www.samhsa.gov/find-help/disaster-distress-helpline/disaster-types

SAMHSA Disaster Response Helpline (call or text): 1-800-985-5990

SAMHSA Disaster Response Overview: https://www.samhsa.gov/find-help/disaster-distress-helpline