Recovering from Katrina: Lessons from 9/11

By Sandra Bostwick, MA, OTR/L, RMT

"History is merely a list of surprises. It can only prepare us to be surprised yet again."
— Kurt Vonnegut, writer and artist

As I watch the live news coverage of the disaster in the Gulf Coast, I think back four years ago to 9/11, the day the twin towers fell. As I walked into the psychiatric unit that day to begin my shift as a music and occupational therapist, I sensed something was wrong. The staff, a strong team which manages tense situations with ease, looked stunned and anxious. Someone pulled me into a conference room and said a plane had gone off course and hit the nearby World Trade Center. The rest is history.

I learned much in the following months as a school- and hospital-based OT in a community healing from a disaster. Most importantly, I discovered that the definition of community can be subjective. It does not necessarily mean physical proximity as much as it reveals the degree of emotional connectedness an individual feels. When a national disaster occurs, it touches every citizen on some level.

As with the World Trade Center disaster, the aftermath of Hurricane Katrina will be a powerfully uncomfortable reality. The differences between these two disasters are too many to mention and the job ahead, I fear, will be much tougher. By proactively anticipating needs, taking advantage of specialized training, taking a role in planning teams, and adapting programs, OTs will be prepared for the road ahead.

Staff and Resource Shortages

The initial need in the disaster area will spread to surrounding areas and eventually across America as survivors relocate. Infection and disease from unsanitary conditions will require treatment. Lost and orphaned children will require homes. The destabilizing effects from stress and lack of medical attention can cause exacerbation of mental illness. Disrupted medical regimes will need to be reestablished. Recovering addicts may need support to prevent or to deal with relapse. A percentage of the workers—including soldiers, police, firemen, media, medical teams and sanitation workers—can be expected to suffer reactive stress. The percentage of the population at risk for suicide can be expected to increase. Family members caring for survivors in crisis will be at risk for caretaker stress.

School and early intervention therapists will need to provide services for those relocated students who are classified in the special education system. Additionally, a new at-risk population of students will require screening. Students who fall behind as a result of stress reactions or other disaster related causes may benefit from a 504 plan, which is a modified approach for non-classified students who demonstrate a physical or mental impairment which substantially limits one or more major life activities. The effect of exposure to the unique mixture of toxic waste in the waters will need to be monitored to rule out any developmental reaction.

Finding solutions for the anticipated staff and resource shortages will require creative planning, and OTs can act as a resource in this effort. OTs can in-service newly mobile staff on how to organize a program in a rolling suitcase. OTs can design creative budgets, develop efficient screening programs and educate support staff and teachers on the use of screening tools. Streamlining methods for collecting and measuring data to monitor progress of goals and objectives may be necessary as caseloads increase and more clients are seen per session.

Crisis-specific Intervention Plans

A complex form of dual diagnosis is seen when survivors present with a preexisting set of symptoms as well as symptoms of recent survivor trauma. The typical emotional issues which are found during relapse from an addictive illness can be compounded by acute stress disorder or post-traumatic stress disorder. The typical sense of loss experienced by an amputee can be compounded by the extreme emotions resulting from loss of home and family. The typical difficulty a new student may face during transition to a new school can be compounded by traumatic evacuation from a disaster area. Transition into existing schools and community programs can be complicated by stress reactions, physical illness and/or a potentially higher level of emotional reactivity.

Standard preparation may include training staff to recognize stress reactions and other triggers for referral to specialized groups or individual counseling. Many OTs are providers of these specialized interventions, as well as skillful observers for referrals to other disciplines.

OT can assist our hospitals and schools by examining existing systems and anticipating the needs of survivors. A proactive approach to learning crisis management and de-escalation skills is necessary to manage survivors who may present a danger to themselves or others. Independent contractors may wish to inform administration that they would like to be included in training offered to employees. OTs with hands on experience in mental health may offer to provide in-services or support to other staff who will encounter crisis management for the first time.

Meeting Mental Health Needs

Community hospital mental health units, already challenged to provide cohesive programs for a wide variety of ages and mental health needs, will experience even more challenges as they treat hurricane survivors.

The issues and emotional reactions of survivors to topics such as goal setting, relapse prevention, daily routine management, stress management and suicide prevention can be very different from those expressed by traditional mental health patients. Decisions as to how to adapt hospital programs to an influx of survivors will need to be determined, considering existing structures, staff and facilities. OTs facilitating verbal or task focused groups may choose to create specialized groups rather than inserting survivors with other patients. Group co-leading with other disciplines is particularly helpful during potentially volatile situations.

During my post-9/11 experience, I was blessed to have been part of a mental health team which truly put the needs of the patient first and individual egos last. A good team anticipates when a co-worker needs assistance and takes initiative. Setting limited amounts of time to "debrief" or scheduling breaks for coffee or a walk with no work talk at all will help with team building. Volatile and potentially dangerous situations can occur at any time and a strong team approach will keep all involved as safe as possible.

Good Judgment

In the months ahead, some OTs may work with survivors with disabling depression, anxiety, anger, agitation, preoccupation, grief, hopelessness or apathy during treatment. Some traumatized individuals experience flashbacks accompanied by physiological reactions.

Understand the procedure to follow when a client expresses suicidal ideation, including who needs to be informed and how that information needs to be delivered. Preparation is the key to being fully focused and empathetic with a client in crisis.

Planning and preparation can be tentative, calling for quicker thinking in view of shifting emotional states. This can be especially draining when the therapist may also have strong emotions attached to the issue at hand, interfering with the detachment and objectivity which helps us maintain clear clinical judgment.

When a survivor looks into our eyes, shares a terror, and pleads for help, we are no longer observers. The suffering becomes personal as we, too, become survivors of a tragedy.

This is often the time when a patient will reach for a hand or a hug. While this can challenge the physical distance many have become accustomed to for definition of boundaries, the effect of a trusted listener suddenly recoiling to touch is hardly therapeutic. Clinical judgment in view of each individual setting and situation will need to be considered. Another distressing situation for many therapists occurs when fighting back tears becomes impossible.

Maintaining Direction

When chaos reigns, it is common to attempt to find order by deciding who to blame, who to thank, who to hate, who to pity, who to support, who to help and who should 'just get over it.' As OTs, our primary goal is to help our clients return to functional and purposeful living. OTs will need to take a proactive approach to discouraging debates which will interfere with the therapy goals at hand. We are here to stabilize and restore order to chaos for the survivors who come to us for help.

Opening a session with a goal directed mission statement sets a tone and purpose which assists with maintaining control. Rather than stopping a debate by saying "That isn't important right now," we can offer redirection such as, "That is interesting, but can you give us something to add to the list of job interview skills that we need to complete?"

Being very specific about the topic and goals will discourage tangential conversation. Be aware that, often, clients with no real purposeful focus will turn back to a debate or an opinionated platform in order to detract from the fact that they are having difficulties reorganizing themselves to offer comments which would help the group move closer to its goal.

Therapeutic activities can also serve as a non-threatening outlet for these emotions. The benefit of activities was evident during several news broadcasts. In the crowded Astrodome, the smiling faces of displaced children who had just viewed a movie, a smiling young girl displaying the picture she had drawn, and a group of boys bowling with water bottles demonstrated that activities had succeeded in providing a cause for joy in the middle of a national disaster.

It is not uncommon for people who are being helped through a crisis to express the feeling that they have been over-analyzed, drained from talking, and in need of a break from the very people who are trying to assist them. The value of our music, creative arts, games, religious services and recreational activities cannot be underestimated in this situation.

It is also not uncommon for a client to make a major breakthrough during a non-threatening activity. I witnessed a touching breakthrough for an angry man who had suffered an addiction relapse in the months following 9/11. He refused to speak to peers or staff and remained isolated on the unit. Finally, he agreed to come to an individual music therapy session on the conditions that he could choose the music and that there would be no talking. I remember sitting quietly and feeling a bit awkward as we listened to the music in silence, until the man spoke with no encouragement at all. "I've gone back to drugs so many times and each time I've asked Jesus to forgive me and I just don't think there could be any forgiveness left," he expressed. Our training to shape breakthrough moments into personal growth turns activities into powerful healers.

Who Will Need Our Services

An unprecedented number of displaced and possibly traumatized survivors will be required to pick up what little they may have left and get on with their lives. Never before in our country's history has the framework of our community support systems had to stretch to accommodate such sudden need.

A few months after 9/11, while looking at the lights of a fire truck during a school fire drill, I started feeling heaviness in my chest and an uncomfortable rise in my anxiety level. I realized I was reviewing the images, sounds and smells I'd imagined while counseling a patient who described a horrified dash away from the World Trade Center. I was on alert, as if my students were in danger from falling bodies and debris. I was a visitor in someone else's flashback. Health care workers can suffer from a type of second-hand post-traumatic stress disorder.

I learned a lesson in one group during which a woman cried because she could no longer see the twin towers when she viewed the New York skyline. A second woman, traumatized from flashbacks of running from the falling towers, angrily reported she was tired of listening to people who, in her opinion, had no connection to the event at all. The discussion challenged us all to define just who can call themselves a survivor of the disaster. By the end of the group, I realized that I, too, was a survivor in need of healing.

When we enter into a disaster, whether by providing attention, compassion, prayer, donations or services, the boundary between "us" and "them" blurs. We become part of a huge movement, and each of us keeps pace to the degree we can embrace our own hope, faith and courage. Those of us who suffered helping others healed ourselves only when we admitted that we, too, are survivors.

Sandra Bostwick, MA, OTR/L, RMT, is a certified teacher of music and has close to twenty years experience working in schools, hospitals and in private practice. She has published several creative & technical writings and has lectured in the United States and Canada.