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In the Eye of Katrina: Surviving the Storm and Rebuilding an Academic Department of Psychiatry

Received August 7, 2006; revised October 24, 2006; accepted November 8, 2006. Dr. Osofsky is the Kathleen and John Bricker Chair of Psychiatry and Chair of the Department of Psychiatry at Louisiana State University Health Sciences Center, New Orleans, Louisiana. Address correspondence to Dr. Osofsky, Department of Psychiatry, LSU Health Sciences Center, 719 Camp Street, New Orleans, LA 70130; hosofs{at}lsuhsc.edu (e-mail).

INTRODUCTION

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 
On August 29, 2005, I was in New York consulting with colleagues about research related to disasters and terrorism. When Hurricane Katrina hit New Orleans, all indications were that the city had suffered damage but that it would recover relatively rapidly. Then the levees were breached and we watched in horror the flooding of our city. My wife, Joy, and I took the first available plane to Baton Rouge (the New Orleans airport was closed), where the state police had somehow arranged a room at a hotel for displaced people. We immediately went to work at the command center. The Louisiana Office of Mental Health asked me to be the clinical director of statewide crisis mental health efforts and Joy to oversee efforts for children and adolescents (1). As we all worked feverishly in dealing with evacuation, shelters, human destruction—the overwhelming problems of our city and state—Mayor Ray Nagin asked that I and the Department of Psychiatry at Louisiana State University Health Sciences Center (LSUHSC) provide the direct services for first responders and their families. Seventy percent to 80% of first responders had lost their homes, their families were displaced, and they were in temporary districts and lodgings. St. Bernard Parish, just to the south of New Orleans and nearly destroyed, then requested the same services.

Joy and I returned to New Orleans each in a separate state police car surrounded by armed police, taking a circuitous route because of the flooding. As we approached New Orleans and witnessed its devastation, we were aware that a piece of our identity had been ripped from us. We walked through water to City Hall, then up the nine floors to where the police were headquartered, and began our work. We were hugged by ranking police officers, who were relieved to see us, wanting to talk about the ordeals and the suicides of two respected officers. Together with a limited number of colleagues from the LSUHSC Department of Psychiatry who could return, we worked in the streets and the temporary shelters for first responders. We further served public health workers, physician volunteers, and others who were desperately trying to help the city. We and our team provided psychological first aid (1), working with the basic needs of the responders and providing support. For so many, they were concerned about their families, the sights they had seen, their inability to rescue everyone in need, and their inability to keep the city secure. We listened to many stories of bravery and sacrifice, individuals who were torn between responsibilities for family and loyalty to buddies and the responsibilities they had sworn to serve.

When the cruise ships arrived to allow officers without homes a place to stay, a place where family members could return, we and colleagues from our department joined them. Joy and I were given a room on one of the ships; one of our colleagues rarely left the cruise ship where she was staying for the next 3 months. Together with the Substance Abuse and Mental Health Services Administration (SAMHSA) volunteers, we and our faculty worked to provide some degree of family and community normality in an abnormal environment. We worked with the initial 45 dispirited children who had returned; there would eventually be 700 to 800 children living on the cruise ship at any time. After we had been on the cruise ships for 2 weeks, Charles Curie, the Director of SAMHSA, came to review the process and lend support. He described how struck he was by the quality of services being provided to the families as well as those being provided in the temporary police districts, at the temporary fire facility for firefighters, and at the headquarters for emergency technicians. Over time we were able to provide daycare, enrollment in the suburban Jefferson Parish reopened school system, after-school activities, and family activities. I respected my colleagues enormously. Some had lost their homes and had displaced family members. Yet, in shorts and sandals, children followed them and clung to their backs, laughing and returning to a world of childhood.

We have continued to work with our brave first responders and their families throughout the months, providing support in the field, services as requested, and assistance for their children and families. In our most recent surveys, one in 10 first responders reported symptoms of posttraumatic stress disorder; approximately 25% reported symptoms of depression; 40% reported increased marital conflict; and contrary to the widespread belief that first responders do not desire mental health services, 35% to 40% requested additional services from our family.

Medical Student Education

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 
The Louisiana State University Health Sciences Center, displaced from New Orleans, moved educational facilities into temporary, cramped quarters provided by Louisiana State University in Baton Rouge. Initially, we were without regular Internet or telephone service. We could not contact and did not know the whereabouts of many faculty and staff. Administration and faculty who could return to Louisiana worked as rapidly as possible to restore adequate medical student education. Students, too, had lost not only classroom facilities but dormitory rooms and homes. Many of them were from areas that were completely flooded; they and their families had endured extreme losses. Our faculty somehow did not miss a beat in providing education for students. We were able to fulfill our commitment to provide monthly small group instruction for first-year medical students, an endeavor requiring 16 faculty members. These sessions, devoted to behavioral sciences in medicine, with a developmental focus, now included discussions about strategies for working with patients affected by the hurricane, even while students and faculty were themselves displaced. The second-year curriculum in behavioral health was fully carried out with no lectures missed, although we needed to substitute faculty members because some were still not able to return. Dr. Erich Conrad, our director of the course, was voted the semester’s outstanding clinical faculty member by second-year students. Third-year rotations for students were carried out in scattered state mental hospitals where patients were located, in shelters in Baton Rouge, in emergency and community settings, and in area hospitals. Much effort focused on providing students with high quality education in a complex and difficult environment.

Graduate Training

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 
I am pleased to report that almost no residents left our training programs in spite of the many difficulties encountered. Many lost their own homes, endured physical hardships, and lived in temporary or shared facilities. Our Directors and Associate Directors of Training coordinated resident training where displaced patients were relocated, including emergency and community settings, shelters, and state mental hospital facilities. Didactics were frequently taught from Capitol Area Mental Health Clinic offices in Baton Rouge via telemedicine to include residents whose rotations did not allow them to come to one central site. Ochsner Hospital, always a key part of our training, continued to provide training in its emergency room, outpatient clinics, and small inpatient psychiatry unit. Our chief of child psychiatry, with his faculty and residents, accompanied patients being evacuated from New Orleans Adolescent Hospital to a temporary site 100 miles west of New Orleans; they remained there for 8 months.

The LSUHSC department of psychiatry faculty put in exceptional efforts to allow completion of subspecialty training, internship training in psychology, fellowship training in infant mental health, and other training experiences. Given the uncertainties, our residency training director decided to offer six positions, rather than the customary eight to 10, in the 2006–2007 academic year. We were gratified that in spite of the difficulties, the department matched fully. Similarly, in infant and child and adolescent psychiatry, the match was an excellent one with three fine residents entering the program. Initially, the decision was made not to accept psychology interns for this academic year because of the uncertainties; however, at the request of predoctoral students who wanted to be in the program, after review by the American Psychological Association, the department is offering internship training again this year. Other fellowships, including our Harris Fellowship in infant mental health, are also fully operational.

Further Constraints and Furloughs of Faculty

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As noted, initially, communication was extremely difficult and we were uncertain about the whereabouts of some faculty who had to evacuate with family members because of the hurricane. As we were able to reestablish contact, most made efforts to return. At times, these efforts were constrained or unsuccessful given the initial unavailability of housing in the Baton Rouge area and other areas where training sites were temporarily located. Furthermore, LSUHSC was facing severe financial concerns, with the possibility of running out of funds in February 2006. In November, a force majeure was put into effect, with resultant faculty furloughs based on economic necessity. The process involved was a painful but transparent one. Contracts that were interrupted because of the hurricane, including contracts for the New Orleans homeless clinic and LSUHSC’s HIV program, were eliminated from the departmental budget. The Medical Center of Louisiana at New Orleans with its two hospitals and the adjacent Veterans Affairs Hospital were destroyed by the hurricane. State funds for LSUHSC were considerably reduced. Focus had to be placed on the core mission-based programs for medical student education, general psychiatry, and child and adolescent psychiatry training. After the hurricane ended, I was personally resilient in spite of the extremely long hours needed to provide services and work to hold the department together. Still, my resilience temporarily crumbled as I needed to cosign furlough letters for valued faculty members, most of whom I had recruited for their positions. Remarkably, many of these faculty members have remained in the area and have been devoted to the department, and as contracts have been gradually restored, we have been able to reinstate some of these positions. With the approval of the chancellor, the department is also recruiting for specific positions covered by new contracts.

I think it is worth stressing that faculty members returned in spite of severe personal hardships. A number lost homes. Some have returned to work while family members still remained displaced. Faculty members have worked tirelessly in the field, reopening outpatient services and limited inpatient services as soon as circumstances allowed.

Where Are We Now? Where Do We Go From Here?

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 
Department of Psychiatry offices were in a building flooded by the hurricane. Multiple severe hurdles remain and the building will not be reopening for a minimum of 1 year. Temporary offices were established initially in the living room of the assistant business manager (whose baby had been born 2 weeks earlier). Supervisory and support meetings were held in living rooms of faculty with minimally damaged homes. Our "offices" were cell phones and automobiles; frequently, "consultation rooms" were coffeehouses. Our reduced administrative staff now has a limited number of examining rooms for offices in a building formerly used as an outpatient clinic.

As I write this article, public psychiatry services in New Orleans remain markedly restricted. Charity Hospital, where much of our education and training were based, had 92 short-term psychiatric beds and a crisis intervention unit for stays up to 24 hours for as many as 40 patients. The occupancy rate always hovered at close to 100%, and still at least 100 patients had to be sent off to other facilities each month. The Louisiana State Department of Health and Hospitals Office of Mental Health and the LSU Health Care Services Division responsible for the Charity Hospital Division have been working together to try to reopen facilities. We recently were able to reopen a child and adolescent psychiatry clinic and a small number of public inpatient beds: five for young children, 10 for adolescents, and 20 for adults. There remain many other problems with infrastructure. Many day treatment programs, ACT teams, step-down programs, group homes, and nursing homes have yet to reopen. The New Orleans Metropolitan Human Services District (MHSD), which provides public mental health and substance abuse clinics, has limited facilities and staff at this time. I am working, together with the MHSD, to help rebuild their infrastructure, plan disaster, behavioral health services, and work to meet regional needs. Our trauma-trained child psychiatry faculty have been working with displaced and returning students, and with preschools, early Head Start, and daycare programs. However, some of these programs are just beginning to return, with limited facilities and staff who themselves are living with much stress. Many fine hospitals in the region have reached out to our department and are working with us to establish training programs and other partnerships.

Lessons Learned

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 
As a department chair, I have learned many important lessons during Hurricane Katrina. Our city, state, and national governments were unprepared to respond to the impending disaster or adequately address the immediate and long-term needs following the devastation resulting from Hurricane Katrina and the flooding following the breach of the levees. This is especially surprising given the knowledge that has accumulated following previous disasters (2–5), such as the Oklahoma City bombing and the 9/11 terrorist attack (6), and creating systems of postdisaster care (6–9). Our medical facilities were similarly unprepared with crucial operations in basements or at ground levels and, in some cases, inadequate plans for evacuation. There is still no comprehensive national plan to train mental health professionals to meet special health needs. There is no coherent disaster plan to address the needs of children and families.

Our faculty has reached within themselves to provide high quality education and training under extremely complex and difficult circumstances. Some have worked on the front lines applying their knowledge and skills in ways they never would have anticipated prior to the hurricane. Faculty "worked in the field" to establish clinic sites and offer treatment when relatively little was available in the community. Faculty members have endured the pain of furlough; others, who have retained their positions—at times, with a cut in overall salary—have also been pained by furloughs of respected colleagues. I am aware that not every faculty member would choose to stay during the slow recovery and the uncertainties about the future. Some still have houses that are uninhabitable; some have partners or spouses who have lost their jobs; others with young children have concerns related to the devastated surroundings and schools with friends who have not returned. Yet most have a true commitment to the department, our medical students and our trainees, and are devoted to the work that they are doing. Most also love New Orleans and want to help in the rebuilding efforts.

With the extent of the devastation and the slowness of recovery, and with realistic concerns about the security provided by the levees, mental health symptoms are common. Patients who have prior mental health difficulties are more prone to significant difficulties at present, at times worsened by both the hurricane and the limitations in obtaining mental health care. As noted, depression is considerably more prevalent and it deserves treatment. We know that posttraumatic stress disorder has a slow burn and that some cases will develop with later onset under a variety of circumstances. In addition to substance abuse problems, more people are reporting increased drinking to deal with their stress. All of these problems needed to be addressed.

At the same time, it is important to recognize that Hurricane Katrina has resulted in a life-transforming experience. I can speak for many of our departmental members in stating that we have grown a great deal as individuals, educators, and clinicians. We, as many members of our community, have come to realize that we have strengths that could not be anticipated before Hurricane Katrina. We have also established new collegial relationships and friendships that will be important in the years to come.

One final comment needs to be added. In St. Bernard Parish, a community that was almost completely destroyed by the hurricane and then had a toxic oil spill, our department has been working with first responders, and with all students as they returned. At first, all lived in tents and trailers with no power or running water and went to school in trailers, and now to the one school rebuilt by the courageous community. Last summer, together with national consultants, we worked collaboratively with the St. Bernard Parish Unified School District to establish a pilot youth leadership program to build resilience and selfefficacy (10, 11). This program has remarkable teachermentors and students who selected themselves, not because of academic or prior leadership capabilities, but because of their desire to participate and the ability to fit the program into their work or remediation schedule. The students have developed a number of projects to help fellow students, others in the community, and the community itself in rebuilding. During the last week of the summer program, the students planted a garden in front of the one high school that currently exists for the parish. In their garden, they selected plants with colors of each of their prior high schools in order both to memorialize these schools and plant the seeds for their future. Like these courageous students at a time of uncertainty, the LSUHSC Department of Psychiatry can memorialize and remember some of the important things that we have lost as a result of the hurricane, but we can equally rebuild and establish an exciting new future.

REFERENCES

TOP INTRODUCTION Medical Student Education Graduate Training Further Constraints and... Where Are We Now?... Lessons Learned REFERENCES

 

1. National Child Traumatic Stress Network and National Center for PTSD: Psychological First Aid: Field Operations Guide, 2nd ed. July, 2006
2. Mollica RF, Lopes Cardozo B, Osofsky H, et al: Mental health in complex humanitarian emergencies. Lancet 2004; 364:2058–2067[CrossRef][Medline]
3. Norris F: Range, magnitude, and duration of the effects of disasters on mental health: review update 2005. Hanover, NH, Dartmouth College Research Education Disaster Mental Health, 2005. http://www.redmh.org
4. Norris F: Psychosocial consequences of disasters. PTSD Res Quart 2002; 13:1–8
5. North CS, Kawasaki A, Spitznagel EL, et al: The course of PTSD, major depression, substance abuse, and somatization after a natural disaster. J Nerv Ment Dis 2004; 192:823–829[CrossRef][Medline]
6. Norris F, Hamblen J, Watson P, et al: Toward understanding and creating systems of postdisaster care: a case study of New York’s response to the World Trade Center disaster, in Mental Health Intervention Following Disasters or Mass Violence. Edited by Ritchie E, Watson P, Friedman M. New York, Guilford, 2006, pp 343-364
7. Orner R, Kent A, Pfefferbaum B, et al: Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. Edited by Ritchie E, Watson P, Friedman M. New York, Guilford, 2006, pp 121-135
8. Pynoos RS, Steinberg A, Piacentini JC: A developmental model of childhood traumatic stress and intersection with anxiety disorders. Biol Psychiatry 1999; 46:1542–1554[CrossRef][Medline]
9. Shalev AY, Freeman S, Peri T, et al: Prospective study of posttraumatic stress disorder and depression following trauma. Am J Psychiatry 1998; 155:630–637[Abstract/Free Full Text]
10. Benight CC, Bandura A: Social cognitive theory of posttraumatic recovery: the role of perceived self-efficacy. Behav Res Therapy 2004; 42:1129–1148[CrossRef]
11. Masten A: Ordinary magic: resilience processes in development. Am Psychol 2001; 56:227–238[CrossRef][Medline]

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