A few days after the terrorist attacks of 2001, mental health experts descended on New York, poised to help residents cope with a wave of psychiatric problems that never materialized. But experts in disaster psychiatry predict that the repercussions from Hurricane Katrina, a catastrophe without parallel in modern American history, are likely to be far greater and to last for years.
"This is unprecedented," said New York psychiatrist Spencer Eth, who was involved in treating survivors of the World Trade Center attack, which unlike the hurricane, killed many victims at the scene and destroyed several office towers, not entire communities. "People are not going to bounce back and resume their lives and recover" at the pace seen after other disasters, Eth predicted.
The previous disasters on which experts rely for lessons about how to handle the victims of mass tragedy -- plane crashes, earthquakes and hurricanes including Andrew, which struck Florida in 1992; the bombing of the Oklahoma City federal building in 1995; the attacks of Sept. 11, 2001 -- are all dwarfed by the devastation wrought by Katrina.
Even some veteran disaster mental health specialists say they are staggered when they contemplate the enormity of what is unfolding. More than 1 million people have been displaced by Katrina, and more than 400,000 jobs have been lost.
"We've got parents and children separated from each other, and as a mother I just cannot fathom what it would be like not knowing where my child is," said Oklahoma City psychologist Robin Gurwitch, who is working with evacuated children as a member of the American Psychological Association's disaster response unit. "Young children are asked, 'What's your mother's name?' and they say 'Mommy.' "
A spokeswoman for the National Center for Missing and Exploited Children in Alexandria, the federally-designated clearinghouse for Katrina-related missing persons, reported that as of yesterday the group had reports of 1,753 children under 18, the youngest a three-week old-infant, who don't know where their relatives are.
Researchers say that the majority of survivors of mass disasters eventually rebuild their lives and most do not develop a diagnosable psychiatric disorder such as post-traumatic stress disorder (PTSD). The disorder, which is also seen among rape victims and soldiers in combat, can occur any time after a trauma; its symptoms include crippling panic attacks and terrifyingly vivid flashbacks and can last for years.
Acute stress reactions -- nightmares, pervasive anxiety and intrusive thoughts -- typically occur in the month following a traumatic event. Acute stress is more common than PTSD, which affects between 10 and 30 percent of survivors, and its symptoms usually fade in less than three months. Acute stress reactions rarely require formal treatment beyond the supportive care now known as psychological first aid.
An intervention based on scientific studies of previous disasters, psychological first aid is designed to blunt the initial fear, anger, anxiety, sleeplessness and guilt that follow a catastrophe by ensuring survivors' physical safety and fostering a sense of calm, reassurance and hope. Its chief tenets include imparting accurate information to victims and offering practical help about coping with the aftermath of a mass disaster.
Effects to Last 'For Years'
To psychiatrist Robert J. Ursano, who directs the Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine, the military medical school in Bethesda, the obliteration of Gulf Coast communities most closely resembles the Asian tsunami, which also destroyed the local infrastructure and overwhelmed resources.
"We are going to be dealing with this for years," he predicted.
While little is yet known about the psychological fallout from the tsunami, one unusual characteristic of Katrina worries disaster psychiatrists: its duration. In most cases, once the rain stops, the tremors subside, the tidal wave recedes or the buildings collapse, the event is over. It doesn't go on for days.
Studies have found that the longer and more intense the threat to a person's life, the greater the likelihood of developing PTSD. The disorder is more common among people who are socially isolated, those with a history of psychological or physical trauma and people with preexisting mental health problems, including depression or anxiety.
The glaring racial and economic disparities exposed by the hurricane may complicate recovery efforts, experts predict. So will the influx of impoverished victims into a public health system that was already dangerously frayed and strapped for cash.
"Oh, hell no," replied Chicago psychiatrist Carl Bell when asked whether the mental health system is prepared for the predicted onslaught of people who need help. "This is very different than anything we've ever seen. I think the country is ignorant of how many poor people there are," the problems they face, and how to help in a sensitive way.
While many African-Americans traditionally turn to churches for help, observed Bell, a trauma expert, "I'm not sure the faith-based people have the mental health technology necessary" to deal with psychiatric problems such as PTSD, although they will undoubtedly provide solace and valuable support.
Traumatized children and teenagers may exhibit symptoms that differ from those seen in adults. Gurwitch, who is working with pediatric hurricane evacuees in Oklahoma City, said that some may become unusually aggressive or clingy, while others may withdraw. Children "who got out earlier might fare better than those who watched dead bodies float by, who saw their parents fall apart, or who witnessed violence," she said.
"It's going to be very hard for children to make sense of this," Gurwitch added. "Young children simply don't comprehend that everything is gone." And parents who are worried about things like getting a job and finding a place to live may have trouble responding to a child who says she wants to go home right now or who is pining for a beloved stuffed animal or a missing pet.
Studies of 550 school-age children who lived through Hurricane Andrew, which flattened the poorest part of Dade County, Fla., killing 15 and uprooting 353,000, found that one year later 30 percent demonstrated moderate to severe levels of PTSD. Children who experienced the greatest threats to their physical safety, who lost their homes or possessions, and who were forced to move, were most at risk, researchers found. Children who had been anxious before Andrew also had higher rates of PTSD.
What Not To Do
Some studies have found that disaster victims who focus on practical things, even mundane ones, tend to have fewer long-term psychological problems than those who were preoccupied with who was to blame for their predicament.
A handout developed by the Center for the Study of Traumatic Stress at the Uniformed Services University, which is being circulated to mental health workers around the country, cautions them not to engage in certain behaviors, such as telling Katrina survivors how they should feel, making blanket reassurances that "everything will be okay" and criticizing services or relief efforts in front of victims because "this undermines an environment of hope and calm."
One popular intervention that should be avoided, Ursano and other experts agree, is the use of stress debriefing, in which people are encouraged -- or required -- to spend hours recounting in graphic detail what they went through. Four years ago dozens of debriefing specialists flocked to New York to offer these sessions in the days after Sept. 11 to firefighters and police officers in the hope of preventing PTSD.
Most experts oppose these sessions as ineffective and potentially damaging. A report published by the Cochrane Collaboration, a group that evaluates scientific studies, found that stress debriefing is ineffective and can increase the risk of PTSD and depression.
Psychiatrist Carol North, a trauma expert at Washington University in St. Louis who recently returned from Baton Rouge, La., said she was concerned by signs prominently posted around the command center and medical treatment areas offering debriefings.
Harold Ginzburg, a New Orleans psychiatrist who fled hours before the hurricane destroyed his house, said that the basic task now is "encouraging resilience" among survivors and helping them find jobs and housing.
"We need to keep people focused on what they can do, and make the resources available for them," said Ginzburg, who is helping direct psychiatric services in southern Louisiana out of Baton Rouge.
Psychological recovery, notes Gurwitch, the Oklahoma child psychologist, is a long process that sometimes takes the form of simple reassurance.
"I saw a 5-year-old yesterday at the airport, and he asked me whether hurricanes come to Oklahoma," she recalled. "I could answer him with 100 percent certainty that no, we never have hurricanes in Oklahoma, and he relaxed. There was no need to tell him about tornadoes."
A Gulf Coast resident showed the toll of loss and fatigue while waiting in line for help last week at a Federal Emergency Management Agency (FEMA) center in Ocean Spring, Miss. Mental health experts predict long-lasting psychological effects from what they call an unprecedented catastrophe in this country.