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Moving Beyond the Hospital: Medical Family Therapy in Fieldwork

Posted By Tai Mendenhall, Tuesday, January 14, 2014

I, like most of us, will never forget September 11, 2001.  As our nation – and, indeed, our world – watched in horror as the day’s events unfolded in New York City and Pennsylvania, I think that my desire to do something to help was both impassioned and commonplace.  We all wanted to help, in whatever ways we were able.  I was a graduate student back then, and when I was asked by one of my professors to join a trauma-response team being mobilized to NYC, I dropped everything and went.  En route (in an otherwise deserted airplane), several of us participated in an intensive just-in-time training regarding Psychological First Aid and Ambiguous Loss.  When we arrived, our team joined a number of other teams and began to do a type of mental health work that I had never done before.  It was one of the most awful, painful, terrible, inspiring, and amazing experiences of my life. I returned a different person.  

I have continued to serve in fieldwork ever since that September.  Today, within the capacity of a faculty role at the University of Minnesota and through the lenses of a trauma responder, trainer/supervisor, and team coordinator, I offer the following as some of the things that I see to be Medical Family Therapy’s (MedFT) principal contributions to this effort:

Creating Meaning

One of the most common questions that people struggle with when they are hurting is "Why?”  When someone is living with depression, he asks "Why do I feel this way?” When relationships are dissolving, couples ask "Why are we fighting like this?”  In conventional therapy, clinicians can work with people who desire such insights by connecting a presenting problem to historical or present-day circumstances that somehow help it "make sense.”

Our efforts to engage those who are suffering to create meaning is importantIn fieldwork, we do not have this luxury (e.g., weekly visits until treatment is defined as "complete”). However, our efforts to engage those who are suffering to create meaning is still important (if not more important). And because MedFTs are comfortable working with multiple people at once, we can support and facilitate conversations and conflict that can be extraordinarily painful and/or newfound narratives that are profound and empowering. For example, a couple I worked with who lost their child to a tornado came to believe that their experience was God’s way of reuniting their extended family after years of emotional cut-offs. A boy I worked with who lost his mother in a hurricane was initially inconsolable because he could not understand how the "all-knowing” and "all-loving” God she raised him to believe in could take her away like this. Normalizing and empathizing with this young man’s pain, while engaging his father and sisters to begin a longer journey with him to make sense of what had happened to (all of) them, helped to ease his acute grief and anger.

Coping with Ambiguous Loss

When there is a mismatch between a loved-one’s physical and psychological presence, families are faced with a complicated type of loss that is not "normal” in the sense that we usually think of when we think about "loss”. In the aftermath of a traumatic event, family members of a missing person often do not know if s/he is still alive (e.g., displaced in an unknown area without cell phone coverage, buried – but still alive – under rubble). And if the person has, indeed, been killed, families may never have tangible confirmation of this fact (e.g., because the body was lost forever to the ocean or vaporized in an explosion). How can families cope or support each other when some members believe that their loved one is still alive while others still believe that s/he is dead?How can they have a funeral without a body?

MedFTs are well-equipped in situations like this to listen to and process family members’ respective views. Sometimes they must agree to disagree.  They may even embrace their ambiguity and ambivalence. Other times families align together in new and co-created narratives to say "goodbye.” For example, several families I worked with after the East-Asian tsunami walked along the beaches during low tide in search of things that the sea had "given back” to them. As they found things that they believed belonged to their loved ones (e.g., clothes, shoes, toys), many found peace in personalizing these things to represent those they had lost. Then they would bury the items in a funeral like they would if the items were human bodies.

Loving and Appreciating Each Other

Oftentimes disasters remind us – albeit too late – that the people who mean the most to us are usually the ones that we tend to take for granted and/or treat the worst. I recall a couple who were planning to have a dinner party one evening. After having agreed to who was going to pick up what after work to get ready, the husband called and asked (told) his wife that he needed to work later, i.e., that she would have to do his errands for him. They escalated in conflict because she was afraid that this would translate into not having enough time to prepare dinner. The husband started yelling at his wife, and finally hung up on her after accusing her of "not being supportive.” On her way home (about 30 minutes later than originally planned), she was killed in a construction accident. I remember a mother who missed her daughter’s piano recital because she, too, wanted to work late. She chastised the daughter’s distress about having her mom miss the performance, maintaining that there would be "plenty more recitals.” The child was murdered the next day in a school shooting.

MedFTs are readily able to facilitate meetings in which surviving victims of trauma review their lives and develop new or enhanced appreciations for the blessings they have. Working in the field across both natural- and human- made disasters, I have talked with many who have expressed overwhelming grief for the dead, alongside great relief for those who are living. They communicate newfound realizations about how physical things like houses and cars – unlike people – are just "things” that can be replaced. They talk about how they understand now that there is so much more to their lives than work. They stop reserving the words "I love you” for when they say goodbye on a telephone call or write well-wishes in an obligatory birthday card; they begin saying it often and every day. And they mean it.  They stop giving each other the silent treatment during conflicts because they understand that no one knows when or how somebody they care about might be taken away from them. 

Reevaluating our Scope(s) of Practice

I often see new professionals struggle to figure out where the overlaps and gaps are between what they can do and what other team members can do in the field. For example, is it alright for a MedFT to assist medical providers in cleaning wounds, drawing up vaccinations, or opening packages of sterile surgical instruments in preparation for emergency procedures? Should a physician provide emotional support if there is a mental health provider on the team? Can a nurse assess for someone’s suicide risk, or chase them if they bolt? Scholars in MedFT and collaborative healthcare have called for purposeful consideration of questions like these in everyday practice; members of interdisciplinary disaster-response teams must do this as well. 

Some situations call for a distinct skill set (e.g., a medical provider to flush tear ducts or set a broken bone), but many do not. And to be clear: working as a MedFT in fieldwork does not mean that you only provide mental health services. I, along with other family therapy colleagues, have indeed cleaned wounds, prepared vaccinations, and assisted medical providers during emergency procedures. So too have we stocked and distributed food and water, raised shelters, organized and run staging areas, and cleared rubble. We have served as greeters at family assistance centers, held off media, reunited family members and pets, and distributed information about local resources and charitable organizations. We have looked through pictures of the dead (e.g., taken before they were buried in mass graves) with families as they search for confirmation of what they hope is not so. We have looked through destroyed homes with survivors in search of treasured photographs and possessions. Physicians, nurses, medical assistants, social workers, psychologists, and lay community volunteers have done all of these things – and many others – as well. 
Working as a MedFT in fieldwork does not mean that you only provide mental health services

Avoiding Compassion Fatigue

Compassion fatigue, as we all know, encompasses a breaking down of our emotional, physical, and even spiritual resources. This is an occupational hazard for any provider in healthcare, but the intense nature of fieldwork is something that can easily push us over the edge. 

MedFT’s systems orientation requires that we, as providers, understand how our own functioning influences the patients and families that we serve. This is important because impaired providers (of any type, representing any discipline) can harm the very people they are supposed to help. Field supervisors thereby work to ensure their team members’ safety by limiting any deployment to two weeks in duration, and we only allow members to work up to three sequential days before taking (at least) a day to recover. We encourage consistent attendance to physical and mental health through regular group processing and debriefing, frequent hydration, snacks, and rest. We organize our teams by twos (i.e., buddy systems) to help ensure this, and we connect members to specialized support during- and after- deployments when and as indicated.

Closing Thoughts

As I intimated earlier, my work in trauma-response teams represents some of the most difficult and rewarding work that I have ever done. Whenever I return from a deployment, my colleagues and students ask what it was like, what I learned, or what experiences I will remember or affected me the most. Answering these questions is difficult because the experiences of "being there” are not well described in words, stories, or pictures. I encourage them to become involved, themselves.  Many have. When they do, they grow to understand.  I similarly encourage you, the reader, to engage in this type of work. Bring to it your skills and talents as a MedFT, and collaborate with colleagues from other disciplines united in the same mission. Then you will know.  And you will never be the same. 

Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the co-Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program (in which he teaches and supervises doctoral MedFT interns and family practice residents), and holds an adjunct faculty position in the UMN's Department of Family Medicine & Community Health. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

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