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 federal agency.

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 better."

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 population."

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 health."

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 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>.▪