People who fled Hurricane Katrina from New Orleans and surrounding areas
crowd the Lake Charles Civic Center, on Wednesday, August 31, 2005, in Lake
Charles, La. The American Red Cross along with local volunteers gave out food,
toiletries, and toys for children. However, psychiatrists and mental health
workers had difficulty gaining access to other shelters. See story below.
(AP Photo/The American Press, Brad Puckett)
Following hurricanes katrina and rita last year, people with psychiatric
diagnoses or other overt emotional problems were excluded from entry into some
Red Cross shelters, segregated within facilities, or denied reentry if they
left, according to a July report from the national Council on Disability, a
In addition, several psychiatrists say they encountered difficulties
entering or working in some shelters.
"There is broad consensus among people with disabilities, advocates,
professionals, first responders, and service providers that people with
psychiatric disabilities encountered enormous problems with general shelters,
especially those run by the american red Cross," said the report."
Many smoking-dependent people with psychiatric disabilities were not
allowed to reenter shelters when they left to smoke. Some shelters `dumped'
difficult evacuees by sending them to jails, emergency rooms, nursing homes,
or mental institutions."
The red Cross had no formal policy on dealing with people with psychiatric
disabilities, said Julie Carroll, J.D., senior attorney advisor at the
national Council on Disability. "everyone was operating on the fly with
no training and no information."
Red Cross spokesperson Jane Morgan, B.S.N., manager of individual
assistance for the organization, said she was "not aware" of
specific incidents, but said that the organization would modify its procedures
to avoid the kinds of problems stated in the report.
"There's no question that things happened that shouldn't have
happened," said Morgan in an interview with Psychiatric News."
We do ask for specific instances so we can continue to do
At least some storm evacuees with psychiatric conditions found that shelter
from the storm was a mixed blessing, according to the council.
"Shelters were crowded, noisy, chaotic, confusing, and sometimes
violent, all inadequate circumstances for a person with psychosis, anxiety, or
depression," the report said. "Many ended up living right outside
the shelters, and services were not provided to people living outside the
shelters. In other shelters, people with psychiatric disabilities huddled in
corners behind physical barriers segregating them from the general
The american red Cross was given authority by Congress in 1905 to provide"
a system of national and international relief in time of peace and
apply the same in mitigating the sufferings caused by pestilence, famine,
fire, floods, and other great national calamities." Under the national
response Plan—which delineates how the federal government coordinates
with state and local governments and the private sector during
incidents—the red Cross holds primary (but not exclusive) responsibility
for feeding and sheltering victims of catastrophes.
Red Cross procedures in place at the time of last fall's hurricanes
required shelter managers to assess informally whether incoming evacuees could
care for themselves in the shelter, said Morgan. If the managers decided they
could not do so, the evacuees were referred elsewhere, often to a
special-needs shelter intended for the elderly or the physically disabled.
"The individuals who volunteer for the Red Cross are representative
of the U.S. population as a whole," said one psychiatrist who asked to
remain anonymous because he continues to have working contacts with the
organization. "They have the same stigma as all parties. The Red Cross
has an internal system to provide disaster mental health, but it does not
allow psychiatrists to diagnose patients or prescribe medications. Generic
mental health counseling may be valuable, but for people with psychiatric
diagnoses, the care of psychiatrists is vital for their ongoing safety and
The Red Cross's relations with physicians varied. Some psychiatrists,
especially those who arrived in the Gulf Coast region weeks or months after
the storms, reported having little or no problem serving in shelters. Others
had mixed responses.
"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
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
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
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
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
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
"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
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
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
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>.▪