Dispersed across the nation, survivors of Hurricane Katrina are suffering such severe psychological distress that the federal government has launched the broadest -- and probably the most costly -- counseling program in the nation's history.
An estimated 500,000 people need some form of mental health service, which could include treatment for post-traumatic stress, substance abuse counseling, anti-anxiety medication, even art therapy for children too young to talk out their grief.
The federal government has allocated $141 million to serve evacuees scattered among at least two dozen states, said Seth Hassett, who directs the emergency response unit of the federal Substance Abuse and Mental Health Services Administration.
Officials are negotiating a separate grant for the state of Louisiana; it could be as high as $70 million. That would bump the total cost of hurricane counseling well above the $178 million appropriated for the mental health needs of victims of the Sept. 11 terrorist attacks.
Cost aside, the Katrina response is proving the agency's toughest challenge ever, Hassett said.
In New Orleans, even those trained to offer solace break down easily and often: A hospital nurse, a school psychologist, a paramedic, a counselor all lose composure as they talk about Katrina.
"The truth is, we are not OK. We are so definitely not OK," said Burke Beyer, 31, who leads a federally funded team of counselors in New Orleans.
Experts knew from the start that Katrina would be traumatic. The storm killed more than 1,300 people, submerged 80% of New Orleans, flattened neighborhoods and forced friends and relatives apart. But the scope of the mental health crisis is only now emerging.
The half-year mark should be a milestone; many locals expected recovery to be well underway. Instead, their lives are still a mess, their city is still in ruins, and they can see no end to the chaos.
"You try to adjust but you can't," said Walter L. Collins Jr., 30, a truck driver.
Federal officials estimate that 25% to 30% of hurricane survivors in hard-hit cities such as New Orleans will suffer "clinically significant" mental health problems. Another 10% to 20% need psychological help, but aren't classified as clinically ill.
Lyn Shraberg, who directs the nonprofit Cope Line in New Orleans, hears the strain in call after call. Before the storm, her counselors handled at most three suicidal or severely depressed callers a day. Now, they get 12 to 14 a day.
"And the calls are longer and more intense," Shraberg said. "The community is overwhelmed."
Nationally, calls to the National Suicide Prevention Hotline are up 60% since Katrina.
Adding to the unease, hurricane season is approaching; a local radio station counts down the days. Yet it feels as though Katrina has just blown out of town. The streets are still strewn with the moldering remnants of upturned lives: a red teddy bear, a striped blouse, a half-used jar of poultry seasoning. The Red Cross still sends vans through the streets with free food.
"For many people, strange as it may sound, it's still the week after the storm," said Anthony Speier, a psychologist who directs the state's mental health programs for disaster victims. "They have not had a break to regroup, to rebuild resilience."
Professional help is hard to find. Before Katrina, the metropolitan region had about 550 hospital beds devoted to mental health patients. Now there are at most 200, said Joe Eppling, director of behavioral health services at East Jefferson General Hospital.
Much of the region is thinly populated: barely 40% of New Orleans' population has returned. So in theory the number of hospital beds should be adequate. But mental health crises are so common these days, Eppling has to keep some patients in the emergency room for days before a psychiatric bed opens up.
Even patients who don't need to be admitted to the hospital face long waits. Private psychiatrists are booking appointments four to six months out.
To build residents' coping skills, the state has directed its share of federal grants to a program it calls Louisiana Spirit. In the New Orleans region, outreach workers trudge door to door offering free counseling, distributing self-help guides -- and giving plenty of pep talks.
"You give me strength!" outreach worker Richard Kay called to a burly man working on a gutted house one recent afternoon.
Face beaded with sweat, Cornelius Bentley Sr. came over to parry the compliment with a confession: He's afraid.
He trusts God wouldn't send another hurricane this way. Still, he can't seem to keep his equilibrium -- or to shake the fear that he's doing all this work for nothing. "Every time it starts to rain, it gets you to feeling funny," said Bentley, 61.
He gestured at the wreckage of his Upper 9th Ward neighborhood: "Emotionally, something was taken away from us when this happened."
A few blocks down Desire Street, Wade Manger was struggling too. A gaunt man with tattoos up and down his arms, Manger, 47, paced past bulging garbage bags, running through an endless list of worries.
His ex-wife needed surgery but he couldn't track down her doctors. His grandchild's vaccination records had been washed away when her pediatrician's office flooded. He couldn't figure out how to work his new cellphone. There was a toilet on his sidewalk.
"Everything's all screwed up," Manger said. "I feel like I'm going crazy. I just wish I could put it all back in order."
Kay, 61, tried to calm him with a plan of action: Call a clinic. Make an appointment for the ex-wife. Find transportation. "What's the next thing you're going to do?" Kay prompted.
Manger couldn't focus.
"Hopefully," he said, "I'm strong enough that I don't have a nervous breakdown." Kay promised to check on him soon. Then he took off again down Desire Street, leaving Manger pacing.
Later that morning, three Louisiana Spirit counselors headed south to the Belle Chasse Primary School in Plaquemines Parish.
A recent student survey there had uncovered overwhelming anxiety. Asked how they were feeling, kindergarteners drew frowning faces dripping tears. Second- and third-graders wrote down their fears:
"I'm worried that I will never see my family again."
"Katrina threw my house somewhere."
"My cat is gone."
"My friends are gone forever."
"What will we do? Where will we go?"
To the gentle rhythm of classical music, counselor Nikky Redpath led a kindergarten class through half an hour of art therapy. When she asked them to draw any emotion they wished, five of the 15 kids drew "scared," illustrated by the dark, angry swirls of a hurricane.
At the next session, Redpath asked fourth-graders to draw something they had lost.
They drew teddy bears, pets and, above all, houses: Perfect squares with triangular roofs and chimneys puffing smoke and flowers by the front door.
"I had a big old window right here," one girl said, reaching for a crayon.
"Have you seen your house? How is it?" another counselor asked a boy.
Still sketching, he answered: "It's bad."
When they gathered in a circle to share their drawings, several students could not talk. They held up their pictures in silence.