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Disaster Psychiatry

Chapter 35

DISASTER PSYCHIATRY

ARTIN TERHAKOPIAN, MD, MPH*; DAVID M. BENEDEK, MD†; and ELSPETH CAMERON RITCHIE, MD, 

MPH‡

INTRODUCTION

HISTORICAL BACKGROUND

RECENT MISSIONS

The September 11, 2001, Attack on the Pentagon

The December 26, 2004, Southeast Asia Tsunami

Hurricanes Katrina and Rita in 2005

SUMMARY

*Major, Medical Corps, US Army; Chief, Inpatient Psychiatry, Department of Behavioral Health, William Beaumont Army Medical Center, 5005 North 

Piedras Street, El Paso, Texas 79920; formerly, Chief, Behavioral Health, 10th Combat Support Hospital, Baghdad, Iraq 

†

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814

‡

Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

The US military has made significant contributions 

to medical relief efforts for many devastating civilian 

events around the world. More recently, military psychiatrists and allied mental healthcare professionals 

have played major roles in these relief operations. This 

chapter outlines general principles of disaster psychiatry and illustrates the application of these principles 

via the response of military psychiatry to recent mass 

casualty disasters.

The field of disaster psychiatry continues to evolve 

and inform the conceptualization of disasters and their 

behavioral health consequences. Knowledge of the 

proper psychiatric interventions for times of disaster 

is essential. Although generally well-trained in war or 

battlefield psychiatry and the application of PIES (proximity, immediacy, expectancy, simplicity) principles, 

some military psychiatrists, like many of their civilian 

colleagues, are less familiar with the care of traumatized 

patients outside the sphere of standard inpatient or 

office psychiatric settings. Most psychiatrists may be 

more experienced with the management of conditions 

such as acute stress disorder or posttraumatic stress 

disorder (PTSD) in the office than with management of 

symptoms in the austere and disrupted postdisaster environment. The treatment of disaster-related behavioral 

health conditions can challenge psychiatric concepts 

such as those related to intrapsychic determinants of 

mental disorders1 and psychiatrist–patient boundaries (eg, cohabiting a tent with a patient).2

 Although 

knowledge about individually experienced trauma, 

such as rape and automobile accidents, along with 

that of war psychiatry, informs the basic principles of 

disaster psychiatry, psychiatric reactions to disasters 

where there are often acute, unexpected, and collectively experienced large-scale traumatic events may be 

different. Much has been learned in recent years as a 

result of experience following the September 11, 2001, 

(9/11) attacks, the devastating Indian Ocean tsunami 

of 2004, and Hurricane Katrina in 2005. The participation of military psychiatrists in relief teams responding 

to these events has provided a unique opportunity to 

practice disaster plans, assess the existing framework of 

disaster psychiatry knowledge, and consider possible 

modifications for advancement. 

This chapter will outline the historical background 

for the current principles of disaster psychiatry. Descriptions of military psychiatric response to the 9/11 

attack on the Pentagon, the Indian Ocean tsunami, and 

Hurricanes Katrina and Rita will illustrate not only 

the application of principles of disaster psychiatry but 

also what military psychiatrists may expect in disaster 

situations and how they can best assist in relief and 

recovery. Finally, areas for future research and training 

emphasis will be identified. 

HISTORICAL BACKGROUND

Substantial empirical data regarding medical and 

surgical needs at times of catastrophe have been accumulated. However, relatively little is known about 

mental health needs and appropriate psychiatric services. Nonetheless, the nature and extent of mental 

health needs of populations affected by a disaster and 

the appropriate psychiatric response has been well 

articulated in reports regarding a variety of natural 

and man-made disasters, wars, and public health 

emergencies. 

In disasters, many experience grief and depression, 

anxiety, and somatic and dissociative reactions.3–6

Disaster stress reactions may mimic physiological 

symptoms anticipated by a specific type of disaster 

event; for example chest tightness and nausea because 

of anxiety may follow the explosion of a truck carrying 

chlorine gas. This phenomenon complicates assessment and care of disaster-affected populations and 

necessitates the collaborative work of psychiatrists 

with their medical counterparts. Among people with 

preexisting mental disorders, anxiety and somatic reactions are compounded by fears regarding community 

disruption, availability of care, and availability of 

medication supplies. 

Psychological reactions to disaster, resulting in 

presentation for treatment, are well documented in the 

literature. For example, during the Persian Gulf War 

(1990–1991) about 40% of Israeli civilians near Scud 

missile attacks reported symptoms consistent with 

a chemical weapons’ explosion despite the absence 

of any such exposure.7

 A similar phenomenon was 

observed in the 1995 sarin gas attack on the Tokyo 

subway system.8–10 In a cross-sectional assessment of 

182 survivors from the 1995 Oklahoma City bombing 6 months after the disaster, North and colleagues 

showed elevated rates of PTSD (15% predisaster and 

34.3% postdisaster) and depression (12.6% predisaster 

and 22.5% postdisaster).11 Five emergency rooms in 

lower Manhattan near the World Trade Center collapse 

experienced a surge in patient care in the aftermath of 

the 9/11 disaster. Of the 950 patients examined during the first 48 hours in these emergency rooms, 14% 

reported cardiac, neurological, and psychiatric problems.12 In the months following the World Trade Center 
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Disaster Psychiatry

destruction, a survey of Connecticut, New Jersey, and 

New York residents showed nervousness, worry, sleep 

problems, and increased smoking and alcohol use as 

a result of the attacks.13

The terrorist anthrax attacks in Washington, DC, 

during November 2001 again demonstrated the need 

for psychological, emotional, and behavioral healthcare of the affected populations. During the 2 weeks 

following the anthrax attacks on the Hart Senate Office 

Building, 1,129 patients with symptoms and concerns 

of anthrax exposure visited the emergency room of 

Inova Fairfax Hospital, located in nearby northern 

Virginia. Of these patients, only two were diagnosed 

with inhalational anthrax.14 The reactions of civilians 

to disasters are fairly similar to those documented 

among troops as early as World War I.15 Historically, 

psychiatric reactions (such as those noted above) have 

been divided along the time phases of a disaster 

(predisaster, disaster, and postdisaster), with each 

phase having its own characteristics with differences 

essentially determined by the nature and duration of 

the disaster.16 Thus, the emotional and behavioral consequences of disasters may cause considerable disruptions in the health and functioning of individuals and 

societies along a significant timeline. Investigations 

in the fields of social science, psychology, psychiatry, 

and public health have provided useful information to enhance resilience, promote effective disaster 

behaviors, and mitigate mental disorders following 

traumatic exposures. These have been summarized 

by Ursano, Fullerton, and Norwood6; and Ritchie, 

Watson, and Friedman.17 Three broad mental health 

intervention areas that are informed by the empirical 

evidence are: (1) community support, (2) education, 

and (3) definitive care (Table 35-1). These domains of 

intervention areas are consistent with long-standing 

TABLE 35-1 

ESSENTIAL DOMAINS OF DISASTER MENTAL HEALTH INTERVENTIONS

Community 

Support

Basic Needs: provide safety, security, water, food, shelter/housing, transportation, contact and/or communication with family and friends

Psychological First Aid: minimize further harm; reduce psychological arousal and physical pain; mobilize 

support; maintain families and facilitate their reunion; provide information and education; foster communication about risks; contemplate need for translators

Needs Assessment: assess current status; know predisaster circumstances; consider silent populations like 

children and the disabled; think of needs on three levels: (1) populations, (2) groups, and (3) individuals

Monitoring: listen to those affected; gauge the level of basic needs that are met; measure psychological 

vital signs like attitudes, hope, expectations, and substance misuse; monitor and dispel rumors

Fostering Resilience and Recovery: encourage social interaction; allow regular activities such as school 

and work as far as possible; enhance coping skills; strengthen role system; suggest community action to 

decrease helplessness and instill hope; build on existing community and organizational fabric; encourage protective community rituals (speeches, memorial services, funerals) to reduce distress and enhance 

cohesion 

Education Outreach and Information Dissemination: ensure wide dissemination of practical information and easyto-do instruction through media and trusted local leaders; inform the public clearly and repeatedly about 

recommendations and the rationale behind them; educate about risky behaviors and signs and symptoms 

of abnormal functioning; be available at common gathering places; make informal services as well as 

referral to formal services available; use the language of the affected people 

Providing Consultation and Training: transfer needed skills to existing community organizations to improve their ability to meet psychological needs; be available to and educate public officials and religious, 

civic, and business leaders; encourage local participation in recovery efforts

Definitive 

Care

Triage and Clinical Assessment: stabilize and refer cases of mental disorder or dysfunction; screen highly 

vulnerable populations; hospitalize to avoid harm

Treatment: reduce or eliminate symptoms; improve functioning; use psychopharmacy and psychotherapy 

(individual, family, and group interventions); apply multidisciplinary approach coordinating care with 

clergy, spiritual healers, counselors, and employers

Adapted from: Ritchie EC, Friedman M, Watson P, Ursano R, Wessely S, Flynn B. Mass violence and early mental health intervention: a 

proposed application of best practice guidelines to chemical, biological, and radiological attacks. Mil Med. 2004;169(8):575–579.
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Combat and Operational Behavioral Health

psychiatric conceptualizations of trauma and response 

such as those of Pierre Janet,18 Sigmund Freud,19 and 

Ivan Petrovich Pavlov.15

The appropriate balance of community support, 

education, and definitive care may enhance individual, 

group, or community capacity to integrate traumatic 

experiences, thereby reducing depression, anxiety, 

somatization, and dissociation. The benefit of interventions along these lines will vary depending on the 

type of disaster as well as its timing and intensity. Also, 

many of these efforts (eg, support and education) may 

be conducted by nontraditional mental healthcare providers, highlighting the importance of liaison among 

mental healthcare providers and disaster rescue workers including volunteers. 

Self-triage and self-soothing can also be enhanced 

by community support, education, and definitive care. 

Psychoeducation can help reduce somatization by 

explaining (and normalizing) the impact of traumatic 

exposure on personal psychology, spirituality, and 

physiologic function. Knowledge and understanding of stress reaction may boost the ability of affected 

individuals to contain their anxiety, curb fear, and 

mobilize psychological defenses in response to distress 

by assisting survivors in making sense of the disaster 

and their emotional responses to it. Support and education may reduce disaster-related chaos by providing 

instruction and may thus minimize “compensation 

syndromes” by advocating for postdisaster assistance 

and community rebuilding programs. Educational 

and support programs can guide survivors with preexisting mental illness to definitive care centers for 

medication refills, reevaluation, and hospitalization (or 

other services as indicated). These mental health interventions, when sustained and tied to surveillance and 

outreach efforts, may lessen the conversion of minor 

and short-lived emotional symptoms into more serious 

and long-lasting mental health problems. Community 

support, education, and definitive care (when clearly 

available to those who require it) all serve to enhance 

community ability to integrate frightening and devastating experiences into cognitive, emotional, and 

behavioral schemes. From a cognitive and neurobiological perspective, this integration may be viewed as 

the accumulation of “safety memory,” which inhibits 

the expression of fear memory.20

“Project Liberty,” a government-funded entity set 

up after 9/11, illustrates the benefits of the provision of 

support, education, and definitive care. This program, 

which provided counseling, education, and outreach 

services to an estimated 1.2 million individuals during the 27 months following 9/11 in the area around 

“ground zero” in New York City, is an example of successful community support, education, and definitive 

care interventions. Project Liberty was particularly 

effective in facilitating survivors’ return to predisaster 

functioning and guiding those survivors with more 

serious problems, such as depression and PTSD, to 

definitive care.21,22

An emerging area of concern in disaster psychiatry has been the mental health of disaster workers. 

Although the evidence is somewhat mixed,23,24 health 

problems appear to disproportionately affect disaster 

workers exposed to psychologically traumatizing exposures.25–29 Traumatic exposures may have lasting effects on volunteers and rescuers and can diminish their 

mission effectiveness. Traumatic exposures in military 

disaster relief and humanitarian assistance operations 

can include: “a) dead bodies, b) orphaned or abused 

children, c) uncertainty regarding mission . . . [objectives] and d) unclear chain of command.”30(p63) Every 

disaster response plan should include mental health 

interventions for the affected population and also 

consider the emotional, behavioral, and mental health 

needs of rescuers. A psychiatrically informed plan for 

the support of rescuers can improve mission effectiveness by enhancing worker ability and willingness to 

report to duty.31,32 In this era of tremendous advances 

in medicine, including control of infectious diseases 

and emergency surgical provisions by disaster workers, 

and given the recognized health burden of long-term 

psychiatric illness, the refinement of disaster psychiatric 

interventions would seem a natural next step in reducing disaster-related morbidity and mortality.

RECENT MISSIONS

Military psychiatrists have supported various disaster relief efforts in the past several years. Among 

these were the response at the Pentagon following the 

9/11 attack, the mission in Southeast Asia following 

the 2004 tsunami, and the relief operations on the US 

gulf coast after Hurricanes Katrina and Rita, both in 

2005. Military disaster mental health interventions 

for these catastrophes were tailored to enhance safety 

and security, mitigate negative long-term psychiatric 

consequences, ameliorate suffering, and address clinically significant psychiatric reactions. Where possible, 

research and process improvement procedures were 

established to gather and document lessons learned. 

These operations were facilitated greatly by the readiness of military psychiatrists to respond. The extent to 

which responders were successful depended largely 

on their military psychiatric training, experience with 

the practice of caring for war-traumatized soldiers, and 
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Disaster Psychiatry

access to consultants at national centers of excellence 

in trauma response and disaster psychiatry such as 

the Psychiatry Department at the Uniformed Services 

University of the Health Sciences, located in Bethesda, 

Maryland. 

The September 11, 2001, Attack on the Pentagon

American Airlines Flight 77 crashed into the Pentagon at 9:43 am edt on September 11, 2001. It was 

followed by a rapid, comprehensive, and sustained 

rescue and recovery response. As part of this response, 

all military services located near the crash scene dispatched mental healthcare teams to the Pentagon. One 

rapidly assembled stress management team arrived 

from Walter Reed Army Medical Center (WRAMC). 

Other crisis management teams arrived from Andrews, 

Bolling, and Keesler Air Force bases. A psychiatric 

intervention team came from the National Naval 

Medical Center in Bethesda.33–36 The teams worked 

with other support personnel, including members of 

the American Red Cross, Salvation Army personnel, 

various church volunteers, and Department of Defense 

(DoD) and fire department chaplains.34

Soon after the attack, the DiLorenzo Clinic at the 

Pentagon was designated as the headquarters for the 

disaster response. There, on September 12th, more 

specific plans were developed for the mental health 

support of personnel at the Pentagon, and the Army 

was assigned the lead for this mental healthcare effort. 

Because the Pentagon did not have in-house mental 

health services for its occupants (beyond a threeperson employee assistance program and a single 

chaplain), Army and Air Force assets were focused 

on the Pentagon while Navy assets where charged 

with supporting the Arlington Annex, Marine Corps 

headquarters,34 which was a few hundred yards from 

the crash site.

As observed in other disasters, distressed, sometimes anxious or panicked survivors visited the various 

organized clinics for assistance and guidance early 

after the crash. To address the growing need for social 

and mental health services, a family assistance center 

was established on September 13th at the Sheraton 

Crystal City Hotel, which was a short drive from the 

Pentagon. This facility provided assistance to families 

of Pentagon personnel as well as families of passengers 

and crew on Flight 77. Many Air Force mental health 

personnel, joined by WRAMC mental health team 

members, supported the mission of this center, including grief counseling, until it was closed 2 weeks after 

the October 11th memorial service because demand 

for services had declined.36

Consistent with the initial planning, the Air Force 

established teams that specifically served the personnel falling under the various deputy chiefs of staff in 

the Pentagon. These teams rotated in the DiLorenzo 

Clinic generally for 2-week periods until December 

10th.36 The Army divided its charge into an “inside” 

and an “outside” mission. The “inside” mission included the support of Pentagon personnel while the 

“outside” mission focused on the large population of 

first responders encamped on the lawn surrounding 

the Pentagon. The WRAMC mental health response 

was based on the accepted premise that most adverse 

mental health consequences following disasters are 

“subclinical” (ie, transient and normal responses to 

trauma).33 Hence, WRAMC mental health support 

often took the form of promoting awareness of basic 

needs such as sleep, food, water, and family contact. 

It involved modified debriefings through informal 

conversations and outreach through monitoring of 

reactions to traumatic exposure among Pentagon employees and responders, particularly high-risk groups 

such as casualty assistance officers and healthcare 

workers. This approach allowed for the delivery of 

support while minimizing the stigma associated with 

mental health service utilization. When warranted, 

referral for clinical services was offered for formal 

evaluation and treatment.33

In addition, the WRAMC Psychiatry Consultation 

Liaison Service (PCLS) team contacted and lent support 

to attack survivors who were admitted to local civilian 

hospitals. Using a novel and flexible approach adapted 

from critical incident stress debriefing models, but with 

a more targeted emphasis on the observed psychological state of each injured survivor, the WRAMC PCLS 

team approach helped reduce psychological symptoms, prevent the development of psychopathology, 

facilitate compliance with medical care, speed recovery, 

and arrange social support for the 18 attack survivors 

from the Pentagon who required lengthy hospitalization37 (Exhibits 35-1, 35-2, and 35-3). 

The “therapeutic debriefing” approach advocated 

mental health contact with all disaster patients and 

normalization of responses to the disaster with bedside 

techniques such as cognitive reframing.37 Here the 

goal was to help patients integrate their memories in 

a way that would prevent the disaster experience from 

“overwhelming” their defenses and that would minimize long-term morbidity.37 “Therapeutic debriefing” 

included the use of relaxation breathing, distraction, 

humor, and creative visualization to speed the return of 

a sense of agency and mastery to the patient. Addressing the quality of sleep, pain control, and satisfaction 

with medical treatment was also emphasized.37 The 

support provided to the Pentagon was sustained for 

weeks while psychiatric clinical services and gradu-
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Combat and Operational Behavioral Health

ate medical education continued at many of the commands from which the mental health intervention 

teams came.33 Psychiatry residents involved in this 

response reported that their education was enhanced 

due to their participation in the rescue and recovery 

operations. The potential benefit of including residents 

in disaster plans has been echoed by other psychiatry 

training programs affected by Hurricane Katrina.38

Particularly traumatic during the early days of the 

response to the Pentagon attack were the work of the 

groups that helped in the recovery of the remains of 

the dead in the Pentagon.39 A descriptive report on 

the effect of recovering human remains on 10 military healthcare workers showed that mental health 

responses were quite varied and included acute but 

short-lived—in the order of days—restless sleep, nightmares, and flashbacks. Mission clarity and expectations were cited as ways to enhance coping.40

In summary, the military response to the Pentagon 

attack was rapid; military-specific efforts that were 

integrated through a series of ongoing planning efforts 

began immediately after the attack. Sustained mental 

health outreach efforts helped maximize support for 

the survivors and rescue workers. The support effort 

was enhanced by the multidisciplinary composition 

of the responders, which included psychiatrists, social 

workers, and chaplains. The “therapeutic debriefing” 

described by Wain et al42 stands out as a promising 

modification of the critical incident stress debriefing 

model applied in a psychiatry consultation liaison setEXHIBIT 35-1 

GOALS OF PSYCHIATRY CONSULTATION 

LIAISON SERVICE FOR DISASTER 

INJURED 

	 •	 Liaison between medical staff, patients, commands, family, and friends.

	 •	 Facilitate medical treatment.

	 •	 Reduce psychological-psychiatric morbidity.

	 •	 Maintain a flexible evaluation and treatment

approach.

	 •	 Recognize and reinforce patient’s adaptive

defense mechanisms.

	 •	 Advocate for patient’s needs.

	 •	 Educate patients and staff.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):20.

EXHIBIT 35-2 

TREATMENT GOALS OF “THERAPEUTIC 

DEBRIEFING” 

	 •	 Establish support.

	 •	 Make debriefing a routine preventive measure.

	 •	 Emphasize environmental safety.

	 •	 Normalize responses and feelings including

survivor guilt.

	 •	 Reframe loss by recognizing the injured

patient’s significant sacrifice.

	 •	 Help the patient consolidate a narrative of

what occurred.

	 •	 Console the patient.

	 •	 Identify and reinforce healthy coping mechanisms.

	 •	 Teach patient mastery techniques using imagery, relaxation, or humor.

	 •	 Teach the patient that he or she can be in

control.

	 •	 Encourage the patient to use social supports.

	 •	 Normalize sleep patterns and dietary intake

if medical condition permits.

	 •	 Clarify patient’s medical concerns.

	 •	 Educate on the pitfall of self-medication with

substance abuse.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):20.

ting. This PCLS approach, which is used with returning 

injured soldiers at WRAMC, may have contributed 

to the lower-than-historically observed initial rates 

of PTSD among battle-injured soldiers and deserves 

further study in disaster response.41,42

Scrutiny of the response to the Pentagon attack 

points to some weaknesses in terms of coordination 

and planning of response efforts, as well as mission 

ambiguity.33,34,36 Mental healthcare teams that arrived 

at the Pentagon did not coordinate their initial efforts with the on-scene commander of the disaster 

response.34 Each service and each mental health organization came with its own theoretical perspective, 

response plan, and set of priorities, complicating the 

response effort. Many have suggested that developing 

a joint doctrine of disaster response, perhaps along 

the same lines as the Federal Emergency Management Agency (FEMA) National Incident Management 

System, and drilling this plan would be a worthy 

future consideration.33,34,36,43 Also, the lack of military 
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Disaster Psychiatry

administrative support was viewed as contributing to 

some of the difficulties with coordination.33 This lack of 

administrative support may have also contributed to 

the missed opportunity by military providers to fully 

integrate the civilian assets into combined plans.33,34

Inclusion of administrative support for disaster mental 

health response teams should also be considered. 

The December 26, 2004, Southeast Asia Tsunami

A powerful earthquake struck the Indian Ocean basin on December 26, 2004. The aftermath was a tsunami 

that affected many coastal countries, particularly Indonesia, Thailand, and Sri Lanka. Estimates placed the 

number of dead and missing at over 250,000 people. 

The affected people, even if physically unharmed, 

faced profound grief, loss, and guilt.44 The US military 

responded to this disaster by organizing Operation 

Unified Assistance. The magnitude of the disaster was 

so great that even highly capable and independent 

nongovernmental organizations (NGOs) needed the 

assistance of the US military to reach the devastated 

areas.45 The US military mission was subdivided into 

two groups: one was destined for Sri Lanka and the 

other to Indonesia. A third group from the Armed 

Forces Research Institute of Medical Sciences led the 

assessment of needs in Thailand and coordinated the 

delivery of assistance in that country.46

Soon after the tsunami struck, an advance team was 

dispatched to the region, which helped coordinate 

the arrival of US military assets with the respective 

US embassies and other local and international aid 

agencies. In addition to military members, the group 

to Indonesia deliberately included civilian volunteers 

involved with Project HOPE (Health Opportunities 

for People Everywhere), an NGO, to enhance the 

prospects of meeting the mounting needs of the affected people there.47,48 This group was dispatched to 

Banda Aceh, Indonesia, on USNS Mercy in early 2005, 

while the other groups were air-lifted to Sri Lanka and 

Thailand. The group in Sri Lanka eventually worked 

in the northeastern corner of the island. Once in Thailand, the third group began the task of assessing the 

damage in Thailand’s six coastal provinces affected 

by the tsunami.

As is established practice with disaster relief and 

humanitarian assistance operations, relief work entailed providing as much care as possible in situ and 

only bringing back to USNS Mercy patients who could 

not be treated ashore. All operations were in the “spirit 

of cooperation, collaboration, mutual respect, teambuilding and team participation, trust, interdependency and consensus-building.”49(p33) Although only the 

USNS Mercy included mental healthcare providers, all 

three groups considered the mental health needs of the 

affected populations as well as the disaster responders. For example, when choosing the housing location 

for the relief team in Sri Lanka, planners considered 

the psychological benefits of distance from the major 

concentration of affected people and physical devastation, allowing team members respite from constant 

traumatic exposure.50 Although the team in Sri Lanka 

provided many interventions that can be considered 

beneficial to improving mental health, they avoided 

specific psychological counseling and formal evaluation as it was deemed that these services could not be 

provided in a culturally relevant manner.50

Although the care provided by the team sent to Sri 

Lanka did not involve formal mental health interventions, the mental healthcare team on USNS Mercy

specifically planned for and engaged in the provision 

of mental health services in Banda Aceh, Indonesia. 

And although the team in Thailand did not directly 

provide mental health services, its rapid needs assessment alerted Thai officials to the poor preparedness of 

hospitals for meeting the mental health needs of the 

affected population. This prompted Thai authorities 

to organize and deploy mental health teams to the 

disaster-affected areas and consider changes in their 

EXHIBIT 35-3 

PSYCHIATRY CONSULTATION LIAISON 

SERVICE LESSONS LEARNED IN THE 

RESPONSE TO THE SEPTEMBER 11, 2001, 

ATTACKS 

	 •	 Psychiatric consultation liaison services may

need to be exported after a disaster.

	 •	 All disaster patients should be seen by mental

health providers as a standard protocol.

	 •	 Responses of disaster patients should be

reframed as normal responses to abnormal 

events.

	 •	 Mental health providers should establish an

early therapeutic alliance with other healthcare providers and patients.

	 •	 Patient’s mature psychological defenses

should be supported.

	 •	 Mental health resources should remain available to patients irrespective of their current 

medical status.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):21.
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Combat and Operational Behavioral Health

disaster plans that originally did not include mental 

health elements.46 The assessment team in Thailand 

also reported on other facets of disaster response 

relevant to mental health, such as availability of basic 

needs, and found them to be well provisioned.46

A lesson learned in Operation Unified Assistance 

was the value of telecommunications. Through datasharing networks and communication links, the mental health team on the USNS Mercy was supported by 

a virtual group of disaster mental health experts from 

around the globe. These links enabled the team to 

assess the needs of the affected population and plan 

a response. Once it became clear that children were 

going to be the focus of the team, the same links were 

invaluable in accessing the latest literature, consulting 

with experts, and developing an intervention plan.51,52

With support from consultants, the mental health team 

aboard USNS Mercy was able to implement a program 

that provided over 80 hours of training in 85 content 

areas, which reached over 200 child-service staff 

members and 1,200 teachers in Aceh Province.53 The 

data and communication links continue to enhance 

the effectiveness of the mental health intervention in 

Aceh Province as they remain in use by mental health 

providers in the disaster-affected areas.53

One study examining rescuers who responded 

to the tsunami disaster provides some evidence to 

suggest that certain preventive measures—teaching 

rescuers about expected traumatic exposures, the 

range of psychological responses, and appropriate 

interventions—can reduce the incidence of negative 

consequences among members of this group. In this 

study, surveys were used to assess participant health 

before and 3 months after the mission. Although the 

small sample size precluded statistically significant 

conclusions regarding changes from baseline in overall 

health status, depression, posttraumatic stress disorder, or risk behaviors, responders tended to view 

favorably and find helpful the mental-health–related 

briefings and “just-in-time” training they received on 

the eve of their deployment.30

Thus, Operation Unified Assistance rapidly applied 

validated methods of disaster response. The effort also 

involved some new components, such as virtual access to global information resources and field experts. 

This mission illustrated the potential for successful 

cooperation between military personnel and civilian 

rescuers. Policies for these types of missions were later 

enumerated in DoD Directive 3000.05, Military Support 

for Stability, Security, Transition, and Reconstruction Operations.

54 Some areas that require further investigation 

include those that pertain to clarification of the optimal 

training for prevention of psychological trauma among 

disaster workers. One possibility might be the expansion of “just-in-time” training along the same lines as 

“Battlemind,” a training developed for troops before 

deployment to combat.55,56

Hurricanes Katrina and Rita in 2005

Hurricane Katrina struck the coast of Louisiana and 

Mississippi on Monday, August 29, 2005. As a result 

of the hurricane’s winds, torrential rains, and massive 

waves, an area the size of the United Kingdom was 

severely affected. In the aftermath, hundreds of thousands of people remained away from their homes in 

temporary shelters. Thousands of others less fortunate 

were stranded in a city that would soon be flooded 

because of breaches in levees. The contaminated 

waters pouring into New Orleans flooded hospitals, 

community mental health centers, pharmacies, and 

physicians’ offices alike, forcing closure of facilities 

and total displacement of healthcare professionals 

and patients in the four parishes of Jefferson, Orleans, 

Plaquemines, and St Bernard.57–59 Many persons with 

chronic medical conditions, including those most 

vulnerable because of psychiatric conditions, were left 

without care, medication, medical supplies, or support services. Under normal circumstances, Charity 

Hospital’s Crisis Intervention Unit managed about 600 

patient encounters each month. These numbers predicted a high post-Katrina demand on mental health 

services.60 This potential was identified early on by 

military disaster psychiatrists and communicated to 

planners and caregivers.61,62

The National Guard mobilized 48 hours before Hurricane Katrina made landfall. The military response, 

which eventually involved more than 60,000 active 

duty and National Guard members, accelerated its 

activities within hours of Hurricane Katrina’s landfall 

despite the presence of half of the Louisiana National 

Guard in Iraq.57,63,64 A shelter was established at the Superdome before the hurricane and a medical treatment 

facility was organized at the convention center 1 day 

after Katrina made landfall. A field hospital was also 

established at Louis Armstrong International Airport. 

By mid-September, Army, Air Force, and Navy medical teams were in and around New Orleans working 

with the Coast Guard, the US Public Health Service, 

the Environmental Protection Agency, the Centers 

for Disease Control and Prevention (CDC), and the 

Louisiana Department of Health and Hospitals.57 The 

first 72 hours following Katrina’s landfall were the 

most hectic. It was during this time that thousands 

of people were evacuated from the Louis Armstrong 

International Airport under some of the most distressing conditions.65

Health surveillance by the CDC, which commenced 
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on September 9th (with the assistance of the military), 

revealed no outbreaks of disease or hazardous environmental exposures as of September 25th. Early surveys 

noted 42 cases of intentional injuries among the 2,018 

cases of injuries reported.66 The communication of accurate news regarding outbreaks of disease and contamination, as well as education about risks through 

printed material and the media, were in line with 

disaster mental healthcare practices that likely calmed 

public fears of exposure and curbed the propagation 

of rumors. The rescue of city residents from rooftops 

kindled hope and strengthened survivors’ trust in the 

arrival of assistance. The hope for outside assistance, at 

least in terms of augmented medical operations, was 

realized through the Navy ship USNS Comfort. The 

Comfort supported relief efforts at Pascagoula from 

September 9th through September 20th and at New 

Orleans from late September to October 8th. Navy 

medical personnel and volunteers from Project HOPE 

with experience from the Indian Ocean tsunami helped 

triage and treat nearly 2,000 patients.67 However, the 

confusion regarding the responsibility of recovering 

human remains and safe travel routes, and the subsequent graphic media coverage, could not have helped 

allay people’s worries and sense of helplessness and 

abandonment.57,65

As the situation in the city stabilized and some 

degree of order was restored, the mental health 

burden became more apparent. Hurricane Katrina 

had caused the deaths of over 1,000 people by early 

estimates68; this would rise to over 1,400 in Louisiana 

once more accurate counts were available.69 The dead 

included two police officers who died by suicide.70

The news of deaths combined with the realities of 

scattered families and friends, community destruction, loss of social supports and healthcare, economic 

devastation, and numerous uncertainties distressed 

people profoundly, particularly those with existing 

mental illness. The burden of stress and dysfunction 

was brought to attention by a CDC survey in October 

2005, which showed that 56% of the respondents had 

a chronically ill family member and only 35% were 

employed, in contrast to the 73% who were employed 

before Katrina.71 Nine hundred New Orleans police officers and about 500 firefighters who completed a CDC 

survey during October and November 2005 reported 

mental health problems with symptoms of PTSD and 

depression, with depression affecting more than a 

quarter of each group (26% of police officers and 27% 

of firefighters).72

Over half of female caregivers living in FEMA trailers or hotels responding to a February 2006 survey 

scored at levels consistent with clinically diagnosable 

depression, anxiety, or other psychiatric disorders.73 It 

was not surprising that the New Orleans Coroner’s Office reported increased suicide rates from 9 per 100,000 

per year to 26 per 100,000 per year in the months from 

Katrina to the end of 2005.74 These consequences were 

exacerbated by the disruption of mental health services 

at large medical centers like Tulane University and 

Louisiana State University Health Sciences Center, 

including problems with methadone clinic patient 

records.59,75 Response to Katrina survivors was further complicated by Hurricane Rita, which followed 

3 weeks later.

As problems became more evident, programs were 

organized with the support of local, state, federal, and 

military organizations. Social workers at Louisiana 

State University at Baton Rouge arranged for the 

care of special-needs children displaced by the two 

hurricanes; Public Health Service staff streamlined 

credentialing and pharmacy processes for displaced or 

volunteer physicians.76 FEMA funding allowed for the 

start of Project Recovery in Mississippi and supported 

Louisiana Spirit mental health counselors.58,70 Project 

Recovery, which was spearheaded by the Substance 

Abuse and Mental Health Services Administration 

(SAMHSA), provided assistance and education to 

over 1,000,000 people, resulting in more than 10,000 

referrals to mental health and substance abuse services. 

Another SAMHSA program, the Katrina Assistance 

Project, conducted thousands of counseling sessions.58

Despite these efforts, the pre-Katrina burden of chronic 

mental illness in the city, including substance use problems, may have prolonged the “duress” experienced 

by survivors.70 Fortunately, psychiatric teaching and 

treatment programs in New Orleans, borrowing a 

page from the disaster response literature, were able 

to return quickly to the city by reestablishing communications, minimizing uncertainty, and applying 

academic flexibility.77 Disaster response and recovery 

in the Gulf Coast still continues, as do efforts to quantify the psychological burden of this disaster and find 

more effective disaster response paradigms. 

SUMMARY

In disaster psychiatry, vast areas of knowledge and 

practice are by necessity evidence-informed rather 

than evidence-based. Military psychiatric observation and experience form the basis of much of today’s 

understanding of population response to disaster and 

mass violence. Considerable knowledge exists with 

regard to the psychological effects of disasters, but 

only a smaller body of empirical evidence supports 
588

Combat and Operational Behavioral Health

current disaster response practices. Difficulties in 

the conduct of studies examining relevant questions 

in this field largely stem from the nature of the traumatizing event; few disasters are clearly anticipated 

and still fewer are slow to unfold. Further efforts 

by military and civilian disaster researchers must 

include rigorous longitudinal studies with baseline 

predisaster characterization of populations followed 

by comprehensive health surveillance and ongoing 

recharacterization of the disaster-affected populations. Measurements of symptoms and functioning 

before and after mental health interventions with 

control population comparisons (if ethical) will help 

quantify the efficacy of intervention programs and 

help separate cause from effect and modifiers from 

mediators. 

Another area of focus may be the education of 

disaster psychiatrists. Much is learned and lost in the 

field of disaster response as a result of the infrequency 

of large-scale tragedy. Disaster psychiatry training 

programs may help preserve the gains made in disaster psychiatry and function as institutional memories 

and resources to be called upon in times of need. Such 

training programs should emphasize and develop 

models for cooperation and coordination among the 

various agencies such as FEMA, the National Center 

for PTSD, SAMHSA, Uniformed Services University 

of the Health Sciences, National Institutes of Mental 

Health, and Project HOPE. Disaster response programs 

must also strive to more effectively incorporate various 

professionals (eg, psychiatrists, emergency medical 

technicians, public health workers, and community 

politicians) into disaster preparation, response, and 

recovery efforts. 

Specific areas for consideration by the military psychiatric establishment beyond the support of academic 

centers and research in this area include:

	 • 	 the development of a common disaster response doctrine, perhaps along the same 

lines as the National Incident Management 

System;

	 • 	 inclusion of disaster psychiatry in psychiatry

residency training programs and possible 

involvement of residents in disaster relief efforts;

	 • 	 furtherintegration of psychiatry consultation

liaison services in the medical care of disaster 

survivors to reduce stigma and enhance outreach; and

	 • 	 further development of the concepts of stress

inoculation and resilience to find ways to 

protect disaster workers. 

Direct military correlates may be found in the aims 

of the “Battlemind” program, as discussed in the attachment to Chapter 4, Combat and Operational Stress 

Control, in this volume.

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