Surviving Disasters — The Trail of Trauma, the Reach for Resilience
By Sue Coyle, MSW
Social Work Today
Vol. 18 No. 3 P. 14

As communities continue the recovery from the natural disasters of 2017, trauma-informed clinicians and other service providers work to meet a complexity of needs.

In 2017, hurricanes, wildfires, mudslides, and other powerful forces of nature permanently altered communities throughout the United States. Houston experienced the first major hurricane to make landfall in the continental United States in 12 years. Now in Texas, many families displaced by Hurricane Katrina in 2005 found themselves yet again bracing for the impact of an unstoppable, immovable storm. Florida and Puerto Rico were rocked by Hurricane Irma, and two weeks later Puerto Rico was devastated by Hurricane Maria. The death toll there continues to rise, as food, electricity, water, and help are in short supply in many parts of the island. And in Northern California, wildfires ripped across the state, killing at least 44 individuals.

These events dominated the headlines but were by no means the only natural disasters to affect the country last year. To varying degrees and in varying ways, individuals throughout the United States found themselves at the mercy of nature.

As Social Work Today reported  after Hurricanes Harvey, Irma, and Maria, social workers and other clinicians and service providers focused in the first days and weeks after the storms on the immediate needs of both their clients and their staff. They provided food, childcare, safety, and support, among other services.

Now, in 2018, the needs persist and have evolved. In some communities, much of normalcy has been restored, while in others it looks as if the storm happened days instead of months ago. In both scenarios, providers are tasked with offering trauma-informed services to best assist individuals and their communities.

Immediate Needs
To best understand the needs of individuals in the months after a hurricane, wildfire, or similar event, social workers must first reflect on the initial aftermath of a natural disaster, when much of the population requires the necessities.

"The immediate needs of our clients following Hurricane Harvey were centered around basic needs, including housing, transportation, and income," recall Adrian Lira, LPC, clinical manager/senior clinician, and Catherine Arevalo, LCSW, senior clinician, both at Family Houston. "Many of our clients are hourly workers and were not receiving a paycheck for days, if not weeks. Additionally, many of them were unfamiliar with the process of applying for unemployment benefits. Our clients who do not have legal status were left without the ability to work or to apply for unemployment benefits. Our child clients were unable to attend their school and were displaced to other schools."

Mary-Frances Walsh, MHS, executive director of NAMI Sonoma County (National Alliance on Mental Illness), adds that for families whose children are not yet in school, childcare became an urgent barrier. "In the Coffey Park neighborhood, 11 home-based childcare providers lost their homes [to the wildfire], leaving families with young children and two working parents scrambling."

Beyond even these needs were those of basic housing and utilities. Hurricane Maria reportedly knocked out electricity in all of Puerto Rico, shutting down not just homes but essential offices and organizations, such as hospitals and government facilities, as well. The island was left, literally, in the dark. At the same time, buildings were destroyed. For many, there were no walls or roofs to shield them.

"It took all of the island's supplies. That kind of experience of that intense natural disaster is new for many. They didn't know what it is to see your roof flying away and running with your kids to another house. They didn't know what a massive flood was, [what it's like] to see animals' dead bodies floating away. We have seen many hurricanes but not with that intense consequence. It was eight hours over the island," says Jessica Heredia, LMHC, clinical director of Hispanic Family Counseling with its main offices in Orlando, FL. Heredia is originally from Puerto Rico and now lives in Florida, where many families were displaced to after Maria.

Though perhaps not at the forefront of their minds, mental health was also an immediate concern for those who experienced a natural disaster. "Even those individuals who were not impacted directly found it important to process their experiences out loud. Many of us were at home for several days at a time, just continuously watching the news on television," say Lira and Arevalo. "This added to anxiety, and once counseling resumed, those clients that were not necessarily affected by flooding and/or displacement were able to discuss feelings of helplessness, anxiety, and depression.

"For those clients that were directly impacted," they continue, "providing them with conflict resolution and coping strategies was important. They were often emotional while attempting to locate assistance and were faced with roadblocks and little empathy [from some] individuals who were there to help." The individuals impacted were seeking assistance from others who had also experienced the storm. It was a high-stress situation, and so when additional obstacles such as identification presented itself, it was difficult for some aid providers to be as emotionally supportive as they could have been.

Heredia adds that many will experience grief, particularly those forced to leave their homes. "Most of the clients displaced from Puerto Rico were showing high levels of anxiety, depression, trauma, or grief/loss."

Continuing Basic Needs
In the months since the natural disasters of 2017, some are in the position of determining what comes next and how best to move forward while still confronting loss. "Those who lost homes are facing the pressures of insurance that will not cover the full costs of rebuilding; the loss of familiar surroundings, neighbors who have had to relocate, and personal belongings; and facing decision after decision: to rebuild or not, to stay in the community or not, to fix problems identified like soil contamination, water concerns, or not," Walsh describes.

However, others are still working to regain safe housing, electricity, and water before they can focus on next steps. Estrellita Moronta and Cindy Rojas, BSW students in their senior year at Rhode Island College, went to Puerto Rico in early March with a team of social work students and two professors. "We were in disbelief. We didn't think we were going to see what we saw," Moronta says. "People need so much. They need everything you need to start a new life. Some need to rebuild their homes completely. There are older adults living in their homes without doors or windows or even walls. The hurricane has taken everything they have."

Moronta and Rojas note that there has been rebuilding in different areas of the island, but for many in certain locations, the improvements are as minimal as a tarp over their roof.

The same is true of utilities. "The center of the island—there are many places still without electricity," Heredia says. "The water comes and goes; the electricity may have come but it disappears again for two or three days. Those who have claimed they have electricity are coastal cities."

What's more, for those who left Puerto Rico, the realities of their displacement are, for some, forcing them to return despite these ongoing challenges. "Some that showed up in the beginning had very high expectations that were not realistic," Heredia says. "They [were] surprised that the housing was a hotel room and only for 60 to 90 days. For those who didn't have childcare, how can they work?

"Many are returning because they have support over there no matter what. It's better for them. They haven't found any work [in Florida]. There's no immediate opportunity or resource to have their kids taken care of," she says.

Mental Health Needs
On top of the ongoing need of housing and other essentials, mental health remains an issue as the long-lasting effects of trauma become apparent.

"Six months after the hurricane, we are beginning to see emotional disturbance in our clients including grief over the loss of their home, family, and friends," Lira and Arevalo say.

Heredia's team has been working with many children, receiving referrals from school districts as school professionals notice signs of anxiety and depression. "[There's] isolation, mostly because they [the kids] are not being understood due to a language barrier. There are some limited social skills, because 'I can't speak your language, and you don't understand me,'" she says. "Mostly, it's anxiety and adjustment, some depression symptoms." Heredia adds that many of the youths have been sent to live with relatives while their parents in Puerto Rico attempt to regain stability. As a result, the children are also dealing with the separation and fear that they won't see their parents again.

Triggers are also a concern. Natural disasters occur with frequency, and a 24/7 news cycle allows individuals—particularly youths—to relive and reimagine their trauma. "We have seen children beginning to experience weather-related stress and phobias, either because of the storm or news coverage," Lira and Arevalo say. "We anticipate that anxiety, worry, and preoccupation will likely increase at the start of this year's hurricane season."

Moronta notes that that anxiety already exists in Puerto Rico. "I feel like the community is very scared," she says.

Barriers to Service
While the mental health needs are great, there are many barriers to providing care. For one, mental health treatment is still not at the forefront of individuals' minds. Heredia notes that most of the hurricane-related work has been with youth at Hispanic Family Counseling because the adults are not able or looking to seek treatment.

"At the moment, it's not a priority," she says. "I haven't met many parents that are in crisis or wanting to handle the mental health part now because they're focused on getting jobs, finding a healthy setting."

In Puerto Rico, even if individuals are ready to seek treatment, they will have a difficult time accessing the care. Jeremy Thayer, LICSW, an assistant professor in the BSW program at Rhode Island College, says that while in Puerto Rico with the students, he saw numerous signs for psychologists and psychiatrists but heard equally as many stories about residents' inability to engage.

"I had a conversation with a woman talking about her nephew who she provides some caregiving toward. He has substance use disorders and mental health [concerns]. The issue for him is that he is unemployable. There's no employment on the island. That impacts access to health insurance.

"This impacts a lot of the folks," he says, "even for folks who may have applied for assistance. There's no outreach to apply for these programs. They go untreated."

Pam Watson, LICSW, also an assistant professor at Rhode Island College and chaperone to Puerto Rico, adds, "We never even saw the resources that are typically offered by the aid agencies. We were there for a week."

Providing Services
Should the barriers be overcome, providing services starts first with preparing the staff. Employees must be able to assist their clients through mental health crises. While most clinicians are well educated and trained, it can be incredibly helpful to reassert that knowledge following a traumatic communitywide event. At Family Houston, the Mental Health First Aid training was sought.

A nationally recognized training program, Mental Health First Aid equips individuals with the tools they need to assist a person in a mental health crisis. The course itself allows for interaction and practice, so that the first time trainees put to work what they've learned is not during a crisis.

This training is not only helpful to clinicians but also to other professionals who may come into contact with individuals in crisis. Moronta and Rojas knew this and made the training a key component of their trip. "On Tuesday, Estrellita and I hosted a mental health first aid workshop with the clinicians and policemen who worked [in Puerto Rico]," Rojas says. "They were taught to be aware of mental health symptoms—what to do, how to approach that person."

Outside of crisis, in therapy and other one-on-one settings, the techniques employed will vary. Heredia emphasizes that clinicians must remember they are working with individuals, even as they work within a population who have shared the same trauma. "Each client is treated individually because the needs are individual," she says. "Therefore, the theories or therapeutic approaches can differ from [eye movement desensitization and reprocessing], [cognitive behavioral therapy], person-centered, etc. Each case has to be assessed to explore history, symptoms, [and] situations, and determine the best approach to implement."

Lira and Arevalo agree, adding that the nature of the trauma does impact approach. For example, when basic needs are still in question, "The focus of counseling changes to meet the client's basic needs by following Maslow's Hierarchy of Needs. The counseling approach is centered on crisis counseling, to help clients regain their feeling of safety," they say. "Counseling becomes more solution-focused to accomplish immediate, short-term goals." Clients are helped to focus on what they can control and to plan for future events.

"This will allow the client to have more of their own resources to act with in case another storm hits," Lira and Arevalo say. "For those that were impacted, we help them to discover the posttraumatic growth and resiliency they are capable of."

In that same vein, Moronta and Rojas, along with their fellow students, aimed to employ a strength-based perspective when meeting and working with the residents of Puerto Rico. "Part of our goal was to empower the people in the communities and remind them they are strong, resilient people, and they matter to us and to the rest of the world," they say. "We also utilized attentive listening because most residents just wanted to be heard."

The most important approach, Heredia says, is simply to be present and positive. "Don't lose hope," she says. "Go day by day."

In doing so, clinicians have the opportunity not only to help individuals and communities but also to witness the strength that already exists within them both.

"There was a lot of resilience," Moronta says of what she saw in Puerto Rico. "It is such a strong community, doing what the government isn't doing for them. You can see neighbors fixing houses and putting up windows. They are coming together to rise."

— Sue Coyle, MSW, is an award-winning freelance writer, social worker in the Philadelphia suburbs, and frequent contributor to Social Work Today.