"it ain't over... but we're moving forward" by douglass faust

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?”