Red Cross Unprepared To Deal With Mentally Ill

“I was told that various services were not being provided because shelter operators couldn't decide if they could set up psychiatric services on site,” said anand Pandya, M.D., president of Disaster Psychiatry Outreach and an assistant clinical professor of medicine at Bellevue Hospital in New York, in an interview. “This led to unfortunate results.”

William Breakey, M.D., a retired psychiatrist from Towson, Md., volunteered through APA for a U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) program to provide psychiatric services to storm victims. Breakey said he had no negative experiences with the red Cross while working at a shelter in Lake Charles, La.

In contrast, Jay Holzman, M.D., of Belchertown, Mass., another SAMHSA volunteer, arrived in New Orleans three months after Katrina and had only minimal interaction with Red Cross personnel. “I did have some contact with them when the Lower Ninth Ward was opened and found them strikingly unwilling to partner with other service providers,” he said.

In Houston, all clinical oversight of evacuees was handled by the Harris County Hospital District, part of the county's incident command structure and not under the administration of the Red Cross or the Federal Emergency Management Agency (FEMA), said Avrim Fishkind, M.D., medical director of the hospital's neuropsychiatric center and president of the American Association of Emergency Psychiatrists. Fishkind's team set up its clinic next door to the Red Cross's shelter in the Astrodome, offering emergency services and counseling 24 hours a day. His only interaction with the Red Cross was trying to get the organization to send him patients, he said.

The Red Cross has traditionally allowed within its shelters only those volunteers who had completed its requiRed mental health training class.

That course, the “Foundations of Disaster Mental Health,” is intended to help psychiatrists, psychologists, social workers, psychiatric nurses, and other professionals to adapt their skills to disaster settings. There are 4,000 licensed mental health providers on the Red Cross's nationwide roster of volunteers, said Morgan. Yet getting them to shelters after Katrina proved problematic, even as outside professionals were excluded.

“The Red Cross doesn't recognize the expertise of anyone other than graduates of its own training program,” said Arshad Husain, M.D., chair of APA's Committee on Psychiatric Dimensions of Disasters and director of the University of Missouri International Center for Psychosocial Trauma.“ Its view is that unless you come through the Red Cross, you're not qualified.”

Husain has taken the organization's mental health training and called it“ very superficial.” This view was confirmed by a long-time Red Cross volunteer with knowledge of the organization's mental health policies but who asked not to be further identified to prevent career damage.

The same volunteer added that the Red Cross thinks the problem lies with doctors who, in the organization's view, won't serve in shelters if they have to answer to nurses managing health care. A disaster of Katrina's magnitude exposed the weakness of this attitude, said the volunteer. “The Red Cross has never had a situation where their outmoded views have been challenged.”

Still other doctors said that the organization seemed bound by inflexible rules intended for less extreme settings.

“The Red Cross was prepared for a different kind of disaster, a smaller, briefer one where displaced populations were not so severely ill,” said Jeff Stovall, M.D., also a SAMHSA volunteer in Louisiana at the end of September 2005. He did not run into any restriction or segregation of evacuees, he said.

“I was impressed that the Red Cross was not prepared to address the mental health or other medical needs of people in the shelters,” said Stovall. “In many cases, we SAMHSA volunteers were the first physicians into the shelters. They did have nurses on every shift, but they were not trained to assess or treat psychiatric needs. The role of psychiatrists was vital, for people with both pre-existing and storm-caused disorders.”

The Red Cross's relationship with doctors not affiliated with the organization was complex, said Morgan. In typical emergencies, the Red Cross tries to assure the quality of medical services by working with physicians it has registered in advance or by creating ties with local agencies. Local chapters must have local doctors who can provide that support. But following Katrina and Rita, such coordination was often not in place, she said.

“Maybe [doctors] were turned away if they were not known to the Red Cross staff,” she said. The organization did work with SAMHSA to give local substance abuse counselors access to their existing clients.

Poor coordination within the Red Cross caused other problems, said David edward Post, M.D., medical director of the Capital Area Human Services District, which serves seven parishes (counties) around Baton Rouge, La.

Mental health workers from Post's district were assigned to visit shelters, screen evacuees, offer brief interventions, and refer patients for more care, if needed. At some sites, shelter directors turned them away. Before Katrina, said Post, the Red Cross's attitude could be characterized as: “We're all about shelter, not about medicine or mental health.”

The crisis grew so acute that Louisiana's Department of Health and Hospitals signed a memorandum of understanding with the national Red Cross on September 23, three weeks after the storm. The agreement permitted state mental health employees to enter shelters and provide screening or services to residents with mental health difficulties, substance abuse problems, developmental disabilities, or limitations caused by aging. However, in most instances, very few of the local shelter managers had even seen the two-page memorandum, said Post.

“On several occasions, I had to go out personally to several shelters and plow through the issue,” he said. “When I showed them the memo, they often looked perplexed, then accepted it with trepidation. The problem was that the Red Cross rotated [volunteer] shelter managers in and out. We taught the old one, then had to educate a new one after three weeks.”

Post said he explained to each Red Cross shelter manager that there were undoubtedly residents who had been through traumatic experiences. Some had been on psychiatric medications and needed help to maintain continuity of care.

“Our outreach staff was under clear direction to ask in a voluntary manner if they could discuss stress or how evacuees were coping,” he said. “if a person did not want to participate, we'd accept that and leave a brochure for our clinic. Yet, also I also made clear to shelter managers that if our mental health staff were prevented from screening, and some of the evacuees became psychotic or suicidal, the manager would end up calling us anyway. We were trying to balance all interests and get evacuees back on their meds and reconnect to mental health services before trouble occurred.”

In the end, mental health teams from Post's district identified and screened 6,000 people in the shelters.

The national Red Cross needs to ensure that its volunteers on the scene understand its policies, Post said. “You can have it on paper but they need to have the mindset,” he said. “Last year, there was a communications gap between the national organization and their local people. The national Red Cross did a poor job of communicating to their local field leaders that mental health personnel should have access to shelters.”

The overwhelming scale of the destruction inevitably led to sporadic failures and service breakdowns, but everyone interviewed for this article said all parties involved are trying to learn from the experience and prepare to function better after future calamities.

“Remember, this was the worst natural disaster in U.S. history,” said Post.

Government emergency plans should make sure that people with psychiatric problems, whether pre-existing or caused by a disaster, should have access to shelters, said the National Council on Disability.

The Red Cross should ensure that shelters and other emergency services are open to people with disabilities, including psychiatric disabilities, admit people who do not require care in an institutionalized setting, and be prepared to help even those who have evacuated from institutions until further help is assured, added the council.

The Red Cross published a report in June listing its plans to upgrade its business systems, improve financial accountability to stop waste and fraud, and connect better with local communities and minority groups. However, the report said nothing about treatment of people with psychiatric disabilities.

The number of volunteers trained in mental health by the organization wasn't enough to provide services after Katrina, said Morgan. “We're working hard to increase our capacity to blend in local resources.”

The Red Cross is also developing systems within shelters to handle extended crises by writing down information to carry over to the next shift or round of volunteers, said Morgan. Red Cross officials have met with organizations like the National Mental Health Association and APA to improve Red Cross training to handle people with mental disabilities. They are also working with other groups and agencies to ease licensing and malpractice insurance requirements that still impede out-of-state physicians from volunteering beyond very short stints. Discussions are now under way between the organization and the Department of Health and Human Services and with FEMA on how to meet the full range of medical needs in future disasters, said Morgan.

“The Needs of People With Psychiatric Disabilities During and After Hurricanes Katrina and Rita” is posted at<www.ncd.gov/newsroom/publications/2006/peopleneeds.htm>. The Red Cross report “From Challenge to Action” is posted at<www.redcross.org/hurricanes2006/actionplan>.▪