When I moved to New Orleans in February 2006, it was five and a half months after Hurricane Katrina ravaged the city, and the storm still pulsed in its streets and people. A rescue boat appeared to be parallel parked outside of my Marigny apartment on Elysian Fields, and dogs ran wild in packs, having long forgotten a different reality—one with a full belly and scratches behind the ear. People carried around loss and abandonment like a bag of rocks they tugged from one day to the next, with nowhere to set it down. Their pain was palpable, and so too was their skepticism as they carefully scrutinized passersby to determine who had gone through Katrina, and who hadn’t. Who was an insider and who wasn’t. Jeannette David, the disaster mental health coordinator at Georgia’s Department of Behavioral Health and Developmental Disabilities (DBHDD), says what I witnessed was collective trauma. She should know. To date, David has provided administrative oversight as well as training and consultation in the Federal Emergency Management Agency Crisis Counseling Assistance and Training Program (FEMA CCP) in the aftermath of numerous disasters. She’s overseen six CCPs in Georgia and provided training and consultation to another six CCPs in other states. The program offers short-term disaster relief to help people and communities recover through access to crisis counseling services as well as community networking and support. CCP grants are awarded to a state after a presidential disaster declaration.
David says collective trauma can be passed from one generation to the next. It happened in the United Kingdom with blitzkrieg (sometimes called lightning war), Germany’s bombing campaign during the Second World War. “Many of the people who lived through the Blitz aren’t alive anymore, but their children are, and they inherited the trauma. You can feel it in them even though they didn’t live through it themselves.” She notes that we will likely see similar collective trauma in future generations because of Katrina, 9/11, and on a global scale, COVID-19.
While the residual effects of a disaster can linger throughout lifetimes, increased demand on behavioral health services often has a delayed curve. “It’s usually when the helpers have picked up and left that we begin to see the spike in mental health calls.”
This is, in part, says David, related to stigma, marketing, and how people see themselves. “In the wake of a disaster, many people are more apt to call a disaster distress or emotional support line than one that has the words suicide or mental health in it.” This matches with what John Draper, Ph.D., project director of the SAMHSA-funded National Suicide Prevention Lifeline (800.237.TALK or chat), told us earlier this week: that while COVID-19 is often the backdrop for calls to the Lifeline, the number of calls themselves haven’t risen. At the same time, said Dr. Draper, calls to the Disaster Distress Helpline have increased from about 50 a day to 600.
The delay is not just due to stigma, points out David, but also because of the natural phases of recovery after a disaster, which typically include periods of communities coming together, readily available help, and then a sense of abandonment. That said, she notes that COVID-19 presents challenges unlike anything she’s ever seen.
COVID-19: The Invisible Threat
A tornado comes and then it’s gone in minutes. Hurricanes have a bit more variability. They can sit around longer. Hurricane Harvey hovered over Southeast Texas for days, dumping more than 27 million gallons of water on the region. Experts called it a once-in-1,000-year flood. Hurricane Maria passed over Irma-impacted Puerto Rico with such force that meteorologist Jeff Webber said it was as if a buzz saw had been taken to the island. In New Orleans, when Hurricane Katrina hit, the levees and floodwalls failed, flooding the below-sea-level city and displacing more than 400,000 residents.
COVID-19 is different, says David. It’s an invisible threat. “You don’t know if it’s on the grocery bags you’re bringing home or on the mail.” This makes the virus a source of anxiety for everyone and exacerbates the symptoms of people who live with anxiety, an obsessive-compulsive disorder, or who are experiencing paranoia. It’s not just adults who are impacted but also children whose parents try to explain that “there are germs, so we have to stay in the house as much as possible, and we can’t be around other people.” David wonders as we teach children the importance of social distancing, what it will be like for them when they go back to school. “We are teaching them to stay away from people. What’s the long-term impact?”
For many Americans, life changed rapidly during the week of March 9th as presumptive cases became confirmed, and by Friday, March 13th, schools across the nation were experiencing their last day. It’s now April, and there’s no return date in sight. It’s not just that COVID-19 upended our day-to-day lives, says David, it’s living with the unpredictability of it all that’s also taxing. “People don’t know when they are going back to normal, everyday life, or what that will even look like.”
She says that the stimulus package and emergency order waivers will help, but unpredictability, along with financial uncertainty, isn’t going away anytime soon. “So, you don’t have to pay rent for April or May, but you will eventually have to pay April and May’s rent. People are always going to be behind, which is particularly challenging for people with few resources.” David says the same is true for job stability. People are living with the apprehension of what the future holds, not knowing what is going to happen next.
With a population of 391,006 people, New Orleans often feels like the biggest, small town. Many people know each other or know of one another. It’s the two-degrees of separation rule: two people passing by might not know each other, but chances are they are friends with someone who does. A couple of weeks ago, the names of people dying started to be familiar: someone I’d met a time or two, a good friend of a friend, and the grandparent of one of my closest friends. In small and tight-knit communities, people are collectively grieving the loss of someone who dies in a disaster. “In Dougherty County, Georgia, which was devastated by a tornado in 2017, everybody knows everybody. So, if someone dies, it affects everyone.” In the time of COVID-19, deaths are both grief- and fear-inducing. Simultaneously, David points out, people are grieving the loss of normalcy and the disruption of activities like birthdays, weddings, graduations, and religious holidays and traditions, and expectant mothers wonder if their partner will be allowed into the hospital delivery room. David couldn’t be at her grandson’s birthday. He turned seven. They FaceTimed, but it’s not the same. “There are layers to the grief.”
There’s also a loss of normalcy during loss. People can’t hold hands with their loved ones as they die, and some can’t even attend the funeral because they are quarantined. “It has disrupted even that.” After 9/11, the disruption to the grieving process was similar, though the outcomes looked different. In New York, funerals for police officers and firefighters had the same attendees. “You could go to a funeral at 10 am and later see the same people at the one at 2 pm. First responders were attending funeral after funeral.”
Communal grief is painful, but it can also bring people together. David says that’s what she’s witnessed in Dougherty County, which has just finished a CCP in the aftermath of the 2017 tornado. “That community pulls together like nothing else, and perhaps there could be some collective resilience as a result.”
Communities Coming Together
After the impact of a disaster begins what SAMHSA calls the heroic phase. David says this is characterized by people coming together. “It’s when everyone is out and helping one another.” After a tornado or hurricane, it can come in the form of a person removing a tree that has fallen in their neighbor’s driveway or people with electricity cooking for those in the community who do not.
Because of social distancing, the heroic phase is looking a bit different during COVID-19, but it’s still there: people at home and businesses, working into the early morning hours sewing do-it-yourself masks, cutting face shields, and making hand sanitizer for their loved ones and hospital staff. “It’s something tangible they can do, while still following lockdown rules.” David says it has a lot to do with chemicals like adrenaline, which is why people are also rushing out to buy all the supplies they might need. “We aren’t just taking care of other people but also our families.” The challenge, of course, is that while communities typically get through disasters together—in this case, we must stay apart.
After the heroic phase, there’s typically a honeymoon period where “all of the helpers arrive.” It’s a relief, says David, because people think to themselves, “Help is here. We are going to be okay.” In most disasters, people quickly discover that they aren’t going to get the help they need, and that’s when the disillusionment phase sets in. “This is when people’s greatest needs begin to make themselves known.”
The goal of the Crisis Counseling Assistance and Training Program (CCP), and for mental health disaster response, generally, is to help people in the community as early as possible to mitigate the practical challenges they will experience in the aftermath. “That’s why it’s critical to connect people to resources like making sure they apply for FEMA. Many won’t apply. They either don’t think they qualify, don’t know how to apply, or are afraid to ask for help.”
David says that meeting people’s basic needs and connecting them with social supports will aid their recovery, lessening the chances of more severe problems down the road. It also means being mindful of the challenges each community faces, and how they feel about the responsiveness to the crisis. “Katrina survivors were clear from the beginning that they didn’t want to be compared to those of 9/11. They told the CCP instructor, ‘Don’t make the comparison; 9/11 survivors had so much more support than us.’”
Throughout the COVID-19 disaster and in the aftermath, David said people who are particularly at risk are those with severe, persistent mental illness who are chronically in treatment but also those who may be undiagnosed and experiencing symptoms that are interfering with day-to-day life. That’s why there must be clear entry points for support, said David. “During the pandemic and after, will people come through the public health system, will they have insurance, or did they lose insurance because they lost their job? It’s important to understand the complexities of what’s going on.”
While the overall mental health curve is delayed, the substance dependency trajectory is even more so. After Hurricane Katrina, David says CCP counselors encountered more survivors with substance use disorders in the fall of 2006, a year after the storm. They also saw a rise in domestic violence at this time. During Coronavirus and amidst movement restriction orders, domestic violence calls have already increased worldwide. Contrarily, the number of child abuse calls haven’t risen, and that is a cause for concern because child abuse is more challenging to detect when people are at home. On April 1st, Governor Brian P. Kemp of Georgia said in a press conference that the state was seeing a reduction in child abuse reports. “Teachers and administrators are often the first ones to see the signs of abuse, and with schools closed,” they do not have as much face-to-face time with students. “This is important for us to think about as we set up CCP programs: the unintended consequences of stay-at-home orders that we need to be aware of and find ways to help mitigate.” Some abusers monitor calls but not text messages or monitor text messages but not online chats or Facebook, which makes it vital for support services to have multiple avenues of communication for victims to be able to reach out for help in the safest way possible for them.
Supporting and Retaining Healthcare Frontline Responders
When speaking about any disaster, the group often most impacted are first responders. During the pandemic, healthcare workers are the frontline defense against COVID-19. “EMS, the hospitals, and the public mental health system are the first responders to this crisis, and we don’t want to come out of this losing providers due to the virus or trauma.” David points out that she often has to remind the healthcare community in Georgia that the services the Department of Behavioral Health and Developmental Disabilities (DBHDD) runs, keep people out of the emergency room. “Right now, that’s also going to help stop the spread of the virus.”
Many healthcare workers who stepped in after the mass shootings at Pulse nightclub in Orlando and the Route 91 Harvest music festival in Las Vegas soon left the profession. “In disaster situations, healthcare staff are not only trying to save people in the aftermath of a tragedy, but they also have to make difficult, ethical decisions.” As hospitals become overcrowded with COVID-19 patients in the U.S. and worldwide, healthcare staff have a limited number of tools, like ventilators, at their disposal and must determine who gets access and who doesn’t. Like after a mass shooting, David suspects that without adequate mental health support, healthcare workers will leave the field because of trauma and PTSD avoidance. She notes that, like other first responders, healthcare workers often don’t think they need help. “It’s been my job over the years to teach them about self-care because they often think, ‘I’m okay. I can do it. I have to be part of the team and can’t show that I’m weak.’” That’s why, she says, we must meet their medical and behavioral healthcare needs throughout this journey.
Though we’ve never been through anything quite like COVID-19, David says the best way to mitigate the disillusionment phase is to get people the help they need sooner, which is the objective of the CCP. She thinks the outcome will likely follow the 33% rule with one third having a hard time recovering emotionally, financially, socially, and physically. “Another 33% will get back to where they were, while the last 33% will be more resilient or find the motivation to do something new in their lives.”