AFTERMATH OF AFTERMATH OF DISASTERDISASTER

Short and Long-Term Effects of Short and Long-Term Effects of Disasters: An overview, impacts, Disasters: An overview, impacts,

related statistics, and a case related statistics, and a case presentation for Attorneys in presentation for Attorneys in MS and LA after Katrina and MS and LA after Katrina and

RitaRita

Alexis Polles, MDAlexis Polles, MD

Outline for Outline for PresentationPresentation

• Disasters-Causes of vulnerability

• Psychological responses to traumaticstressors

• Impacts on Attorneys• Statistics• Case Presentation• Closing Comments

BackgroundBackgroundDisaster: An event or occurrence- usually

sudden and unexpected- that intensely alters the objects and localities under its influence. It results in loss of life and health in the local population, causes severe environmental damage and the destruction or loss of material goods resulting in a dramatic disruption of normal patterns of life. Such disruption…gives rise to the need for immediate intervention and humanitarian aid.

Principles of Disaster Mitigation in Health

Facilities

Involves response to (and preparedness for) natural or man-made events that affect an entire community or communities. (Usually) involve massive numbers of casualties and extensive property damage.

Randal Beaton, PhD, EMT

DISASTER RESPONSEDISASTER RESPONSE

Other Areas of Other Areas of VulnerabilityVulnerability

• Administrative/Organizational• Systemic • Individual

Psychological Responses to Psychological Responses to Traumatic StressorsTraumatic Stressors

Traumatic Stressor: Any event which is outside of the realm of normal human experience and very distressing is a traumatic stressor or critical incident.

86% of individuals exposed (directly or indirectly) to a traumatic event or critical incident tend to have some kind of reaction within 24 hours of the incident but such reactions may be delayed for days to weeks.

Stress Management and Disasters

MaslowMaslow’’s Hierarchy of s Hierarchy of NeedsNeeds

Self-Actualization

Esteem

Love/Belonging

Safety

Physiological

Prevalence of Adverse Prevalence of Adverse Psychological Psychological

Effects Following DisasterEffects Following Disaster• 0-24 hours

– 90%+ exhibit some untoward psychological effects

• 12 weeks– 20-50%+ still show significant signs of

distress• 1-2 years

– 25%+ still show significant symptoms and others previously free of symptoms may first show a response

Coping with Disasters; Ehrenreich, John October, 2001

Factors Affecting Vulnerability Factors Affecting Vulnerability to to

Adverse Psychological EffectsAdverse Psychological Effects• Greater severity and terror = greater

likelihood widespread and lasting negative effects.

• Intentional > unintentional > natural• Mothers of children (5-10), people with

prior mental illness, those with poor social adjustment, and those with prior personal experience of trauma

Coping with Disasters; Ehrenreich, John October, 2001

Vulnerability factors cont.Vulnerability factors cont.

• Specific disasters (e.g. witnessing death of loved one, losing a child, being entombed or trapped, serious injury from disaster, hospitalization as a result of the disaster)

• Stigmatization of the victims (e.g. rape, in some cultures the victims are unable to tell the family or friends for fear of punishment or blame)

• Lack of availability of social support networks. Coping with Disasters; Ehrenreich, John October, 2001

The more severe the disaster, the less the characteristics of individuals matter. In very severe disasters, virtually everybody shows adverse emotional responses.

Coping with Disasters; Ehrenreich, John October, 2001

Katrina and RitaKatrina and Rita• Nationally

– Top headline from NY Times and LA Times all but five days between 8/30/05 & 9/26/05

• Regionally– SouthCentral region had a much lower rate on a

happiness index through the 2nd week of September

– Income does have a noticeable relationship to happiness

– Many people care about others but few are “Saints”

• Locally “Unhappiness after Katrina”, Kimball, et al, March 2006

Potential Victims Of A Traumatic Potential Victims Of A Traumatic StressorStressor

1 Primary Victims

Those individuals most directly affected by the event, e.g., the persons whose houses are blown down in a hurricane.

2 Secondary

Victims

Those individuals who in some way observe the consequences of the traumatic event on the primary victims, e.g., bystanders, rescuers, and emergency response personnel.

3 Tertiary Victims

Those individuals who are indirectly affected by the traumatic event as a result of later exposure to the scene of the trauma or to the primary or secondary victims of the trauma, e.g., family members of primary or secondary victims or passers by. Stress Management and Disasters

Responses To A Traumatic Responses To A Traumatic SituationSituation

1 No Reaction

2 Normal Stress Response

3 Psychological

and Behavioral Syndrome

4 Psychological

Disorders

Stress Management and Disasters

PRE-IMPACTPRE-IMPACT

PHASE:PHASE:

The majority of persons make some effort to prepare The majority of persons make some effort to prepare for the potential impact of a disaster. Others become for the potential impact of a disaster. Others become indifferent and deny that there is any impending indifferent and deny that there is any impending danger and still others become anxious and somewhat danger and still others become anxious and somewhat disorganized. A few persons remain quite calm and disorganized. A few persons remain quite calm and focused.focused.

WARNINGWARNING

PHASE:PHASE:

During this phase a greater proportion of persons tend During this phase a greater proportion of persons tend to become agitated and over-react but a few continue to become agitated and over-react but a few continue to remain calm and purposeful.to remain calm and purposeful.

Persons tend to be fearful and they attempt to cope by Persons tend to be fearful and they attempt to cope by either giving up, running away, or rescuing others.either giving up, running away, or rescuing others.

HEROISMHEROISM

PHASE:PHASE:

During this phase, efforts are made to survive and During this phase, efforts are made to survive and recover property. This is a time of great altruism and recover property. This is a time of great altruism and overwork with possible irritability and exhaustionoverwork with possible irritability and exhaustion

HONEYMOONHONEYMOON

PHASE:PHASE:

Persons tend to share their experiences. Good Persons tend to share their experiences. Good outcomes are anticipated and hope and elation outcomes are anticipated and hope and elation prevails.prevails.

DISILLUSIONMENT DISILLUSIONMENT PHASE:PHASE:

Disappointment occurs when aid is not as readily Disappointment occurs when aid is not as readily forthcoming as was anticipated and some people are forthcoming as was anticipated and some people are seen as less fortunate than others. Depression often seen as less fortunate than others. Depression often follows.follows.

REBUILDINGREBUILDING

PHASE:PHASE:

People need to accept that they must depend on People need to accept that they must depend on themselves if they are going to move on and rebuild themselves if they are going to move on and rebuild their lives. Failure to do this leads to bitterness and their lives. Failure to do this leads to bitterness and animosity.animosity.

PR

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NC

IDE

NT

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app

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IMP

AC

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AS

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Stress Management and Disasters

NURSESNURSES’’ RESPONSE RESPONSE

• n=443 inpatient nurses in Kobe, Japan following devastating earthquake

• 80% (335) completed general health questionnaire at 1 & 8 months after the quake. Compared to their usual state pre-earthquake, nurses showed considerably increased total scores on psychiatric symptoms; especially somatic symptoms, sleep disturbance, anxiety and social dysfunction.

BMJ 1996; 313:1144 (2 November)

Phases of DisasterPhases of DisasterHONEYMOON(COMMUNITY COHESION)

HEROIC

PREDISASTER

DISILLUSIONMENT

RECONSTRUCTIONA NEW BEGINNING

Warning

Threat

Impact

Inventory

(Com

ing to

Ter

ms)

WORKIN

G THROUGH G

RIEF

Trigger Events and Anniversary Reactions

--1 to 3 DAYS –Time------------------------------------1 to 3 YEARS --------------------------------

Reflection QuestionsReflection Questions

Where do you think you are on this graph?

What is one issue of concern you have for yourself, (one for) your family, your work, your community?

What is one way (smaller is better) you can take care of yourself this week?

Common Reactions of Normal Common Reactions of Normal People to an Abnormal SituationPeople to an Abnormal Situation

Nu

mb

er o

f p

eop

le a

ffec

ted

Many

Few

Examples of moderate reactions:•Persistent Insomnia•Anxiety

Examples of severe reactions:•PTSD•Depression

Examples of mild reactions:•Insomnia•Worry•Feeling upset

Mild/FewSevere/Many

Severity or number of symptoms

Common Immediate ReactionsCommon Immediate Reactions

• Denial/Indifference/Avoidance• Refusal to evacuate• Self-destructive “coping skills”, especially

excessive alcohol and substance use, excessive work, etc.

• Despair• Panic- Fight/Flight/Freeze• Survival Guilt• Destruction of personal

illusion of invincibility

DANGER

Adrenaline Storm Ahead

•Decision making is influenced by Decision making is influenced by personal personal psychological factors and cultural psychological factors and cultural factors.factors.

•Many professionals have an authoritarian Many professionals have an authoritarian style with rigidity, inflexibility, and style with rigidity, inflexibility, and need for highly predictable environment.need for highly predictable environment.

•There is a strong drive for achievement There is a strong drive for achievement and aand a fear of failure. fear of failure.

•They may respond with an attempt to They may respond with an attempt to regain control, though by outwardly regain control, though by outwardly behaving as though everything is normal. behaving as though everything is normal.

Personality TraitsPersonality Traits

• Type A behaviors– driven – competitive– individualistic– perfectionist– compulsive

Common BehaviorsCommon Behaviors

• Inappropriate anger or resentment• Inappropriate words or actions

directed towards another person• Inappropriate response to patient

needs or staff requests

Inappropriate Words/Actions Inappropriate Words/Actions Directed Toward AnotherDirected Toward Another

• Sexual comments/harassment• Seductive, aggressive or assaultive

behaviors• Racial, ethnic, or socioeconomic bias• Lack of regard for others’

comfort/dignity

Inappropriate Responses to Inappropriate Responses to Clients/StaffClients/Staff

• Being uncooperative, defiant, rigid when dealing with problems or responding to requests for help

• Being avoidant or unreliable• Unprofessional demeanor• Recurrent conflict with others• Difficulty with authority• Belittling remarks near

clients/families/staff

Review of Impacts of Review of Impacts of Katrina/RitaKatrina/Rita

• Acutely Traumatized Population• Over-Burdened Professionals• Disrupted Social and Economic

Infrastructure– Family dysfunction– Migration and displacement– Loss of tax base and social services– “Getting on with life” leading to shift of

priorities away from problems of evacuees after the acute crisis has settled

James Griffith, MDPine Grove Katrina Workshop November, 2005

Bringing it HomeBringing it Home

• Cultural and Psychological Issues in Attorneys

Failure = Lack of Failure = Lack of efforteffort

Inability to ask for or receive Inability to ask for or receive helphelp

Depression in AttorneysDepression in Attorneys

• 10% prevalence of Major Depression > twice that of the general population• Applicants = general population• End of first year, 32% depressed• End of third year, 40% depressed• Two years of practice, 17% -20%

depressed, 12% problem drinkers, 6% both

• 33% in practice in Washington with depression, problem drinking, or cocaine abuse

Prevalence of Alcohol Prevalence of Alcohol ProblemsProblems

• < 20 years practice = 18% prevalence

• > 20 years practice = 25% prevalence

Indicators of Problems in Indicators of Problems in LawyersLawyers

• Being late for court• Failing to file legal notifications• Poor records• Misappropriating funds• Delays in taking care of mail• Missing deadlines• Failing to return calls• Intentionally failing to pursue lawful

objectives

Less Specific IndicatorsLess Specific Indicators• Irritability, moodiness, verbal

abuse• Complaints from clients or staff• Changes in schedule or absences• Decline in quality of work• Family problems• Financial difficulties• Isolation• Physical deterioration• Somatic Complaints

Indicators Specific to Indicators Specific to AddictionsAddictions

• Long lunch hours• Long sleeves• Bathroom use• Breath• Coming in late and leaving early• Overt intoxication

STATISTICSSTATISTICS

There are 374 attorneys that were living in Louisiana prior to Hurricane Katrina who are now living out of state.

GULFPORT, MSGULFPORT, MS

• 1st Weekend in June 2006– Total of 8 “911” calls for suicide

attempts

• In the year since Katrina– The number of completed suicides

has quadrupled– The number of suicide attempts has

increased by 30%WLOX News Broadcast 6/16/06

John BarristerJohn Barrister

• 45 year old general practice attorney from a small town

• Married with no children• Family History: Drug addiction in a

younger sibling. Workaholism and perfectionism in his father. Chronic health problems in his mother.

CopingCoping

ResilienceResilience• The capacity to emerge from

adversity stronger and more capable:– Best regarded as “something one does,”

rather than “something one is”– Can refer to competencies of a person, a

family, or a culture in responding to adversity

– Strengthened by identifying strengths, skills, competencies, resources, personal wisdom from lived experience, with which adversity can be countered

James Griffith, MDPine Grove Katrina Workshop November, 2005

• What is a competency you have noticed in yourself, another person, your family, and your culture?

Closing CommentsClosing Comments

• Traumatic events are frequently a source of energy for new ideas, discoveries, and growth.