Lessons in the Current Puerto Rican Disaster

A man tries to repair a generator in the street after the area was hit by Hurricane Maria in San Juan, Puerto Rico September 25, 2017. REUTERS/Alvin Baez

Those who have worked in disaster areas know that coordination and transport can be difficult, but with the USS Comfort leaving Puerto Rico after admitting less than 300 patients when there is unmet need isn’t a great sign of success. Hurricane Maria made landfall on September 20, 2017. The Comfort, which is essentially a floating specialty hospital arrived in Puerto Rico on October 3rd.  November 8th, the Comfort was restocked with supplies but then departed shortly thereafter for “no apparent reason” after providing outpatient services to somewhere around 1500 patients, according to the DOD.

…”I know that we have capacity. I know that we have the capability to help. What the situation on the ground is … that’s not in my lane to make a decision,” he said. “Every time that we’ve been tasked by (Puerto Rico’s) medical operation center to respond or bring a patient on, we have responded (Captain of the USS Comfort to CNN).”

The death count is still hazy, and there is difficulty in confirming how many died during- or as a result, of the disaster.  One group is doing a funeral home count because information is difficult to obtain. CNN has found through a recent investigation that the death toll appears to be more than 9 times the official government report. 

Coordination on a micro, mezzo and macro level must come from multidisciplinary sectors to problem solve. There are many good people working to rebuild Puerto Rico, but there is far too much apathy, throwing up of hands, and of course, corruption.  Many of the Social Work Grand Challenges are highlighted in Puerto Rico alongside the UN Global Goals.

The Whitefish linemen are making $41-64 per hour to restore power to Puerto Rico’s Grid, but the US government is being billed for more than $319 per hour. Whitefish just called a strike because they have not been paid. This, of course, is having a terrible impact on those who are in the most need.

Where do you come in?  We tend to think of trauma on a psychological level: family members and friends who are missing, grief, anxiety, and depression due to home and job loss as well as connecting with those close to you, each processing the trauma differently.

On the mezzo level, we are working with smaller groups and institutions, of which there are many in disaster or mass casualty events.  Local churches, schools, nonprofits and local chapters of larger scale organizations attempt to unite in the local area to help speed services to those that need it most.  Often this is where many of the challenges lie.  Each organization has their own protocols which may not match up with larger scale efforts of the government or international organizations.

On a practical level, resources are often short on a disaster scene- there are not enough clinicians to meet with clients individually, at least not for more than a few minutes at a time. We revert to what the American Red Cross refers to as “Psychological First Aid”.  Human networks through nodes (like shelters) provide a sense of community and belonging when all is lost, with individuals acting as brokers between networks that previously didn’t have ties.

Ground efforts can be supported by a drone equipped with a camera to see if there is a possibility of reaching a scheduled neighborhood by car, saving countless minutes that matter.  The aerial shots from 3 days ago may no longer be relevant. The water may have receded but now a home has landed there, blocking road access.

The volunteers mapping from satellite images can instantly beam their work from anywhere (tracing homes, schools, possible military vehicle parking areas or temporary helipads) while teams on the ground stare at a water covered road, unsure of what is beneath. Life saving choices are made with options and all levels working together. This is how neighborhood Facebook groups saved lives- they were the eyes on the ground in their own neighborhood that identified who was in the most danger.

Facebook may no longer be the hippest new technology (we are nearing the decade and a half mark) but it is arguably the most ubiquitous and well supported (crashes rarely). Many survivors could make a post but were unable to call or text from the same device. An important component to the multi-level view is the understanding that macro tools like mapping serve micro and mezzo levels.

Being a survivor in an active disaster can quietly morph into anxiety, depression and survivor’s guilt.  Being able to participate in practical support efforts can boost the well being of survivors as well. Friends of friends of friends and influencers in social networks have proven to be incredibly powerful.  It’s what happens when “mixed networks” collide.

As we move to a macro level, there’s a realization that there is a great deal of organic movement in even the best planned days for rescue effort workers.  Do you stop here where the need is great (and went unreported) even though it’s blocking you from reaching the mapped area that your team has already scheduled? This is where technology for good can make the difference.  Depending on your training and background, you may make a different choice.  Who is in charge of the government response, and how do we help change course if it is failing?  How do we know if the efforts match our resources?

The simple answer is that we are there to communicate it with others, on all levels—including the virtual one. This may mean volunteering for rescue efforts, collecting tampons in your hometown, or using your own technology for good by mapping for workers on the ground that are not sure what lies beneath—you are helping to ensure their safety and mental well being.  In turn, you get to pass that knowledge into your own networks.

The Skyrocketing Costs of Mental Health Care

Ensuring the mental health of Americans is a costly affair. Three recent unrelated occurrences should help us realize there is no inexpensive way to prevent, diagnose and treat mental illness. By now most of us have heard about the “broken” Veterans Administration and its failure to provide timely services that has led premature deaths of veterans. Newspapers, broadcast media and numerous blogs have reported about various calls for the resignation of VA Department Secretary Eric Shinseki following a few damaging reports about unacceptable medical practices involving veterans—particularly the report out of Phoenix that veterans were dying after secret waiting lists were discovered falsifying wait times for treatment.

VA Summit
Veterans from several generations offered first-person insight to nearly 100 community partners at the VA Palo Alto Health Care System’s Mental Health Summit Aug. 29, 2013

While the focus of the VA investigation has been on medical services, many of the veterans who are not receiving timely treatment are suffering from post-traumatic stress disorder (PTSD) and other brain injuries because the VA simply was not prepared for the huge numbers of soldiers returning from deployments with serious mental health issues. Approximately 2.6 million soldiers were deployed in Afghanistan and Iraq and it is estimated that 20 percent of returning veterans have screened positively for PTSD and depression. The VA estimates as many as 22 veterans commit suicide every day.

So far, President Obama is standing by Shinseki but finds himself faced with another crisis that questions his ability to lead. Unfortunately, there are few topics too sacrosanct not to politicize. But the woes of the VA go farther back than the Obama Administration. The VA budget has been increased significantly over the years even during the sequestration. However, as battlefield medical advances save more soldiers’ lives, they are returning with more complex problems that are quite expensive to treat.

The Veterans Affairs fiasco comes on the heels of the rejection of the National Football League’s offer of $765 million to settle lawsuits by 4,878 former NFL players (and 1,000 family members) who suffered concussions during their careers. U.S. District Judge Anita Brody rejected the settlement reached by the NFL with its former players because she was concerned that the settlement was not sufficient to cover the needs of the claimants. The lawsuit was sparked by the discovery of the degenerative brain disease, chronic traumatic encephalopathy (CTE) in the brain of the late Pittsburgh Steelers center, Mike Webster who died in 2002 at the age of 50 years old. That story was the subject of a Frontline documentary, League of Denial: The NFL’s Concussion Crisis.

Subsequent to the concussion lawsuit, 500 players have filed another lawsuit accusing the NFL of obtaining and administering illegal drugs in an effort to mask the pain and symptoms of various injuries such as broken legs and ankles. Turning a blind eye and even denying the traumatic brain injuries (TBI) suffered by NFL players resulted in incalculable costs to families and children. The NFL has taken dramatic steps to reduce the chance of TBIs but concussions are still a staple of a very violent game.

The third occurrence—another mass killing—in Santa Barbara, California, happened Friday night when Elliot Rodger, the 22-year-old son of Hunger Games assistant director Peter Rodger went on a hate-filled rampage, killing six and injuring 13 others before shooting himself. More human life destroyed by someone who obviously should not have been able to purchase guns. Yet Congress consistently fails to pass laws requiring stricter background checks despite the fact that 90 percent of Americans favor stricter background checks. The last serious attempt to pass a gun sale background bill, S.22—the Gun Show Background Check of 2013—failed last year when five skittish Democrats voted against a bill offered by West Virginia Democrat Joe Manchin and Pennsylvania Republican Pat Toomey. The National Rifle Association has ensured that no gun control law gets passed by holding many of our nation’s lawmakers hostage.

There is no way to address mental health on the cheap. Failure to provide adequate resources for prevention, screening and treatment often come with a heavy price. Threats to mental wellbeing will increase as we become more socially isolated, consumed and fixated on our device of choice. We no longer have to leave home to bowl alone.

Photo Credit: Courtesy of US Dept. of Veteran Affairs

Lies In Silence Part 2 of 3: Interview With SJ Hart

As a mother dealing with her own mental illness and that of her children, SJ Hart displayed an immense amount of resilience. By reading her story I learned that she not only had to advocate and fight for herself, she had to do the same for her children. In this part of the interview we explored how her mental illness impacted her role as a parent and vice versa.

Tragic and inspirational are the two words that come to mind after reading SJ Hart’s book, Lies In Silence. SJ Hart has a unique experience when it comes to these issues because she is someone with bipolar disorder, a parent, and a clinician, all of which will be explored in upcoming interviews. Hart tells the compelling story explaining the heartbreaking impacts bipolar and co-occurring disorders had on her family. The more I learned about this family and their battles, the more inspired I was to share her story with others. Read Part I 

SWH: How did your own history with mental illness impact your role as a parent?

Lies in Silence
Purchase Lies in Silence

Dramatically and profoundly on every level. My history or legacy with my family/father made me more aware and vigilant to the point of obsession. When my oldest daughter got sick I believed I could save her, because she was managing for a while. But around 10th grade I thought she was going to jump off of a bridge. The bridge scenario was random. The fear of her killing herself was very real. This is the point where my personal life and professional life merge for the first but not last time.

When I became horribly ill at the age of 43, it was a group of good friends and my husband who monitored me for 3-4 years. I had an onset from a migraine medication, so achieving some level of stability took a long time. I had to set goals like food shopping, showering, and safety at night, etc. the priority was to make it through the day. Life as the mother I was….vanished.

My children were sick we’d stay together and hold hands. Sometimes we would cry. We were scared. I would hold them and rub their backs saying the medication would work soon, and turn my head so they could not see my tears. Only years before we had been to soccer games, dance recitals, birthday parties, and the beach.

Once I was less in a black depression was when I started writing the book (Lies In Silence), and really fought for my children. I went from being a child with PTSD, to a successful career woman/mom, to the mother of one child onset age 13 with bipolar disorder (severe), to a 43 year old mother with bipolar and anxiety, with another child onset age 11 with bipolar, anxiety, and ADD, and my youngest son onset age 3 of OCD, anxiety, and some form of bipolar disorder. It was incomprehensible.

There were nights I went to bed hoping not to wake up. But I knew if my children had any chance at all it would be hard work and advocacy from me and their dad.

SWH:What were some of the early signs you noticed in your children and what steps did you take to help them?

Each child was different since most mental illnesses are mostly spectrum disorders, and not only are there a variety of symptoms they are mild to moderate to severe. Then add in they are chronic and the child’s age, it takes some time to tease it all out. Some symptoms are red flags immediately. If they tell you they are seeing things and can describe it in such a way you know it is illness that shortens the time period diagnosing. If they report they are afraid to go out because someone will get them and hurt them. Also something like that is a red flag. But the times where symptoms are not crystal clear regrettably you doubt what they report because the reality sets in with profound grief. Eventually decrease their suffering is the only goal.

In our oldest daughter she had a hard time getting up in the morning. She often pushed the limits, wanted to stay out late, started having long periods of instability, was secretive, but she still exhibited some interest in being with the family.

She started seeing a therapist when my mother died from a brain tumor, and they tried a small dose of an antidepressant. That was when we knew. Her mood flipped in 3 days. She went running down the street on night in bare feet, it was very late maybe midnight, and when I finally caught her I saw the look in her eyes and I knew. I am very detailed about that in the book.

Our second daughter felt like she was being watched, and started to describe seeing a vague picture of a bearded man. Since my husband has a beard it took us a while to figure it out. She also flipped from a med, and at that point she would sleep in a sleeping bag next to my bed.

Paranoia is misunderstood I think. I had that symptom from a medication for one day, and it was horrific. Absolutely horrific. It’s more like a whole body experience of fear with no known source. She had daily paranoia for two years.

As far as our son, we were at the beach on a family vacation. We were riding bikes and he was on the back of my husband’s bike. I noticed him coughing, and when I listened closely I knew he had a respiratory problem. He was diagnosed in the ER with pneumonia. Had I thought of the Jane Pauley book I would have refused steroids, but I forgot. Ten days later he started to rage. He raged for hours at a time. We could not console him.

Med trials at the age of three are very complex and controversial. But his suffering needed to be addressed. My husband and I tell educators and medical providers, it is his suffering today that is our focus. Not what could happen with medication in the future? A gut wrenching decision similar to those made of any parent with a child suffering from a life and death illness. We have today.

Concrete things – individual therapy, group therapy, family therapy, psychiatric medications,

Education teachers, guidance counselors, nurses, administrators, encouraging them to confide in one friend that they have something….depression or anxiety. Sadly some of the less stigmatizing illnesses. Otherwise the secret and the feelings of being broken create a lonely self-imprisonment.

SWH:What stigmas did your own children face as they became showing signs of mental illness?

  1. The one who is different.
  2. The one who is not invited out.
  3. The telephone does not ring.
  4. Social situations if triggering anxiety is like being thrown into a room where everyone has chicken pox, and you have not had the immunization. It is a full sensory experience.
  5. The student who comes late.
  6. The student who sleeps during the day.
  7. The person who is always moody.
  8. Parents do not want them over to play.
  9. No one to go to a school dance.

The list goes on and on.

SWH: In Chapter 8, you speak on the looming genetics that claimed the life of your children, what advice cans you give parents with children who are also facing similar circumstances with their mental illness?

  • Early Intervention.
  • Read and Read and Read.
  • Effective therapy and medication.
  • You are smarter than the professionals.
  • Understand that you are their best chance.
  • Advocate every day and when your voice is not enough bring others in.
  • Keep up with research.
  • Find adults facing similar circumstances and share notes.
  • Get involved in special education activities.
  • Take care of your marriage.
  • Try to set firm limits with your child, and have a plan that you follow in circumstances of safety.
  • Take each day as one day.
  • You now have moments.
  • Adjust your expectations.
  • Not every day is a learning day in school.
  • Read, get testing, trust your gut, find effective therapy and prepare yourself for anything. This is an exhausting marathon.
  • Get adult support for you

The third part of this interview is soon to come, and you don’t want to miss the last installment of “Lies in Silence” with SJ Hart.

Intimate Partner Violence has Bigger Implications Around Post Partum Mental Health

Most social workers are familiar with the concerns arising from post partum depression. It has been linked to weakened bonding and possibly disrupted attachment between mother and infant. Newly published research done in Vancouver, B.C. alerts us to the problem as much broader and having some significant links to intimate partner violence (IPV).  Much of the past research has focused on the role of physical aggression, but this research by Susan Desmarais and her colleagues reminds us that the nature of IPV is much broader and each form has impacts upon women and their post partum mental health.

(Photo credit: Kit4na)
(Photo credit: Kit4na)

In their paper, published in the journal Pregnancy and Childbirth emphasizes that IPV incudes actual, attempted or threatened harm that can have an impact or detract from the victims well being across several domains – physical, psychological, sexual, economic and spiritual.

The authors also note that dear of abuse has both physical and psychological consequences on the pregnant mother.  Abuse, whether it occurs or is feared, raises cortical steroid levels in mothers which can have negative outcomes for mother and child.

Post partum mental  health concerns are more than just depression. Social workers must broaden their view to understand that the risks also include anxiety, obsessive compulsive disorder (OCD), and posttraumatic stress disorder along with psychosis.

These researchers studied 100 women to conclude that women who experienced IPV (both during and before pregnancy) reported a statistically significant higher rate of post partum mental health problems.  Physical assault during pregnancy appeared to have the greatest impact on post partum mental health and was associated with depression, OCD and PTSD. Psychological aggression during pregnancy was associated with symptoms of stress and PTSD. Sexual coercion both before and during pregnancy was associated with symptoms of OCD.

These findings have significant concern for child protection workers. It is vital that women be given an opportunity to talk about all forms of abuse that occurred both during the pregnancy as well as the periods leading up to it. In addition, workers must be careful to look for problems beyond depression.

Other research has shown, as acute mental health concerns grow in significance, it impacts the ability of the mother to care for the emotional and physical needs of the child. When we look beyond just the care of the child to understand why the mother is neglecting her child, we may often find various forms of IPV at the root of the behavior. If we do not properly investigate and intervene, then the mother is at increased risk of more intensive mental health concerns which may also lead to substance abuse as a means of managing the mental health concerns.

The good news is that mental health problems are treatable and the need to remove the child from the care of the mother is low. However, safety has to be created for both mother and child which means that the IPV needs to be uncovered. This is tricky, but it is our challenge.

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