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Nov/Dec 2005

By Rob Waters

Published in Psychotherapy Networker

For the people of New Orleans, and for thousands of other residents of Louisiana and Mississippi, Hurricane Katrina was the opening blow in a series of overwhelming events that, for many, have yet to end: a tragically perfect storm of destruction born of nature, incompetence, and official indifference toward the poor. Grim numbers--one thousand dead, a million made homeless, and hundreds of thousands thrown out of work--only hint at the extent of the rupture to people's lives, and at the toll it may take on their emotional and psychological well-being.

Nevertheless, in contrast to the aftermath of 9/11, disaster mental health responders, mostly volunteers, were armed this time with a far more cohesive and unified approach to trauma relief than they had four years ago: chiefly a commonsense intervention known as "psychological first aid." The goal of this approach is to calm people's emotional and physical responses in the wake of disaster by tending to their basic needs and offering them safety, social connections, reassurance, and, ideally, the opportunity to help themselves.

But the potential effectiveness of the approach was badly undermined by the lack of preparedness and haphazard response to the storm by federal, state, and local authorities. Many disaster mental health experts were sharply critical of the lackluster governmental response and say that it, far more than the storm itself, constitutes the biggest threat to the future mental health of survivors.

"There was disorganization at every level imaginable," says Rony Berger, an Israeli psychologist who's developed mental health plans for responding to terror attacks, and who traveled to the Gulf Coast as part of a four-member Israeli response team. "It took them a week and a half to get their act together."

For tens of thousands of New Orleans residents, the pain and anguish of the storm was compounded by the terrifying uncertainty of not knowing the fate of family members, and by makeshift evacuation plans that left them housed for days in dangerous, overcrowded shelters, and forced them to move from shelter to motel to exile in far-off states. "The international community has done a better job of providing Rwandan refugees fleeing into rural Tanzania with decent, humane housing than we saw in Louisiana at the Superdome," said psychologist Neil Boothby, who directs the Program on Forced Migration and Health at Columbia University. He's spent years doing international mental health work, and has made three trips to the Gulf region since Katrina struck. "When you warehouse people like that in these inhumane places, you dampen their natural resilience and sense that 'I survived a threat and I can do anything.' It exacerbates the dependency."

The lack of planning was especially disruptive to children, Boothby adds. "After the initial evacuation, children were sometimes moved two and three times, and a lot of kids had to leave their mothers because there was no place to live, and got shipped off to an auntie in Utah or Colorado," he notes. "We know that kids can do quite well with one bad event, but when you start putting two and three things together, then the risk starts going up. The overall formula for kids ought to be to reduce risk, to reduce separation, to keep children with people they're familiar with. So far that hasn't been the case."

The chief provider of crisis mental health services was the American Red Cross, which placed several thousand mental health volunteers into the field in two-week shifts. Using psychological first aid, these certified professionals, recruited through professional associations, aided people in shelters and evacuation centers. "You start at the bottom of Maslow's hierarchy of needs," explains Brian Flynn, a former assistant surgeon general in the United States Public Health Service, who ran the disaster relief branch of the federal Center for Mental Health Services and now works as a consultant. "You try to stop things from getting worse. You make sure people feel safe and hydrated and rested." Then, as necessary, you offer referrals for more intensive mental health care.

In contrast to the chaos that reigned in New Orleans, some of the shelters set up around the state appear to have fared better with regard to mental health services. Utah psychologist Richard Heaps, a member of the American Psychological Association's Disaster Response Network, arrived in Louisiana just a few days after Katrina and coordinated mental health services in Red Cross shelters in central Louisiana. The shelters, set up in churches, hotels, and sports arenas, served anywhere from 100 to 900 people. Once established, Heaps says, they were secure, well-run places, where he and other volunteers were able to work with people on whatever issues they were facing.

But the provision of such services has clearly been uneven. Boothby says that in the initial days, when people were distraught and traumatized, many shelters had no one offering psychological aid of any kind.

One month after the storm, Red Cross officials say they have 1,100 mental health volunteers in the field, but are unable to meet all the requests for help from shelters and evacuation centers. Despite the urgent need, the agency has had to suspend the processing of new volunteers because it's too overwhelmed to evaluate the backlog of applications, says Bob Dingman, a retired counselor, who volunteers with the Red Cross in their disaster mental health office.

So what will be the mental health legacy of Hurricane Katrina and of the botched response by federal, state, and local authorities? The storm is being called the worst natural disaster in American history, and to many experts, reporters, and members of the public, the sheer scale of the devastation and dislocation suggest a forthcoming mental health crisis with rising levels of post-traumatic stress disorder (PTSD). But that doesn't need to happen, says Boothby and other trauma and community mental health specialists.

"What we've seen over the years working with children is that their developmental well-being is determined more by opportunities that are presented or denied after a traumatic event than it is by the event itself," Boothby says. "Though the early response was far from adequate--it was abysmal, frankly--there's still time for the federal, state, and municipal governments to make it right. It isn't too late."

Boothby doubts that large numbers of people will develop PTSD, an assessment he shares with Carl Bell, a professor of psychiatry at the University of Illinois-Chicago and president of the Chicago Community Mental Health Council, a nonprofit agency serving low-income residents of that city. "I'm not at all sure the Katrina poor people are going to get PTSD," Bell says. "They've already been through hell and high water." He believes that the process of being repeatedly exposed to mild, though not traumatic, stress, and learning to overcome it can help inoculate people to the effects of more severe stress.

The range of responses to Katrina will be broad, Bell predicts. "Some folk will be resilient, some will be distressed, some will have post-traumatic stress disorder, some will become even harder and tougher due to having a harsh, stressful, and traumatic life. Some will grieve, some will develop clinical depression, some will turn to substance abuse, and some will turn to spirituality and become resistant."

Among adults, Boothby worries most about depression and substance abuse. Among children, he fears that being uprooted from their homes, schools, and families will exacerbate preexisting vulnerabilities born of poverty. "Many of these children were already dealing with problems related to chronic deprivation and lack of opportunity for normal development," he says. "I predict you're going to see more depression and more acting out and antisocial behaviors in the children."

Boothby is now working with Save the Children and Big Brothers/Big Sisters to set up a series of structured-activity sessions in two schools for displaced children that have opened in Baton Rouge. Modeled after programs he helped set up in Indonesian schools in the aftermath of last year's tsunami, the sessions allow kids to explore basic emotions--fear, sadness, joy, courage--through dance, music, drawing, and games.

In the end, the healthy recovery of individuals will be very much tied to the healthy recovery of New Orleans and the degree to which people are able to take part in rebuilding efforts. "Much of an individual's outcome depends on how they're treated after their experience, whether they have an opportunity to turn learned helplessness into learned helpfulness," says Bell.

The rebuilding of New Orleans presents opportunities to transform a city that's suffered from years of neglect. "We can have kids see counselors or psychologists, but if your family doesn't have jobs or a house and your schools are rotten, then we're dealing with pattern of neglect and deprivation which is crippling to human beings," says Boothby. "There's an opportunity to break the back of poverty. There'll never be a more opportune time. But it can't be business as usual."

Copyright 2005. Used with permission from Rob Waters.