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Doug Faust, PhD
It ain’t over....but we’re moving forward
Dedication
¨ To those who stayed
¨ Those who joined us in the re-building
If you go out of town....
3 day supplies of medicationmoneyclothing
Planning for a hurricane, new orleans style
1. Late decisions to evacuate
2. Folks used the 3 day model
There is nothing like a good catastrophe...
Somewhere else
For those who got out¨ Watched progressive destruction on
tv/Internet¨ Speculated with those around as to
implications¨ Tried to get more news
There is nothing like a good catastrophe...
Somewhere else
For those who got out¨ Evacuees became diaspora¨ Locked out of home communities,
schools, jobs¨ Meaningful returns started October
1¨ Consider your losses
There is nothing like a good catastrophe...
Somewhere else
We lost everything
How’d ya do?
We didn’t do so badly
How’d ya do?
It didn’t Bother us very much
How’d ya do?
1. Disruptions of everyday life2. Disruptions of jobs & school3. Chronic unremitting
exposure to damage caused by the storm
The impact of Katrina
¨ Forgive my navel-gazing, but I honestly cannot think of a single aspect of my life -- as a writer, a father, a husband, a son, a person -- that is not different from the way it was before.
Chris Rose, Times-
Picayune, 3/29/06
Perceived distance
¨ Immediacy¨ Chronicity¨ frequency¨ severity
Role of the therapist
¨ Typically, One or more degrees of separation from the event
¨ In a catastrophe, the therapist may have no degrees of separation from the event
Provider Sequence
¨ First Responders EMT/Fire/Police Wildlife Services Just about anyone else
¨ Disaster & Catastrophe ARC/DRN
Order out of chaos Emergency Services Short Term
Second Responders
Second Responders
¨ Evacuate with population¨ Not disaster /catastrophe trained¨ Return to standard practice
locations But so many didn’t in the first 30
months90% psychiatry40% psychology/social work/counselor
Second Responders
¨ Traditional therapeutic community Primary
Community Mental HealthAcademic ClinicsHospitalsCommunity group/private practices
Second Responders
¨ Traditional therapeutic communityTertiary care—
Role of Emergency rooms Psychiatric Hospitals Unique role of Charity Hospital
Impact on the practitioner
¨ Primary trauma¨ Serial trauma¨ Secondary/vicarious trauma¨ Compassion fatigue¨ Therapy fatigue¨ burnout
Shared TRauma
¨ Distressed professional
¨ Impaired professional
¨ Role of colleague assistance
Shared TRauma
¨ Has sustained primary trauma
¨ Working with concurrently traumatized population
Shared Trauma
¨ Shock and awe Collateral Traumatization Shared Trauma Serial Traumatization
¨ Direct property damage¨ Loss of jobs
Practitioner Issues
¨ Therapeutic Imperative Disaster centers/shelters Residual Centers Guerilla Therapy
¨ Therapy Fatigue/exhaustion Secondary Trauma Compassion Fatigue
Best Practices
Evidence Based Interventions
¨ Eye Movement Desensitization and Reprocessing (EMDR)
¨ Cognitive behavioral therapy (CBT)
¨ Trauma Focused CBT (TF-CBT)
Evidence Based Interventions
Cognitive behavioral therapy (CBT)
psychoeducationanxiety managementexposure techniquescognitive restructuring
Evidence Based Interventions
Trauma Focused CBT (TF-CBT)cf. deblinger, mannarino, cohen; locally Walker/PFDL
Structured interventionIntegrates trauma narrativeStepped program
1. Anywhere, anytime2. Flexible delivery
Guerilla therapy
1. Little or no training in trauma work
2. Essentially no knowledge of best-practices
Guerilla therapy
1. Unrealistic expectations2. Boundary problems3. Poor distinction between
catastrophe services and second response
Guerilla therapy
1. Competition for service dollars
2. Stafford act3. Competition for jobs
Guerilla therapy
1. Alternative therapies1. How to respond?
Guerilla therapy
Alternative Therapies
¨ Critical Incident Stress Debriefing (CISD)
¨ Thought Field Therapy¨ Meditation¨ Deep Breathing¨ Guided imagery¨ Acupuncturists without borders
Four Phases of Community Response to trauma
¨ Heroic Phase¨ Honeymoon Phase¨ Disillusionment Phase¨ Recovery and Reconstruction
Heroic Phase
Communities Pull TogetherDuring and immediately following a
disaster, individuals and communities often respond supportively, altruistically, and heroically.
Disaster responseARC/DRNShelter support
Heroic PhaseDisaster responseARC/DRNShelter support
Heroic Phase
Unique experiencesTherapy community as part of
evacuee groupRecipients, not just providers, of careShock and awe/PTSD
Honeymoon PhaseAttention Stays Focused on the Victims
Four common patterns of community response:
1) Intense community mobilization
2) Increased community consensus
3) People from outside the community come to help
4) Organizations adapt to help the community
Honeymoon PhaseAttention Stays Focused on the Victims
Therapist community as “victims”
Dissolution of practice community
personal losses
diaspora
lack of disaster training
loss of infrastructure
Disillusionment Phase
Helpers Leave & Residents are Left to Face RealityLongest phase of recoveryImmediate response teams leaveAssistance and help weakens
Disillusionment PhaseLosses become a reality
Outflow of residents up to 30 months
Widespread discouragement
Disillusionment Phase
Widespread discouragement
Scapegoating, resentment, disagreement
Unity fades
Disillusionment PhaseLooking Forward
difficulties in recruitmentIncreased costs of livingChronic problems
Medical careEducationUtilities
It wasn't the flooding that drove Dr. David Jones out of New Orleans for good. His house in the Lakeview neighborhood stayed dry. Instead, it was the way Hurricane Katrina eroded the orthopedic surgeon's practice.
New Orleans threatened by 'brain drain' By MICHAEL KUNZELMAN,
Recovery and Reconstruction
Finding a New Normal• May not occur for a year or more post-disaster• Constantly redefined• Social and economic activities recover• Gradual return to normal routines• Completion of reconstruction and recovery efforts• Community tries to find a new normal• Anniversary events• Difficulty in recovery decisions is compounded by
poor planning and preparedness
The Impact of Hurricanes Katrina and Rita on the practice of Psychology in Southern Louisiana: Results of a survey
Survey
¨ Approx 200 psychologists and 60 social workers
¨ Invited by email to participate online survey
¨ Approx 25% participation
Characteristics of Sample
Gender70
30
0
10
20
30
40
50
60
70
Female Male
70% were female
Characteristics of Sample
Age
0
22
13
51
14
0
10
20
30
40
50
60
Single 30-39 40-49 50-59 >60
Most were Middle aged
Characteristics of Sample
Marital Status
18
60.7
4.9
13.1
3.3
0
10
20
30
40
50
60
70
Single Married Divorced Stable NM Widowed
14% of sample reported a change in marital status since the storm
61% were married
Characteristics of Sample
Race94
2 03 2
0
10
20
30
40
50
60
70
80
90
100
Caucasian AfricanAmerican
Hispanic AsianAmerican
Other
94% of respondents identified themselvesas Caucasian
Characteristics of Sample
Professional Identification
24
02
75
0
10
20
30
40
50
60
70
80
LCSW LPC Psychiatrist Psychologist
25% SW; 75% Psychol
Characteristics of Sample
Years of Professional Experience
3
7 8
13
31
56
0
10
20
30
40
50
60
<3y 3-5 years 5-10 years 10-15years
15-20years
>20 y
Almost 50% with> 20 y experience
Characteristics of Sample
Primary Practice Setting Prior
29
9
4 43
2
0 0
0
5
10
15
20
25
30
Priv Acad MedHosp PrivPsy PubPsych Other Prison CMHC
Numbers of individuals reporting 50% time or more in each setting
Of those responding,Majority involved in Private practice
Characteristics of Sample
Evacuate Prior to storm71.7
28.3
0
10
20
30
40
50
60
70
80
Yes No
28% did not evacuatePrior to Katrina
Hurricane Related Characteristics of the sample
¨ 15% of sample reported partnership changes
¨ Time away from home averaged 9-10 weeks
¨ Time away from primary workplace varied markedly
Impact of stormResidence
¨ 89% reported damage to their homes
¨ 44% report persistent damage at 30 months
Impact of stormWorkplace
¨ 73% reported damage to their offices or workplace
¨ 27% report persistent damage at 30 months
Hurricane Related Workplace Alternatives
¨ Inter/Intra-state commuting; part time practices
¨ Borrowed workspaces
¨ Internet/Coffee shops
¨ Some slept in their offices
¨ Academic positions cut
Impact of stormIncome
¨ 63% reported loss of income due to the storms
¨ 26% report that their income is still negatively impacted at 30 months
Hurricane Related Impact on Income
¨ 2005 income down 30-50%¨ 2006 income down 45%¨ 2007 income improving, working
harder, lower collection rate
¨ A very few salaried individuals had stable income
¨ Loss of clients/referrals¨ Loss of jobs, contracts
Hurricane Related Decisions to Return
¨ Employment by one family member
¨ School relationships for children
¨ Job opportunities – or lack thereof
Hurricane Related TraumaDecisions to Return
¨ Existing support groups, family, referral base
¨ Altruistic intent
¨ Increased valuation of professional skills
Percentages Involved in Hurricane Related Recovery
Activities
DRN/Red cross 29%Food distribution 12%Victim recovery 16%Counseling in shelters 20%
Percentages Involved in Hurricane Related Recovery
Activities
Acute loss couns 28%Reconstruction 28%Cash Donations 39%Pro Bono care 45%
Peer supervision 37%
None 7%
Impact of stormMental Health
¨ 96% reported acute emotional impact
¨ 66% report persistent problems in mental health which they attribute to storms at 30 months
Impact of stormHelped or supported by profession
¨ 69% reported that they did not feel supported after the storm
¨ 82% report persistent feelings that they are not being supported at 30 months
Think locally
Think cross disciplinary
recommendations
‘In the event of a sudden loss of cabin pressure, masks will descend from the ceiling. Stop screaming, grab the mask, and pull it over your face. If you have a small child traveling with you, secure your mask before assisting with theirs. If you are traveling with more than one small child, pick your
favorite.
Recommendations
take care of yourself
How could have state or national organizations been more helpful?
¨ Increase visibility of Mental Health Community Embracement of social work/counselor models
by state Negotiate with state/federal emergency
management for reimbursement to local practitioners, rather than johnny-come-lately’s
Facilitate grant applications
How could have state or national organizations been more helpful?
¨ DRN and Disaster psychology are short term, needs of the practice community are long lasting Who takes care of the second responders
Support groups for professionalsEmphasis on distress rather than
impairment¨ Information clearinghouse¨ Use of state and national databases to
facilitate organization of local professionals and support groups
¨ Support groups for professionals, CE on disaster recovery
How could have state or national organizations been more helpful?
¨ Waiver of continuing education requirements
¨ Where was LPA?¨ Waiver of state organization fees
How could have state or national organizations been more helpful?
¨ There was a perception that bringing APA to NOLA was a good show of support, but... No local coordination of activities No notification to psychologists about
specialized activities intended to be supportive
“what have you done for me lately?”