Hurricane Andrew's Other Legacy

AFTER THE STORM

Psychologists on the scene describe the victims' mental anguish and how they are treating it.

Imagine the enormity, to stand in one place and everywhere, as far as you can see, there is damage. There is a loss and bereavement over everything, from tangible to intangible, from a dream to your leg. The scope of this disaster is a major issue, that everyone is going through the same thing. It's loss on a grand scale."

This eyewitness account of the devastation left by the destructive force of Hurricane Andrew is from Charles Gibbs, Ph.D., a clinical psychologist and chairperson of the Crisis Response Task Force in Dade County, Florida. He is one of the many mental-health professionals sent to the Homestead area as part of a joint effort between the American Red Cross and the American Psychological Association.

"I remember looking up and seeing body parts flying around me," recounted one survivor to Gibbs of his experiences during the storm. "The walls fell down and then the roof caved in on us:' reported another of the first Force 5 hurricane to befall an American city since Hurricane Camille struck Biloxi, Mississippi, in 1969.

Dubbed the Disaster-Response Network, the volunteer mental-health program was conceived as a 100th birthday gift of the American Psychological Association to victims of disaster everywhere. The network includes not only psychologists, but counselors, social workers, and psychiatrists. The idea was simple and a good one: the Red Cross provides physical treatment; the government, in the form of monetary and military aid, provides the basic necessities of life; and volunteers such as Dr. Gibbs offer their psychological services to ease the burden of adjustment into an entirely uncharted and unfamiliar way of life.

In the aftermath of the storm and its relief efforts, from the politicians' "help is on the way so chin up" speeches to the army and Marine invasion of support and aid, how are people reacting to the incredible loss they have suffered now that their basic needs are being met, now that the tents are erected and the kids are back in school?

"The survivors are suffering a myriad of emotional problems," reports Gibbs. "There's a lot of anxiety, restlessness, and an increase in anger and irritability-all of which is a perfectly normal response to a disaster of this magnitude. Many of the children are suffering night terrors. They see 'Andrew' as a real person and they're afraid he's coming back, that he's going to kill them. People feel like they're in a war zone down here-there are 18,000 troops, and the air is filled with helicopters. I know of one family of 65 people, all living in the same shelter, and they're angry because they no longer have control over their lives."

Many, including the armed forces sent to help out, compare the devastation to that of a bombed-out city in Iraq--a sight witnessed by several of those now serving meals and wiring the tents tents electricity Even the bare trees, stripped of their leaves and providing no shade (a normally uncommon sight in South Florida) are constant reminders of the loss.

Psychologists trained in disaster response identify two distinct phases of trauma. Phase One (also called the Impact Phase) is the acute crisis response, typified by feelings of shock, anger, and frustration. During this phase, in which survivors assess their losses and search for what remains, there may be post-traumatic response to storms, a reluctance to accept the need to move into a shelter, and an outbreak of psychosomatic illnesses such as headaches and stomach trouble.

The effects of the Impact Phase may last for several weeks or even months. It is a time when emotional recovery goes hand in hand with physical recovery from the storm-getting food, clothing, shelter. But getting back the basics doesn't necessarily mean getting back to normal, as survivors typically struggle with restoring their emotions and their outlook to the level of confidence and security they possessed before the storm.

In Phase Two (also called the Recoil Phase), the impact of the disaster has begun to sink in, and survivors are beginning to deal with the magnitude of their loss and finding ways to get on with their lives. As a result of the destruction, regular schedules are altered, lives are disrupted, and the feeling that one is basically in control is gone. The long-term effects of this adjustment can last up to 18 months, and is the primary concern of the therapists now in action in the South Dade area.

"Typically, people respond to a disaster with some initial heroic measures," says John Carnes, Ph.D., associate director of family practice residency at Bayfront Medical Center in St. Petersburg, Florida. "Everyone helps everyone else, and there's a kind of honeymoon mentality for awhile, a 'Thank God we survived; we're going to beat this thing' attitude. That can last for a day to a week, and then reality sets in. Very often people will be disillusioned by the slowness of relief efforts or by looters, and they begin to get angry.

"Think of anger as being the flipside of insecurity. Survivors then, when they realize the full extent of the damage, will very often vent that anger at an agency or a representative, something that they're feeling frustrated about. Sometimes, that might even be their children or their spouses."

The result, unfortunately, has been an increase in family violence and especially child abuse. Parents, forced to spend an inordinate amount of time with their kids (often in close quarters and surrounded by a lot of strangers who are in the same predicament), are taking out their frustrations on their especially needy children.

The world has turned upside-down for these kids," says Carnes. "And they don't have the cognitive development to understand it all. So in some cases their behavior is more problematic-they may be more oppositional, and at the same time they may require more cuddling, more nurturing, and more attention. This of course is occurring at the same time that parents are worried about how they're going to rebuild their homes, find jobs-generally when they're already stressed to the Emit' "

In response to the abuse, which many regard as the most serious immediate effect of the storm, Carnes administers short-term goals to parents: getting the kids back in school, finding a suitable place to live, even simple matters such as where to go to get their mail. By achieving these goals, parents can feel they are reestablishing a sense of control over their lives, which in turn reduces their level of frustration.

"There are two methods of treating the violence," says Carnes. "Prevention warning parents that such problems may arise under the circumstances and validating the anger they feel in response to hardships; and intervention, preferably as soon as possible."

By way of intervention, Gibbs will remind parents that they never reacted quite so violently to their children before the storm, as a way of getting them to recognize where their true frustration comes from. He also recommends being straight with families, letting them know the degree of difficulty they will face in attempting to rebuild their lives, without the benefit of rose-colored glasses.

"I can't tell people that things are going to get better when I know that may not be true," says Gibbs. "I let them tell their stories, I stress what's being done to help, but I don't promise that some fairy godmother will come in, wave a magic wand, and make everything okay. They need to know what the situation is if they're going to deal with it effectively and vent their anger in healthier ways."

Anger, it seems, is a motivating factor in response to many of the problems associated with the aftermath of disaster. There is no order in people's lives-other than the structured existence the military has established for them-and there probably won't be for another year. That will include special days, birthdays, anniversaries, the upcoming holiday season spent in a tent crowded with strangers. Certainly not the best of conditions for a family struggling to stay together.

As a hurricane has no face, no identity, that anger is finding no target, and is often turned inward. Feeding on itself, it win likely lead to ongoing problems such as depression and post-traumatic stress disorder (PTSD)-an anxiety disorder that follows a traumatic event normally out of the realm of one's experience. Common symptoms include disturbed sleep, phobic reactions, intense guilt, and vulnerability to visual or mental triggers that remind one of the event-some only vaguely reminiscent of the original trauma.

Carnes and other psychologists estimate that about 80 percent of victims win experience some symptoms of PTSD for about a year; others, approximately five to 10 percent, will suffer a more serious, long-lasting disorder. Some of these will reflect pre-existing conditions, as even before the storm hit, many of the victims were living on the edge of poverty. The hurricane exacerbated the stress of their already highly marginal lives.

Children and the elderly are especially vulnerable to PTSD, according to Sergio Aisenberg, a psychologist at Barry University in Miami Shores, Florida. They tend to feel more helpless and are less adaptable to newer, stressful situations.

"It is important to keep a support group going for kids," reports Aisenberg, who feels that some cases of PTSD can be prevented if children are given the opportunity to talk about their experiences. They need a counselor who will help them understand that, among other things, not every cloud in the sky is a sign that Andrew is coming back.

"The children need to be reminded, over and over again, that even during the storm they had someone who was there to care for them and make sure they were safe. They need to be reassured that that person-parent, grandparent, or guardian-is still present in their lives to watch over them and keep them safe."

Aisenberg and others recommend to parents that family structures be maintained, but perhaps relaxed a bit. Children may need to sleep in their parents' bed for awhile; they may need to stay up and talk later into the night, or have their needs tended to more quickly than under ordinary circumstances. They need to regain the sense of security that the storm shattered.

Sometimes the loss experienced by a child may be so profound, yet center on a tiny object lost in the storm or an image or memory seemingly gone forever. Aisenberg relates the story of one family whose children were distraught that they had lost a small toy their recently deceased grandfather had made for them and which served as a memento.

"In such cases," Aisenberg states, we try to reconstruct the lost object as best as possible. Then we get them to understand that although their possessions are gone, the emotions and images behind them remain. That objects are symbols for what they still possess and which no storm can take away from them."

In counseling younger victims, several psychologists have come up with unique tools for allowing them to vent their anger. Aisenberg uses a puppet with a mean face that he has named "Andrew." Kids are asked to respond to it any way they like. They routinely "punch, kick, and hit the puppet violently," Aisenberg reports. "Many of them will patiently wait their turn to take out their frustrations on the doll."

Aisenberg also introduces a colleague who plays the role of a "sad child" to a group of kids. They, in response, will hug her, try to cheer her up and reassure her that everything is going to be okay. "Helping other kids helps them," says Aisenberg. "That they can help others alleviates their anxiety."

John Carnes, on the other hand, has kids draw their images of Andrew, which he describes as "a cross between the Wizard of Oz tornado and an image of Dennis the Menace. We've also put together a coloring book for kids as a way to facilitate their expression and working through of their fears. And we ask them to describe and mimic the sound of the storm, which they say is like the sound of a freight train blowing through.'

There are other, special considerations that affect people left homeless in the South Dade area. Beforehand, many of the parents had regrets about their ability to adequately provide for their children, given their financial situations, Now they feel especially guilty for having subjected their kids to the trauma of the storm--even though the children survived, they feel bad for having placed them in danger. Others, made more aware of their financial needs in the wake of the storm, regret not having more resources to call upon in their time of need.

"People had many problems before the storm," says Gibbs. "Employment, for instance, is a big issue. Many didn't have steady work before, and the effort is now being made to find them jobs. In fact, quite a number went to the tent cities because they thought that more work would be available in that area."

Many also have fears that, after being shuffled from one shelter to another in the first hours and days after the storm, they will be placed somewhere and forgotten. Almost out of the system of society beforehand, they now feel pushed out entirely.

There are concerns, however, that a simple influx of monetary relief won't help. The object of many therapists is to stress to people that there is a split level of responsibility for recover-y: to first take care of their own family, and then rebuild their lives to be more secure than their pre-hurricane status. Many are told: "You will be receiving help-do something with it."

Diane Blank, Ph.D., coordinator of the mental-health services of Dade County, sums up the psychological response in this manner: "You put a hand on their shoulder, you ask if they're okay, and they see somebody who cares and it makes a difference to them. The job of mentalhealth volunteers is to offer a sense of human caring, human contact in the middle of all the red tape, all the confusion."

Yet the therapists may need therapists soon. If conditions remain as they are and estimates of the time needed for fun recovery-18 months by most standards---prove correct, the survivors will not be the only victims of Hurricane Andrew. Jean Armstrong, Red Cross coordinator for disaster mental-health services, stresses the importance of volunteers talking out their frustrations as well. 'We arrived in Homestead with our Superman capes intact," she says of the volunteers. "With the conditions we're working under now-long days, no sleep, minimal comforts-that cape begins to fall down, and eventually it wraps around our ankles and makes us walk funny."

"The goal is to take the survivors from anger to acceptance," says Gibbs, "while easing the stress that can lead to major mental-health disorders. And, in order to accomplish this, there's going to be a fairly acute need for counseling for at least six months."

Although many appear to be doing remarkably well in their efforts to recover, there are still signs of anger, reports of recurring nightmares, indications that the more serious effects of post-traumatic stress disorder are setting in. The estimates are that it will take years before many people will return to normal emotionally, to get back the feeling of stability and security, in their lives and in their selves, that was blown away as part of the destruction of Hurricane Andrew.

Some, including family practitioner Carnes, however, see signs of encouragement: 'Even people who went from shelter to shelter had a tendency to stay together, to help each other out and take care of one another. That's a good sign. I've seen, for instance, more American flags here than I ever saw at the height of Desert Storm. I'm not sure what those flags represent other than hope and defiance and the collective determination to get through this thing."

PHOTO: In the wake of the strom and its destruction (left). (GAMMA LIAISON)

PHOTO: Relief is doled out not only in the form of goods (inset), but in counseling as well. (GAMMA LIAISON)

PART TWO: RECOMMENDATIONS FOR ANDREW

We have developed practical guidelines for mental-health professionals interested in addressing the psychological needs of natural-disaster victims. In particular, we suggest the following:

1. Direct early relief efforts (3 to 6 months post-hurricane) at assisting individuals and families in obtaining basic goods and services. Don't underestimate the importance of food, water, shelter, and medicines to positive mental health.

2. To the extent possible, encourage people to become involved in collective selfhelp efforts. Continuing the pre-hurricane norm of self-reliance is a set-up for misery. Family should help family, neighbors should help neighbors, coworkers should help coworkers.

3. Watch out for forgotten groups. Certain groups-such as the elderly, the poor, the physically and mentally ill, and those in rural areas-may become isolated following a natural disaster.

4. Educate the public regarding normal psychological functioning in the aftermath of a hurricane, especially regarding normative stress reactions and available stressmanagement tips. Encourage people to share their experience with other people. It is helpful to know that one is not alone in having certain experiences and feelings.

5. Expect largely pro-social behavior from the community in the weeks and months following Hurricane Andrew. Large-scale natural disasters typically bring out the hero in many individuals. However, be prepared for some increase in problematic behavior such as crime, substance abuse, and family conflict (domestic violence, child mistreatment).

6. Be prepared to provide formal mental-health services to individuals and families in need. If some form of psychological recovery is not significantly under way by three to six months following Andrew, a formal mental-health evaluation may be needed.

MEMO FROM THE MEDICAL UNIVERSITY OF SOUTH CAROLINA

Part One: Reactions to Hugo

This memo is based upon the work of a clinical research team centered at the Department of Psychiatry and Behavioral Sciences of the Medical University of South Carolina, in Charleston. The team, including professors John Freedy, Ph.D., and Dean Kilpatrick, Ph.D., specializes in studying the relationship between natural disasters and psychological adjustment. Although the analyses are preliminary, the Hurricane Hugo data may suggest some experiences that might also be associated with Hurricane Andrew

Based on a sample of 776 adults impacted by Hurricane Hugo, our preliminary analyses suggest that the vast majority of adults did not suffer a persistent major mental-health disorder during the two years following the disaster. However, a small percentage of the general population did report either post-traumatic stress disorder (PTSD) or major depressive episode (MDE). Overall, the data suggest that a relatively small percentage of individuals will suffer major mentalhealth difficulties following Hurricane Andrew. However, even small percentages can equate to thousands of people when applied to a large population base.

We have been able to identify factors that contributed significantly to the development of mental-health problems. We recommend viewing these variables as "risk factors" suggesting vulnerability for the development of more serious mental-health problems.

The following factors were associated with a significantly increased risk for developing PTSD: history of general anxiety; history of victimization by violent crime; higher rates of negative life events following Hugo; a lack of necessary resources (e.g. family stability, stable employment, support from others); and higher rates of coping behavior.

These factors were related to the development of MDE: lower income; extreme initial emotional reactions to the hurricane; lack of necessary resources; and higher rates of negative life events following Hugo.

The risk factors outlined above could be used to identify populations at greatest potential mental-health risk. A few people developed physical concerns; however, many people reported individual and community resiliency by reporting the "good" that resulted from the storm. Many seem to be aware of the risk of future storms, and this appears to be good news for future preparedness.

Typical Reactions

It is generally believed that strong psychological reactions are normal during and in the days and weeks following disasters. The intensity and duration of distress is usually proportional to the magnitude of disaster impact on the individual and community. Those more strongly affected (by injury, loss of property, death of family/friends, loss of job, etc.) are likely to be the most upset for the longest period of time.

Psychological distress is usually relieved as the individual is able to return to stable and predictable life circumstances. Recovery is generally under way by three to six months following a disaster, yet can take up to 18 months for those more seriously impacted. It is generally believed that fewer than 10 percent of victims will develop a major mental disorder as a function of their experience.