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3 Current Infrastructure in the United States for Responding to the Psychological Consequences of Terrorism There is a substantial commitment by many individuals, organiza- tions, and agencies to provide assistance to promote psychological recovery following disasters and terrorism events. Given the num- ber and variety of responders, there are inherent difficulties in planning and coordinating these services. In addition, preparedness and preven- tion efforts to buffer the population against negative psychological conse- quences are severely limited. In general, an effective infrastructure should provide the following functions to adequately prepare for and respond to psychological consequences: 1. Basic resources including food, shelter, communication, transpor- tation, information, guidance, and medical services 2. Interventions and programs to promote individual and commu- nity resilience and prevent adverse psychological effects 3. Surveillance for psychological consequences, including distress responses, behavior changes, and psychiatric illness, and markers of indi- vidual and community functioning before, during, and after a terrorism event 4. Screening of psychological symptoms at the individual level Treatment for acute and long-term effects of trauma 6. Response for longer-term general human service needs that con- tribute to psychological functioning (e.g., housing, financial assistance when the event creates job loss) 7. Risk communication and dissemination of information to the pub- lic, media, political leaders, and service providers 64
CURRENT INFRASTRUCTURE 65 8. Training of service providers (in medical, public health, emer- gency, and mental health systems) to respond to a terrorism event, and to protect themselves against psychological trauma 9. Capacity to handle a large increase in demand for services to ad- dress psychological consequences in the event of a terrorist attack 10. Case-finding ability to locate individuals who have not utilized mental health services but need them, including underserved, marginalized, and unrecognized groups of people (e.g., undocumented immigrants, homebound individuals) and others with unidentified needs Effective delivery of these services necessitates a well-defined and coordinated system. An effective response will require the joint effort of public health, mental health, medical, and emergency systems. Currently, a variety of systems are in place at federal, state, and local government levels, as well as in the private sector, that comprise the response to a terrorism event. Lack of coordination among these diverse systems is a significant impediment to effective response. At times, the systems and services provided are overlapping and redundant, while in other cases, there are gaps in funding, services offered, and populations addressed. These complexities are more apparent following a traumatic event such as a terrorist attack when confusion may be present and needs may ex- ceed the surge capacity of the system. Furthermore, these needs may be delayed and chronic, and the system response will follow a different time course than responses to physical needs. This chapter briefly describes the various systems and programs that are currently in place at federal, state, and local levels and emphasizes the gaps that exist in the planning, preparedness, and public health infra- structure necessary for successful prevention and response. FEDERAL GOVERNMENT SYSTEMS FOR RESPONSE The federal government administers a number of initiatives and pro- grams that contribute to reduction of the psychological consequences of disasters. The relationships among the various agencies and programs are complex and promise to change as the newly established Department of Homeland Security continues to take form. In large measure, federal involvement occurs after an event not before or during. The federal gov- ernment will provide assistance on an as-needed basis for declared emer- gencies or major disasters that overwhelm local capacity as outlined in the Federal Response Plan .~ The Federal Emergency Management Agency ~ As described below, the Department of Homeland Security is currently in the process of consolidating the Federal Response Plan and other response plans into an all-hazard Na- tional Response Plan.
66 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM and the Substance Abuse and Mental Health Services Administration pro- vide important support for individuals experiencing mild to moderate psychological distress after terrorism and disasters. A number of other agencies also contribute to restoring psychological well-being after terror- ism, but regardless of federal assistance, primary responsibility for recov- ery from a disaster remains with the local affected jurisdiction. Federal- level efforts and the activities aimed at reducing the psychological impact of terrorism are described in this section. Much of the information dis- cussed in this section was obtained from publicly available information on each agency (see list of Web sites in Box 3-1~. Federal Response Plan The response of the federal government to a major emergency situa- tion is dictated by the Federal Response Plan (FRP), which is designed to coordinate the efforts of 27 federal departments and agencies and the Red
CURRENT INFRASTRUCTURE 67 Cross. The FRP is invoked when the president makes an official declara- tion of disaster or when an event likely to require federal assistance is anticipated; it provides assistance to states whose local capacity to respond is overwhelmed during and after a disaster. Presidential declarations of disaster invoking the FRP occur only about 30 times a year during disas- ters of significant magnitude or complexity. The Federal Emergency Man- agement Agency (FEMA) provides oversight for the FRP, and the various forms of federal assistance are organized into 12 emergency support func- tions (ESFs). These functions include transportation, communications, public works and engineering, firefighting, information and planning, mass care, resource support, health and medical services, urban search and rescue, hazardous materials, food, and energy. A lead federal agency is designated for each function. All health-related activities, including mental health, are designated under ESF 8, health and medical services. The U.S. Public Health Service (PHS) through the Department of Health and Human Services (HHS) is responsible for coordinating the delivery of these services, which include the overall public health response, triage, treatment, and transportation of survivors. The FRP (FEMA, 1999) states as a planning assumption that The damage and destruction of a major disaster, which may result in multiple deaths and injuries, will overwhelm the State and local mental health system, producing an urgent need for mental health crisis coun- seling for disaster victims and response personnel. Within HHS, the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is charged with coordinating federal assistance for psychological needs. SAMHSA is responsible for the following functions: training of disaster mental health workers; assessing mental health needs; and linking local, state, and federal programs for mental health response. SAMHSA pro- vides these functions primarily through the Crisis Counseling Assistance and Training Programs, which are described in the following section. The ESF 6, mass care, is led by the American Red Cross. Because the Red Cross provides disaster mental health services in all of its service delivery sites, psychological consequences of disasters are also addressed under ESF 6. Activities related to responding to the psychological consequences of trau- mas and disasters are not limited to SAMHSA and the Red Cross. A num- ber of other lead and support agencies named in the FRP may provide assistance for psychological issues, although they may not explicitly be labeled as part of the mental health response. As noted below, the newly established Department of Homeland Security will consolidate the FRP with other federal response plans into an all-hazard response plan in the future.
68 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM FEMA, SAMHSA, and the Crisis Counseling Assistance and Training Program In a presidentially declared or anticipated disaster, FEMA coordinates activities at all levels: federal, state, local, and private. Among other tasks, FEMA coordinates public information and outreach, and works with state representatives to identify unmet needs. In order to address mental health needs in disaster situations, FEMA has authorized SAMHSA's Crisis Counseling Assistance and Training Program (CCP) to provide funding to states that provide documentation that their state and local resources are insufficient to respond to psychological needs. FEMA works in part- nership with CMHS, which assesses mental health needs, provides train- ing materials, arranges training for outreach workers, and evaluates grants submitted to FEMA through the CCP. The CCP is a central element of the federal government response to the psychological consequences of disasters. It provides two types of grants to state governments: immediate services grants and regular ser- vices grants. An immediate services grant funds 60 days of counseling services, and applications for individual assistance are due within 14 days of a presidential declaration of disaster. A regular services grant must be applied for within 60 days of the disaster declaration; it funds an addi- tional nine months of crisis counseling programs. Services provided un- der the CCP include education and counseling, community outreach, in- dividual crisis counseling, and referral services. Services are limited to short-term interventions focused on people with ordinary psychological responses to extraordinary stressors. FEMA does not fund longer-term mental health services such as treatment for psychiatric disorders or sub- stance abuse, office-based therapy, or medications (HHS, 2001b). Other Activities of SAMHSA to Respond to the Psychological Consequences of Terrorism In addition to its central role in the CCP, SAMHSA provides a num- ber of other services that contribute to the overall response to the psycho- logical consequences of terrorism. For example, it funds the National Child Traumatic Stress Network (NCTSN), a coalition of 37 centers focusing on childhood trauma, which is overseen by the National Center for Child Traumatic Stress. This network is intended to educate the public and pro- fessionals regarding child traumatic stress, extend the availability of coun- seling, and develop and disseminate evidence-based treatments and pre- ventive programs. The NCTSN has a number of ongoing initiatives relevant to terrorism, including programs to address violence in the com- munity, war and refugees, and traumatic grief, as well as a newly estab-
CURRENT INFRASTRUCTURE 69 fished Terrorism and Disaster Branch located at the National Center. The goal of the branch is to improve national preparedness and response for children, families, schools, and communities, and will collaborate with other NCTSN program areas focusing on school-based interventions to improve responses by schools to the psychological consequences of ter- rorism and mass trauma. NCTSN was also active in responding to psy- chological needs after the September 11, 2001, terrorist attacks, providing mental health services, consultation, training, research services, and pub- lic education. SAMHSA's Emergency Services and Disaster Relief Branch of CMHS, in collaboration with the National Center for Post-Traumatic Stress Disor- der of the Department of Veterans' Affairs, has undertaken a multiyear project called the National Crisis Response Technical Assistance Project. This project has recently been initiated with the goal of promoting "state and local capacity for mental health crisis response across the country" (CMHS, 2001~. In addition, SAMHSA has a Program on Trauma and Ter- rorism within the Division of Prevention, Traumatic Stress and Special Programs of CMHS, and has initiated other programs to provide techni- cal assistance and training to state mental health workers; to aid in the assessment of mental health needs; and to administer grants for services to public health workers. Other Federal Agencies with Roles in Responding to the Psychological Consequences of Terrorism Other segments of the federal government play various roles in the overall system for responding to the psychological consequences of disas- ters, including terrorism. Below is a description of some of these depart- ments with a brief discussion of the nature and extent of their involve- ment in response. This is not intended to represent a comprehensive explanation, but rather to describe some of the agencies primarily in- volved in responses to disasters. The Centers for Disease Control and Prevention As the lead public health agency of the United States, the Centers for Disease Control and Prevention (CDC) has a central role in responding to disasters, including terrorism events, that put the public's well-being in danger. The CDC's responsibilities in the area of terrorism have focused on issues of biological and chemical terrorism, given its expertise in infec- tious diseases and epidemiologic surveillance. The CDC has developed a strategic plan to address the use of a biological or chemical agent in a terrorist attack. As part of that plan, communication with the public
70 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM through the media is noted as an essential component of limiting poten- tial panic and disruption from such an attack (Khan et al., 2000~. The CDC's involvement in other types of disasters is often limited to the area of communication activities. A CDC Emergency Response Team includes as a key element a public information officer who designs mes- sages for the public, the government, and the media. The Emergency Re- sponse Team uses a strategy of centralizing communications operations to decrease conflicting messages to the public. The CDC has agent-spe- cific communication response plans prepared in order to facilitate rapid utilization in the event of a biological, chemical, or radiological terrorist attack. These resources within the CDC function to train and assist local authorities in risk communication; in general, the risk communications activities that follow a disaster or terrorism event are performed by local government and public health authorities. As part of the FRP, the CDC is designated to assist in monitoring emergency worker health and safety. This monitoring is most often fo- cused on potentially toxic environmental exposures, as well as on physi- cal injuries such as falls. Tob-related stress and psychological distress are frequently noted as one of the major categories of occupational hazards (Weeks et al., 1991) and thus should be considered when monitoring the health of emergency responders. Two programs within the CDC also deserve mention here: the Office of Public Health Emergency Preparedness and Response (OPHEPR) and the Centers for Public Health Preparedness. OPHEPR was created in Oc- tober 2001 with the intent of coordinating the terrorism-related activities of HHS. The CDC provides funding for the Centers for Public Health Pre- paredness, a network of 15 academic centers across the nation. These cen- ters are usually based in schools of public health and focus on education, research and evaluation, and dissemination of best practices, with the goal of ensuring that future public health workers are equipped with the knowledge and skills necessary to respond to terrorism (Gilmore Com- mission, 2002~. Department of Defense The Department of Defense (DoD) has its own comprehensive medi- cal system, the Military Health System, which includes mental health units. This system offers assistance primarily to active members of the military (Becker, 2001~. After the attack on the Pentagon on September 11, 2001, this system for mental health response was mobilized and func- tioned in collaboration with civilian and local services. DoD is designated by the FRP as the lead agency for ESF 3, public works and engineering, and also is a support agency for all of the other functions. DoD may pro-
CURRENT INFRASTRUCTURE 71 vice additional resources, equipment, and technical assistance after a di- saster or terrorist attack as needed. During wartime, DoD is responsible for communication with the public, an area of activity that has clear im- plications for psychological well-being. The National Guard is a reserve force of the U.S. armed forces, functioning in a dual state and federal ca- pacity. In times of need, the National Guard will interface at the local level. After the terrorist attacks of September 11, 2001, more than 50,000 National Guard members were activated to provide security in localities across the United States and to fight terrorism internationally (National Guard Bureau, 2003~. Department of Education In the event of a disaster, the primary goal of the Department of Edu- cation is to restore the learning environment for children. As discussed in Chapter 2, terrorist attacks whether they are experienced directly or in- directly can have significant psychological consequences for children. These psychological consequences can be disruptive to learning, whether or not the physical learning environment has been disrupted. Every school district must develop a crisis management plan for responding to violent or traumatic incidents in order to qualify for funding under the Safe and Drug-Free Schools and Communities Act State Grant Program. Ongoing efforts by the Department of Education have focused on developing a model school crisis plan, for comparison by schools to their own plans, thus streamlining the entire development process. Additionally, the De- partment of Education has encouraged school districts to strengthen and reevaluate their crisis plans in light of potential terrorism events and has made available $30 million in discretionary grants to assist school dis- tricts in these activities (U.S. Department of Education, 2003~. The depart- ment has released guidelines indicating that crisis plans should address four major areas: prevention and mitigation, preparedness, response, and recovery (U.S. Department of Education, 2003~. Preparation and planning for recovery include such activities as pre-approving and training teams of mental health providers and creating a notification system for parents. A central aspect of the Department of Education's terrorism response has been through Project School Emergency Response to Violence (Project SERV). This program was established by Congress in 2001 and funded with $10 million through an act authorizing spending on recovery from and responses to terrorism.2 It will have to be refunded each year by an 2 Emergency Supplemental Appropriations Act for Recovery from and Response to Ter- rorist Attacks in the United States, 2001 (P.L. 107-38~.
72 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM act of Congress. Project SERV provides grants and funding for "educa- tion-related services to local education agencies in which the learning en- vironment has been disrupted due to a violent or traumatic crisis"3 and includes short-term (6 months) funding for the immediate restoration of the learning environment and longer-term (up to 18 months) funding for a more extensive plan that coordinates community, federal, state, and lo- cal resources to support the school community. Since its establishment, SERV has funded 12 applications for events such as school shootings. After the September 11, 2001, terrorist attacks, $4 million was pro- vided by Project SERV to the New York Citv Denartment of Education to help city schools cope with the trauma. Department of Homeland Security In October 2001, President George W. Bush issued an executive order creating the Department of Homeland Security. The new department is a major reorganization of the federal government in the United States, bringing together under its authority a number of existing federal agen- cies. The stated mission of the Department of Homeland Security is to prevent terrorist attacks, reduce vulnerability to terrorism, and minimize damage and promote recovery from terrorist attacks. The department will have four divisions: Border and Transportation Security; Emergency Pre- paredness and Response; Chemical, Biological, Radiological, and Nuclear Countermeasures; and Information Analysis and Infrastructure Protec- tion. The Department of Homeland Security is currently active, but many of the reorganizations and proposed programs are either currently being put into place or have yet to be carried out.4 It is unclear how the creation of the Department of Homeland Secu- rity and the corresponding reorganization of the federal government will impact the federal government's response to the psychological conse- quences of terrorism, although the reorganization will affect a number of the aforementioned federal programs and divisions. FEMA is now part of the Division of Emergency Preparedness and Response. The proposal for the department notes that FEMA will be a central aspect of the Depart- ment of Homeland Security and that it will "maintain FEMA's procedures for aiding recovery from natural and terrorist disasters" (White House, 2002a). In addition, the Division of Emergency Preparedness and Re- sponse will work to consolidate existing federal response plans for vari- -) - -r - 3 Emergency Supplemental Act, 2002 (P.L. 107-117~; U.S.C. 7131. 4 The organization, strategies, and vision of the Department of Homeland Security is re- flected in the National Strategy for Homeland Security (White House, 2002b).
CURRENT INFRASTRUCTURE 73 ous types of emergencies (e.g., FRP, National Contingency Plan) into an "all-hazard plan" called the Federal Incident Management Plan which may be operational as early as September 2003. The Division of Emer- gency Preparedness and Response will also serve as a central source of information for state and local officials and administer various existing federal grant programs for training and preparedness of emergency re- sponders. The National Disaster Medical System (NDMS) a collaborative ef- fort of HHS, DoD, VA, FEMA, state and local governments, private busi- nesses, and civilian volunteers is also now operated by the Department of Homeland Security as part of the Division of Emergency Preparedness and Response.5 More than 2,000 civilian, military, and VA hospitals have volunteered to serve as part of the NDMS (Becker, 2001~. The NDMS aug- ments overwhelmed local resources to provide health care services after a disaster and may be activated at the request of a local, state, or federal official. The NDMS is responsible for leading many of the specific re- sponse actions outlined in the FRP. The NDMS includes Disaster Medical Assistance Teams (DMATs), with more than 7,000 affiliated private sector health care professionals, including physicians, nurses, and mental health professionals. As of 2001, four of these teams were specialized mental health DMATs that consist of psychologists, psychiatrists, and social workers (Becker, 2001~. When DMATs are activated, their members are automatically federalized and thus given permission to practice in the affected state. This is important in ensuring that providers have the au- thority to provide care in the event of a disaster. One initiative of the Department of Homeland Security is a public education effort aimed at increasing individuals' knowledge about poten- tial threats in order to increase preparedness during an attack. Informa- tion has been provided in brochure format and through the Internet at www.ready.gov, and focuses on three areas of preparedness: make a kit, make a plan, and be informed. It describes specific actions to take in the event of different types of terrorist attacks, such as "sheltering-in-place" if there is air contamination, and recommends components of emergency supply kits, including such items as clean water, flashlights, first-aid sup- plies, and extra prescription medications. Department of Justice The Department of fustice's Office for Victims of Crime (OVC) pro- vides various forms of support to victims of federal crimes and their fam- 5 Previously, the NDMS was operated by the Office of Emergency Preparedness (OEP) of the Department of Health and Human Services.
74 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM fly members. The OVC was authorized by Congress through the Victims of Crime Act. The OVC provides training and technical assistance, sup- ports emergency responses including crisis counseling, and administers the Crime Victim's Fund. The Crime Victim's Fund supports state victim's assistance and compensation programs that reimburse victim's expenses for health care, mental health counseling, funerals, and lost wages. The OVC also administers grants for programs and research related to victim's issues. The Terrorism and International Victims Unit of the OVC is re- sponsible for coordinating all facets of assistance to survivors of terrorist acts and international crimes. It operates the Antiterrorism and Emer- gency Assistance Program, which provides information, identifies re- sources, administers various compensation programs, and advances train- ing and educational programs for groups such as emergency responders and mental health providers. In response to the September 11, 2001, ter- rorist attacks, this program, among other activities, supported crisis coun- seling provided through CMHS. Department of Veterans Affairs The Department of Veterans Affairs (VA) is recognized as a support agency by the Federal Response Plan. The VA plays a role in coordinating federal responses to the psychological consequences of terrorism through its National Center for Post-Traumatic Stress Disorder (NC-PTSD). Man- dated by Congress in 1989 to focus on the issues of veterans with post- traumatic stress, NC-PTSD activities include education, training, consul- tation, and research on stress and trauma. The NC-PTSD is a central research authority on PTSD and has advised clinicians and others plan- ning mental health services to respond to mass traumas including terror- ism. A training program designed by the NC-PTSD identifies and trains VA experts on disaster mental health so they are able to respond to major national disasters. The VA also operates the Readjustment Counseling Service (RCS), which provides individual mental health care for all veterans affected by stress and trauma. The RCS functions through hundreds of centers lo- cated in communities and is staffed with trained mental health profes- sionals. These staff members also provide psychological services to nonveterans who experience natural and other disasters. Ongoing collabo- ration within the VA between the NC-PTSD and RCS will help to estab- lish interdisciplinary disaster mental health response teams that might strengthen the federal system for response (Young et al., 2000~.
CURRENT INFRASTRUCTURE National Institute of Mental Health 75 The National Institute of Mental Health (NIMH) is not involved in direct responses for the psychological consequences of terrorism, but rather plays the crucial role of setting the research agenda for federal fund- ing. The NIMH issued a request for applications for "Research in Re- sponse to Terrorist Acts Against America" in the months after the Sep- tember 11, 2001, attacks. This funding will support research projects relating to the psychological consequences of terrorism and traumatic events such as evaluations of treatment efficacy. This type of research is critical to effectively inform policy and develop interventions, as dis- cussed at the conclusion of Chapter 2. National Transportation Safety Board The National Transportation Safety Board (NTSB) has jurisdiction over any commercial aviation crash involving significant loss of life oc- curring in the United States, as well as major crashes on other forms of transportation. Following a transportation event, the NTSB is responsible for investigating the circumstances of the incident. Its Office of Transpor- tation Disaster Assistance (formerly the Office of Family Affairs) provides assistance to the families of victims and survivors and is charged with coordinating resources to support state and local entities, including the airlines. Among other activities, the NTSB notifies families of deaths, pro- vides psychological and logistical support to families and survivors, ar- ranges memorial services for victims, and maintains contact with families and survivors regarding the status of the investigation. The American Red Cross has been designated by the NTSB to provide the psychological re- sponse after a transportation disaster. In response to this designation, the Red Cross created the Aviation Incident Response (AIR) team, an inter- disciplinary group of disaster experts that advises the Red Cross on issues unique to aviation and other transportation disasters and leads the Red Cross disaster response in these instances. Summary A number federal agencies play critical roles in the nation's response to the psychological consequences of terrorism. These agencies adminis- ter various programs, and have particular jurisdictions and areas of ex- pertise. While there is increased awareness of the need to prepare re- sponses to psychological issues that result from terrorism events, there remains a lack of coordination among federal agencies. Any future plan-
76 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM ning must account for the new structure of the federal government that has been initiated in response to terrorism in the United States. STATE AND LOCAL GOVERNMENT SYSTEMS FOR RESPONSE The National Strategy for Homeland Security proposes the creation of a national incident management system, in collaboration with federal, state, local, and nongovernmental public safety organizations (White House, 2002b). This system would be adaptable for different types of inci- dents, would identify common terminology, and would provide a coordi- nated command source. Additionally, the strategy proposal states that the federal government will require all state and local first responder or- ganizations to adopt the existing Incident Management Systems model as a condition of federal grant funding. Regardless, there is still currently a great deal of variation among the various state- and local-level systems for response. The state and local infrastructure is vital to effective re- sponse, given the local and regional nature of recent terrorism events. The Oklahoma City bombing was mostly local, while the 2001 Anthrax attacks and September 2001 air attacks were largely regional events. Regional pre- paredness will also be tested in the event of terrorism in bordering coun- tries where border security and related issues will likely need to be ad- dressed. This section will provide a general overview of these systems. State Government Systems for Response Each state is required to have a disaster plan that dictates responses in the event of a disaster. State governments are required by federal law to include a mental health component in these disaster plans. However, there is no standard approach to address the incorporation of mental health issues. The development of mental health components of the plans is of- ten dependent on the presence of individuals with expertise and experi- ence in the area. Funding is another important determinant of state-level preparedness for the psychological consequence of terrorism. Current budgetary constraints on many state and local governments may make the development and implementation of mental health response plans more difficult. State emergency response plans are frequently similar to the FRP. 6 The Incident Management System is also referred to as Incident Command Structure or Unified Command Structure, et cetera, and is a model of managing responses to disasters and other incidents. This type of response system is currently in place in a number of states.
CURRENT INFRASTRUCTURE 77 Usually a state emergency management authority will coordinate service agencies within the state, each of which has responsibility for various functions of response. For example, the Department of Health may direct responses for a bioterrorism attack, but may rely on the state emergency manager to call upon other departments from which it might require sup- port, such as the Departments of Transportation and Human Services. Some states have county-level emergency response managers, who are responsible for coordinating local resources and may be called upon by the director of the state office for specific tasks. In response to new federal requirements, many states have incorporated all or part of the state-level Office of Homeland Security into their existing state emergency manage- ment authority. In practice, much of the immediate and short-term state disaster men- tal health response is conducted through routine community mental health services. In the event of a presidentially declared disaster, funding streams from the FEMA/SAMHSA Crisis Counseling Assistance and Training Program (CCP) are usually directed by the state to the local agen- cies that provide services, although the manner in which this occurs de- pends on how the state mental health system is organized. Some states operate their own mental health facilities, while the majority outsource most treatment functions to community organizations. Preexisting relationships between state and local agencies or organi- zations and among providers become very important in the event of a disaster. These relationships can allow the state to organize services swiftly, provide accountability for funds, and help ensure the quality of services. The scope and range of services provided can be limited if agen- cies without preexisting relationships with state governments do not re- ceive federal support. Services are directed to the natural client bases of the agencies with preexisting relationships, leaving large gaps in services and outreach. A similar issue arises with private practitioners who may have the expertise and experience to provide care, but may not have rela- tionships with government agencies. Although the CCP supports states in providing resources for indi- viduals with mild distress reactions, state mental health response plans must also provide for those individuals with diagnosable psychiatric ill- ness. The CCP provides referrals for mental health services, but federal funding will not provide more intensive and ongoing care for these indi- viduals, even if the illness develops subsequent to the disaster or terrorist attack. Thus, services for psychiatric illnesses often occur through the pre- existing state public mental health care system. The transition from the postdisaster psychological counseling system to more traditional mental health services is a "complex and political process" (APA Task Force, 1997, p. 33) during which individuals may be lost to the system.
78 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Licensing for mental health professionals varies across states. Most states allow mental health professionals such as psychologists to practice up to 30 days in another state even in the absence of a disaster. Many states have agreements with bordering states to activate reciprocal licens- ing for all health professionals in the event of a disaster. Also, some states stipulate that health professionals working under the auspices of the Red Cross are automatically permitted to practice within the context of the disaster response. Local Government Systems for Response Systems for response by local governments are quite variable, per- haps more so than state systems. This section reviews some of the com- mon features and challenges of local government (generally, county-level) systems for mental health response to terrorism events. As mentioned above, many counties and local jurisdictions employ emergency response managers who coordinate local resources in the event of a disaster. These individuals are responsible for informing key people at the local and state levels to mobilize resources. In general, county men- tal health agencies are the principal providers of the crisis counseling pro- grams that will be established after a terrorist attack. This responsibility frequently presents unique challenges to agencies that normally serve in- dividuals with serious ongoing psychiatric illnesses. County mental health agencies must maintain care for their regular population, which may be experiencing worsening of symptoms due to the disaster, while at the same time provide additional crisis counseling services to individuals with psychological impact but not psychiatric illness (Young et al., 2000~. The training and experience to do so may or may not be present in a county mental health agency, which highlights the need for pre-event training and preparation for such an event. The local mental health au- thority must be prepared to fulfill its responsibilities in a potentially cha- otic situation, but must also ensure that its capacity is adequate to re- spond to a significant surge in need for services. Some counties have plans in place to provide assistance and addi- tional resources to other counties in the event of a disaster that over- whelms local capacity. For example, the State of California has crisis teams for each of its medium-size or larger counties that can provide crisis coun- seling after a traumatic event. Through mutual aid agreements, these teams may provide assistance to other counties in need (California De- partment of Mental Health, 2001~. School-based mental health services constitute another area in which county-level governments can play an important role. As discussed ear- lier, county governments and school district officials have been encour-
CURRENT INFRASTRUCTURE 79 aged by the U.S. Department of Education to develop or strengthen school crisis management plans in light of terrorism threats (U.S. Department of Education, 2003~. Many states have developed model crisis management plans for use by individual localities (for example, see Virginia Depart- ment of Education, 2003~. Among other functions, school crisis manage- ment plans will often outline relationships with county-level mental health agencies and include provisions for interventions with directly af- fected students and for counseling support for students and staff. In addi- tion, the plans frequently outline communications procedures for media, staff, students, and parents, including communication of what types of psychological reactions to expect in children. A number of counties have plans in place that specifically acknowledge the psychological conse- quences of terrorism and other forms of traumatic events. For instance, Montgomery County in Maryland has been praised for its response to the psychological consequences of the September 11, 2001, terrorism attacks and the Washington area sniper attacks of 2002. In response to each of these events, the county school system provided supportive counseling to more than 139,000 students and 20,000 staff members (Mintz, 2003~. PRIVATE SECTOR SYSTEMS FOR RESPONSE Private sector systems for response include a variety of groups rang- ing from the American Red Cross, to university departments of psychol- ogy, to individual religious groups and charities. Response efforts may be initiated by organizations, agencies, community groups, and/or individu- als, and frequently are not coordinated with one another. The National Voluntary Organizations Active in Disaster (NVOAD) has sought to in- crease the level of communication and coordinated planning among vol- untary and community organizations. Members of NVOAD include a number of national level organizations such as the American Red Cross, the Salvation Army, and many faith-based organizations, as well as state- level chapters that include most of the states and territories in the United States. Some of the private-sector systems for response are described briefly in this section. American Red Cross The American Red Cross is the largest private organization respon- sible for responding to human needs after disasters. Since 1905, the Red Cross, under charge from the federal government, has provided for the immediate human needs of disaster survivors. In 1989, the Red Cross rec- ognized the need for a systematic plan to respond to psychological needs. The Red Cross Disaster Mental Health Services (DMHS) Program was
80 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM developed and evolved over the next 10 years (Jacobs, 1995~. A central goal of the program is to help Red Cross disaster responders work more effectively by addressing the stress and trauma related to disaster work. The program also provides mental health-related services and resources to disaster survivors, other disaster-relief workers, and families of Red Cross disaster responders (American Red Cross, 1998~. The FRP identifies the Red Cross as a support agency whose duties regarding psychological responses are specified as including the provision of supportive counsel- ing to disaster survivors and family members of victims. The agency also is noted by the FRP as responsible for providing referrals and information to family members regarding available health resources (FEMA, 1999~. The DMHS program, like most Red Cross services, relies almost ex- clusively on volunteers (greater than 90 percent) and focuses on the pro- vision of direct services after disasters. It is based on an integrated nondisciplinary system, using one training program for psychiatrists, psy- chologists, social workers, counselors, marriage and family therapists, and nurses with psychiatric training. All of these professionals have similar roles in disaster response, and these roles are interchangeable. To be eli- gible for training through DMHS, an individual must be licensed in his or her profession by a State Licensing Board if the state requires licensure. The Red Cross training uses a two-day video-based course. By the year 2000, 9,000 mental health professionals had been trained, 2,000 of whom were members of response teams (Weaver et al., 2000~. The activation process for DMHS volunteers varies for local and na- tional disasters. During a local disaster, the local chapter of the Red Cross may call on individuals in the area who received training and registered with the chapter. DMHS activation for national disasters is coordinated through the national headquarters of the Red Cross. The national head- quarters assesses needs together with the state lead chapter for the af- fected area and informs Red Cross state lead chapters across the country of those needs. The state lead chapters then notify all local chapters, who contact individual qualified volunteers. Each local chapter has a Disaster Services Human Resources Office, and all DMHS-trained volunteers who wish to be activated in the event of a national disaster must first register with this office (Smith, 2002~. Additionally, in response to a designation by NTSB to respond to psy- chological needs following aviation disasters, the Red Cross has devel- oped and maintains Aviation Incident Response teams (see above). In the spring of 2003, the realm of responsibility of the AIR teams was expanded from aviation disasters to include all major disasters caused by terrorism and weapons of mass destruction. How this expanded focus will affect AIR team functioning remains to be seen.
CURRENT INFRASTRUCTURE 8 Workplace In the United States, most acts of terrorism have occurred in the con- text of a workplace. Many of the anthrax attacks of 2001, the attacks of September 11, 2001, the Oklahoma City bombing, and the 1993 World Trade Center attack have confronted people in their place of employment. Because most people must continue to perform their jobs after a traumatic event, parts of the recovery process must necessarily occur in the work- place. After the anthrax attacks of 2001, it was essential for the U.S. mail system to continue to function. Postal workers were required to sort and deliver mail despite their fears of exposure. Similarly, after the attacks of September 11, 2001, military employees stationed in the Pentagon carried on with strategic planning in the immediate aftermath of the threat. The workplace environment provides an important opportunity for outreach to individuals. Workplace systems for responding to the psy- chological consequence of terrorism occur on both an informal level in which leaders, managers, and coworkers support one another and a for- mal level characterized by services such as counseling and Employee As- sistance Programs (EAPs). Employee Assistance Programs are systems designed to provide psy- chological support to employees from a skilled source outside the organi- zation, allowing for the preservation of confidentiality. Some common el- ements of EAP responses to a traumatic event include group debriefings and individual and group counseling. The effectiveness of group debriefings is a source of debate (NIMH, 2002), but they are frequently used in the workplace. After the September 11, 2001, attacks, the EAP for Merril Lynch, located in lower Manhattan, established groups of individu- als that met to prepare themselves for their return to the workplace. This preparation covered both psychological concerns and physical concerns such as air quality and safety (National Partnership for Workplace Mental Health, 2002~. EAPs may vary significantly in their scope and prepared- ness for disasters, and smaller businesses frequently have no system in place to respond to the psychological needs of their employees. Often overlooked as sites for workplace preparedness and response are farms and food production and distribution systems. An event in- volving agricultural terrorism has the potential for significant disruption and damage to human lives and to local, regional, and national econo- mies. The outbreak of Foot and Mouth Disease in the United Kingdom in 2001, while not a terrorism event, resulted in significant economic loses, which had psychological consequences for those affected (Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weap- ons of Mass Destruction, 2002~. It is reasonable to assume that the psycho- logical ramifications are a potential risk in the event of an attack involving
82 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM agricultural terrorism, given the stress associated with economic and so- cial losses. While preparations for agricultural terrorism are topics of dis- cussion (see, for example, Greco, 2002), the psychological impacts of these events should be also considered. Primary Care Many primary care visits are due to psychosocial issues that may manifest themselves as physical complaints (Heldring, 2002~. However, there is currently no system in place in the primary care environment to organize primary care providers to respond to the psychological conse- quences of terrorism or other disasters. Primary care providers may have little or no training and experience in disaster response. Efforts are under way, however, to address this issue. For example, a recently initiated project, directed by America's Health Together and sup- ported by the Robert Wood Johnson Foundation is working to enhance mental health responses to terrorism in primary care settings. One of the organization's initiatives, "Mental Health and Primary Care in a Time of Terrorism," will assess the experiences and needs of primary care provid- ers dealing with mental health problems, develop and disseminate educa- tion tools designed to help them, and assess the effectiveness of these tools in light of new knowledge about the nature of mental health responses to terrorism and bioterrorism (America's HealthTogether, 2003~. The Department of Defense used the primary care setting as an entry point for mental health care in its response to the September 11, 2001, attack on the Pentagon called Operation Solace. Individuals attending pri- mary care clinics for any type of care were assigned a care manager if the medical problem was potentially related to the September 11, 2001, at- tacks, anthrax, deployment, or the war in Afghanistan. Care managers were mental health nurses or social workers and provided assistance with referrals for additional treatment, facilitated follow-up, and made avail- able supportive interventions, among other tasks (Hoge et al., 2002~. Faith-Based Faith-based settings, like the primary care setting, are natural envi- ronments for interventions to respond to the psychological consequences of terrorism. Ninety percent of respondents in one survey of reactions to the September 11, 2001, attacks reported that they turned to religion for help with coping after the events (Schuster et al., 2001~. Certain individu- als may prefer to seek help in such settings because they are seen as neu- tral, supportive, and accepting and may help people find some meaning in a tragic event.
CURRENT INFRASTRUCTURE 83 As mentioned above, the American Red Cross operates the Aviation Incident Response team. It also has developed a Spiritual Care Aviation Incident Response (SAIR) team that is responsible for coordinating local spiritual care volunteers in the event of an aviation disaster. Working with the AIR team and the rest of the Red Cross, the SAIR team provides emo- tional and spiritual support to survivors, families, rescue workers, and airline personnel. SAIR may also assist with memorial services for vic- tims. The SAIR team consists of spiritual counselors located throughout the United States who have been certified by one of five professional chap- lain certification and education organizations in the United States: the Association of Professional Chaplains, the National Association of Catho- lic Chaplains, the Association for Clinical Pastoral Education, the National Association of lewish Chaplains, and the International Conference of Po- lice Chaplains (Booth, 2003~. The AIR and SAIR teams were activated af- ter the September 11, 2001, terrorist attacks and responded to the crash sites and the airports from which the hijacked flights originated as well as their intended destinations. Local or Community Providers As described in the section detailing federal-level systems, federal funding for responding to the psychological consequences of terrorism is often funneled through state agencies to community agencies and provid- ers. However, these various agencies may be only loosely associated, or even unassociated, with one another and may be unaware of the activities of other agencies. The backgrounds and trainings of community and local providers will vary significantly; many do not have specific training in disaster mental health or the psychological consequences of terrorism. Summary Given the range of psychological consequences that result from ter- rorism, the venues for response to these consequences must be equally wide. Most of the efforts by governments and the Red Cross described above are generally focused on those individuals who are in the immedi- ate geographical area of the disaster. Other settings that have been men- tioned, such as primary care, the workplace, schools, and faith-based en- vironments, provide opportunities to reach individuals who experience psychological distress as a result of terrorist acts but are not in the imme- diate physical vicinity of the disaster. These settings also may provide opportunities for preparedness during the pre-event phase of an attack. However, preparedness for psychological consequences currently is not widely addressed.
84 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM CAPACITY OF THE INFRASTRUCTURE TO RESPOND TO THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM There are a number of services and resources in place at federal, state, and local levels that are available to respond in the event of a terrorist attack. However, it is less obvious how these systems work together to provide an effective and coordinated response to the range of psychologi- cal consequences that will present in populations. There is a general con- sensus among the public health and disaster mental health community that the infrastructure designed to promote and protect the public's health is inadequate to respond to psychological needs after a terrorism event of great magnitude or uniqueness. The best tests of the capacity of the nation's systems have come from the two largest terrorism events occur- ring in the United States in the recent past: the Oklahoma City bombing and the September 11, 2001, attacks. In addition, the uniqueness of the anthrax attacks in fall of 2001 drew attention to a new set of gaps in the infrastructure and brought to light the critical need for preparedness in all parts of the country, not just those areas directly impacted. Although this report is not intended to provide a comprehensive re- view of the nation's responses to recent terrorism events, this section high- lights the aspects of those responses that have been identified as either particularly problematic or successful. Many lessons can be learned from these events. Response to the Oklahoma City Bombing In 1995, the Murrah Federal Building in Oklahoma City was destroyed by a bomb that injured 800 and killed 168 people. Because Oklahoma City is a relatively small metropolitan area with about 500,000 residents, the psychological impact of the bombing extended to most members of the community. More than one-third of surveyed adults knew someone who was killed or injured in the bombing (Smith et al., 1999), and similar re- sults were found among youth (Pfefferbaum et al., 1999~. The response to the psychological impact began almost immediately and continues to this day. In the immediate aftermath of the bombing, a family assistance cen- ter, referred to as the Compassion Center, was established at a local church. The church was identified as a disaster response center prior to the bombing because of its central location. The center was directed by the state medical examiner and served as the focal point for an array of activi- ties, including victim identification and care for families, that were car- ried out by multiple state, federal, and volunteer agencies. It was also the center for coordination of the emergency mental health response. The
CURRENT INFRASTRUCTURE 85 American Red Cross played a large role in many of the initial activities. Three to four hundred mental health professionals took part in this re- sponse, some of whom were mobilized through official channels such as the Red Cross Disaster Services Human Resources program. However, most came to the Compassion Center informally to offer their services. Many of these individuals had limited training and experience in disaster mental health care. Problems of coordination quickly arose, and it was necessary to develop a system for confirming credentials, screening for experience, and scheduling volunteers (APA Task Force, 1997~. Many lo- cal clergy members offered assistance to the Compassion Center. Similar problems of credentialing, qualifications, and lack of experience arose with clergy as with other mental health professionals (APA Task Force, 1997~. Furthermore, there was no preexisting response plan to organize clergy. Mental health volunteers at the Compassion Center focused their as- sistance in four areas: family services, support services, death notifica- tion, and psychological services for volunteers in the center. Support ser- vices for rescue workers were largely modeled on Critical Incident Stress Management (CISM), which is frequently used, despite limited research and inconclusive findings regarding effectiveness. The Compassion Cen- ter also included a separate physical space for children staffed by a psy- chologist and other mental health professionals. This space provided structured play activities for children and assistance to parents and fami- lies in dealing with children's grief and with death notification. In addition to this local organization of response, resources were mo- bilized at the state and federal levels to plan for a longer-term effort to promote psychological recovery. The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) was designated by the governor of Oklahoma to oversee the emergency mental health ser- vices that would be needed (Tucker et al., 1998~. However, the ODMHSAS had neither a disaster response plan nor preexisting relationships with other state emergency response agencies (Call and Pfefferbaum, 1999~. The ODMHSAS established a crisis counseling hotline, mobile outreach teams, debriefings, and provider trainings. The office prepared an Imme- diate Services Grant proposal to the CCP of FEMA-CMHS, and funding was provided by May 8, 1995 (APA Task Force, 1997~. A Regular Service Grant was also approved that extended the funding for an additional nine months. These funds were used to establish Project Heartland, a public mental health program to provide crisis counseling, outreach, education, and re- ferrals as dictated by the CCP. The ODMHSAS provided oversight dur- ing the transition from the immediate crisis services provided by the Red Cross at the Compassion Center to the ongoing activities of Project Heart-
86 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM land. Tensions arose between local Red Cross relief workers and the ODMHSAS during this process (Call and Pfefferbaum, 1999~. Less than one month after the bombing, a statewide forum was held to collect input from stakeholders and inform them of the activities and priorities of Project Heartland. Particular concerns included the need for accessible and culturally sensitive services, services for children, and education for the media on responses to traumatic events (Call and Pfefferbaum, 1999~. Project Heartland spent the greatest portion of its time providing support groups and client advocacy. Support groups were established for a vari- ety of groups such as rescue workers, widows and widowers, parents who lost children, and school counselors. In recognition of the special needs of youth, some funding was channeled directly to the school sys- tem. Project Heartland also established programs through a number of subcontract organizations that focused outreach, counseling, and educa- tion on special populations such as African Americans, Hispanic Ameri- cans, the elderly, youth, and people with preexisting psychiatric disor- ders. However, CCP-funded programs such as Project Heartland do not provide psychiatric treatment to individuals who need ongoing or spe- cialized care. Issues arose regarding the perception that referrals for treat- ment were inadequate (Call and Pfefferbaum, 1999~. This may have been related to a lack of established relationships with providers, and the limi- tations of funding for such care. In recognition of these limitations, the American Red Cross funded long-term treatment for individuals through the Sunbridge Counseling Program, operated by the Mental Health Asso- ciation of Oklahoma County. After FEMA-CMHS funding expired, financial responsibility for Project Heartland was taken on by the Office of Victims of Crime of the Department of Justice and the network of care that was initiated on the day of the bombing continued to function for years, although over time it has received less government support and has become reliant on founda- tion and other charitable funding. This emphasizes the long-term psycho- logical needs after an event of such magnitude. The rapidity and breadth of the mental health response to the Oklahoma City bombing were admi- rable, particularly in light of the unprecedented nature of the terrorist attack at the time. However, it has been noted, in retrospect, that a num- ber of gaps in the response existed. These include lack of disaster prepara- tion in the mental health department; problems with coordination, super- vision, and training of the numerous volunteers who wanted to help; absence of supervision for some of the unlicensed providers; limitations of funding; and confusion or tension between different authorities, espe- cially when the appropriate jurisdictions were not clearly laid out. A fur- ther limitation was that no systematic evaluation of Project Heartland was performed in order to determine its effectiveness.
CURRENT INFRASTRUCTURE Responses in New York City and the Washington, D.C., Metropolitan Area to the September 11, 2001, Terrorist Attacks 87 The psychological impact of the terrorist attacks on September 11, 2001, was widespread and not limited to the geographical areas of the attacks. The mental health response to the terrorist attacks was necessar- ily an extremely complex effort that was swiftly enacted. Complex re- sponses took place in New York City and the Washington, D.C., metro- politan area; this section focuses on those responses as illustrative examples. Responses in New York City During the immediate postimpact period, as in the Oklahoma City bombing, much of the response to meet psychological and emotional needs of families, survivors, and rescue workers in New York City was managed by the American Red Cross. Family assistance centers were es- tablished throughout the city and the surrounding areas, and support cen- ters providing physical and psychological respite for rescue workers were set up near the site of the World Trade Center. Much of the care and ser- vices provided during this time was made available on a pro bono basis. Mental health professionals with varying levels of experience arrived from all over the country to volunteer their services, many coming without be- ing asked, adding to the complexity of coordinating efforts. A lack of ex- pertise in disaster mental health among providers and administrators was a barrier to rapid implementation of effective responses, but the overall response did benefit from an existing emergency mental health plan in the New York State Office of Mental Health (NYS-OMH). The development of a more formal and long-term network for psy- chological response was taken on by the NYS-OMH, in collaboration with the mental health departments of New York City and nearby counties. A local university department of public health was commissioned by the NYS-OMH to rapidly carry out a needs assessment evaluation through door-to-door surveys and projections based on previous disaster experi- ences. This information allowed the NYS-OMH to make projections of the estimated increase in demand for traditional mental health services for psychiatric illnesses (Herman et al., 2002~. To address individuals with less severe psychological consequences, the NYS-OMH, with help from CMHS, applied for funding from the CMHS-FEMA CCP by successfully demonstrating that the existing mental health capacity was inadequate to meet the psychological needs of the population. The network of crisis counseling and public outreach and education established in New York City and the surrounding areas with funding from the CCP was termed
88 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Project Liberty. Coordinated by the NYS-OMH, Project Liberty utilized more than 100 mental health agencies to provide services (Felton, 2002~. Although preexisting relationships between the NYS-OMH and local mental health departments facilitated the implementation process, it was necessary to develop an entirely new infrastructure and procedures for a number of important functions. These included recruitment and training of outreach workers and counseling staff, development of materials and media campaigns for public outreach and education, and creation of mechanisms for funding and reimbursement (Felton, 2002~. Once in place, Project Liberty included an extensive media campaign, crisis counseling sessions, and group education sessions. In addition, an existing mental health information and referral hotline called LifeNet was used to link individuals in need with other Project Liberty services. This hotline was staffed by English-, Spanish-, and Chinese-speaking individu- als (Wunsch-Hitzig et al., 2002~. A unique feature of Project Liberty com- pared to previous CCP-funded programs was that it allocated funding for evaluation of its efforts. Initial data from staff logs indicate that minority populations were provided services at proportionate rates and that ap- proximately 9 percent of service recipients were referred for further men- tal health services (Felton, 2002~. This increase in referrals for traditional mental health care created a strain on the existing mental health system of New York State, which was already experiencing budgetary constraints. Additionally, federal assistance programs did not fund such care. In addition to the Project Liberty initiative, other sources of assistance for recovery from the psychological impact of the attacks were utilized. The American Red Cross and the September 11th Fund (a charitable foun- dation established on the day of the attacks to assist survivors) imple- mented a program to provide reimbursement for long-term mental health care including psychotherapy, hospital care, medication, and substance abuse programs for family members of victims, people injured in the at- tacks, or residents of lower Manhattan who were displaced due to the attacks (September 11th Fund, 2003~. However, this program is limited in the type and amount of care it can provide. Furthermore, given the scope of the psychological consequences of the attacks, services may not be avail- able to all who need more intensive intervention since this program is not open to the general public as is Project Liberty. As noted earlier, the U.S. Department of Education through its Project SERV program provided $4 million directly to the New York City Board of Education. Experts in the area of children's mental health advised the city's Board of Education on the types of responses to expect from students, teachers, and families and how best to coordinate the use and training of mental health professionals responding in New York City school communities. The experts also will
CURRENT INFRASTRUCTURE 89 help to develop a plan for the appropriate and efficacious use of Project SERV funds (U.S. Department of Education, 2001~. The mental health response provided by Project Liberty and others was unprecedented in its scope and focus. Concerns that have been noted about this mental health response are similar to those voiced after the Oklahoma City bombing. These concerns include the lack of qualified mental health professionals trained in disaster mental health, the lack of a developed infrastructure for rapid implementation of a broad-based pub- lic mental health plan, limited knowledge about what interventions may be most effective, and limited funding for long-term intensive mental health care. Responses in the Washington, D.C., Metropolitan Area After the attack on the Pentagon, the number and diversity of juris- dictions involved made responding to psychological consequences par- ticularly complex. The Pentagon is located in Arlington County, Virginia, and the attack involved a number of nonmilitary individuals (e.g., pas- sengers on the hijacked plane). As discussed earlier in this chapter, the local area government generally has responsibility for the overall response to disasters within its jurisdiction. The Pentagon is, however, operated under the authority of the Department of Defense, with its own command structure and health care system (see above). As in other disasters, there was outpouring of generosity from individuals wanting to contribute to response; mental health providers from both the public and the private sector volunteered their time to assist. As with the response in New York City, the Red Cross played a cen- tral role in the provision of services immediately after the attack to both survivors and emergency responders. The immediate response by the Red Cross was managed by local Red Cross leaders; national-level leaders as- sumed leadership for the response once they were able to get to the area (closure of all area airports hindered their ability to reach the scene). Psy- chological support services were provided at the attack site at the Penta- gon and at Dulles airport, but shortly after the attack, these multiple sites were consolidated into the Pentagon Family Assistance Center, which was based in a nearby hotel. The Department of Defense rather than the Red Cross as would typically be seen with aviation disasters led this effort in order to ensure that federal security concerns and the needs of criminal investigation could be met (Huleatt et al., 2002~. A source of confusion during the immediate response was the chang- ing security environment at the site of attacks. This affected who was per- mitted to provide services at the Pentagon staging area. The diversity and
90 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM number of agencies and individuals who responded immediately after the attack led to uncertainty about who was in charge and to some dupli- cation of efforts since different agencies were unaware of the services of- fered by others. Similar to past experiences, another issue that arose was inconsistency in the credentials and experience of mental health provid- ers (Metropolitan Washington Mental Health Community Response Coa- lition, 2002~. Longer-term responses quickly became active. The Military Health System of DoD established an ongoing program, termed Operation So- lace, designed to provide mental health services to active duty service members, Pentagon employees, and family members in order to mini- mize any long-term psychological consequences of the attack. This pro- gram was based in part on the experiences of Project Heartland in Okla- homa City and focused on four different levels of intervention: community, unit or workplace, primary care, and specialty mental health clinics (Hoge et al., 2002~. It was characterized by direct outreach both in the workplace and in primary care visits, during which individuals thought to have possible psychological consequences were referred for further care. Operation Solace was responsive to needs for confidentiality and sought to avoid "premature medicalization" of normal reactions to the traumatic experience of the attacks (Hoge et al., 2002~. Several community-based counseling services were established through the FEMA-SAMHSA CCP in both Washington, D.C., and north- ern Virginia. One of these, the Community Resilience Project of Northern Virginia, was formed based on FEMA grants to a number of the affected counties in Virginia. These programs remain active today and address distress responses related not only to the attack on the Pentagon but also to the anthrax attacks, the war in Iraq, and the general threat of terrorism. This program provides services consistent with the CCP model of re- sponse, seeking to normalize reactions to traumatic experiences and fo- cusing on community outreach, supportive counseling, education, and referrals for other forms of assistance when needed. After the September 11, 2001, attack, the Community Resilience Project in Arlington County conducted community support meetings at which individuals could share their experiences of the attacks and also identified people in need of ser- vices and provided education by going door-to-door in the community and presenting to groups. None of these efforts have been systematically evaluated for their effectiveness because the funding provided to estab- lish the Community Resilience Project of Northern Virginia did not in- clude support for evaluation. A similarly designed CCP-funded program was established in the District of Columbia. This program, called Project DC, is ongoing, and provides individual counseling, support groups, outreach, and education.
CURRENT INFRASTRUCTURE 91 Approximately 20 ongoing education and support groups for youth are based at recreation centers and boys and girls clubs, and focus on the relationship between anger and fear. Project DC addresses both the indi- rect and direct victims of the attack on the Pentagon, the anthrax attacks, and the sniper attacks of October, 2002: those who were injured or knew someone who was injured or killed; those whose workplace or school was evacuated during any of these events; those experiencing economic ef- fects due to terrorism, particularly low-income immigrants; and those af- fected by ongoing tension related to the risk of terrorism in Washington, D.C. (personal communication, Shauna Spencer, Washington, D.C., De- partment of Mental Health, May 1, 2003~. Project DC, like Project Resil- ience, has been unable to evaluate its efforts given limitations in funding. A central weakness in the response to the September 11, 2001, terror- ist attack on the Pentagon was related to issues of command structure and communication among the different agencies and individuals respond- ing. Although many services were provided, the efficiency and effective- ness of response were hindered by the lack of a central contact point to direct the response; inadequate communication between and among ci- vilian and military agencies contributed to parallel services and duplica- tion of efforts (Metropolitan Washington Mental Health Community Re- sponse Coalition, 2002~. Response to Anthrax Attacks in the Fall of 2001 The anthrax attacks that occurred during the fall of 2001 highlighted a number of unique issues that require the consideration of those respon- sible for responding to psychological consequences. Because the anthrax events were not considered a national disaster, the FRP was not invoked. Instead, the National Oil and Hazardous Substances Pollution Contin- gency Plan (National Contingency Plan) dictated the federal response. This plan is invoked for occurrences such as oil spills and does not specify clear priorities or responsibilities for responding to psychological conse- quences. The unique jurisdictional nature of the anthrax events in the Washington, D.C., metropolitan area made responses particularly com- plex. The Washington, D.C., Department of Public Health and Metropoli- tan Police Department were activated, as was the federally operated United States Capitol Police Department, which has jurisdiction over the Capitol building complex (and some, but not all, of the surrounding resi- dential areas), where some of the contaminated letters were received. In addition, the involvement of the entire United States Postal Service brought the issue under federal jurisdiction. The role of the CDC, the cen- tral public health agency in the United States, was unclear. These overlap- ping jurisdictions resulted in confusion about the locus of responsibility
92 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM and created uncertainty among the public and the affected workers about how the event as a whole was being addressed and how potentially ex- posed individuals should obtain assistance. Because a bioterrorism attack with the anthrax bacteria was unique in the experience of most responders, there was some initial uncertainty con- cerning who should receive testing or prophylactic treatment with antibi- otics. A lack of counseling services to address anxiety and fear in indi- viduals who went to testing centers but were not given prophylactic treatment has been noted as a weakness in the response to the psychologi- cal consequences of the anthrax attacks (Metropolitan Washington Men- tal Health Community Response Coalition, 2002~. Concerned members of the public overwhelmed the resources of public health departments throughout the country. Many public health departments have provisions to set up emergency hotlines to provide information in such circum- stances, but they are not equipped to provide supportive counseling. Project DC does provide outreach and counseling to those affected by the anthrax attacks, with special emphasis on the Ward 5 area of the city where the Brentwood Postal Facility is located. Prior to the reopening of the facility, Project DC staff members went door-to-door to approximately 4700 residences in the neighborhood to address concerns related to the fumigating and testing for anthrax in the facility (personal communica- tion, Shauna Spencer, Washington, D.C., Department of Mental Health, May 1, 2003~. However, Project DC did not become active until March 2002. Resolving the jurisdictional issues and psychological service needs highlighted by the anthrax events is centrally important in preparing for future responses to both actual and hoax events. GAPS IN THE CURRENT INFRASTRUCTURE Despite the relatively successful mental health responses by Project Heartland, Project Liberty, and others, there are gaps in the infrastructure that require attention. These gaps can be classified into five general areas: · Coordination of agencies and services · Training and supervision · Public communication and dissemination of information · Financing · Knowledge- and evidence-based services Although these distinctions are somewhat artificial and there is some degree of overlap between categories, they are useful in that they point to specific areas for improvement.
CURRENT INFRASTRUCTURE 93 Coordination of Agencies and Services Coordination of services includes the organization and management of different types of services to individuals with different needs and to the same individuals over time as their needs change. It also encompasses the coordination and training of service providers, communication between different levels of government, and integration of various sources of fund- ing. Coordination of services is a crosscutting issue that affects all levels of psychological response. Specific issues of coordination that have been identified include questions of command and control and the role of di- . · . verse service provlclers. In the immediate aftermath of a terrorist attack, confusion exists re- garding jurisdiction and responsibility for the mental health response, particularly in cases where different authorities overlap such as at the Pentagon. Overlap in activities between numerous agencies and volun- teers leads to conflict and lack of a clear command structure. The perception of who should provide responses for psychological needs is often limited to mental health professionals. However, the popu- lation of potential providers may also include health care providers, faith- based professionals, educators, and other members of the community. There is also a need for social services in general since psychological con- sequences of terrorism may be related to indirect contributors such as economic hardship from losing a job or housing displacement from physi- cal destruction. Current mental health response plans and funding mecha- nisms are often limited to crisis counseling and outreach and do not specify who will be responsible for making sure that the breadth of popu- lation-based needs are addressed. Questions regarding who has responsibility for various aspects of the mental health response must be answered prior to the chaos of the imme- diate aftermath of a terrorist attack. Similarly, beyond the issue of who is responsible, all relevant support agencies and organizations must have established, defined, and well-understood roles and an appreciation of the necessity of their participation prior to the event so that the overall response can be facilitated. To this end, further research that investigates the sources and specific results of the widespread lack of coordination may be useful for identifying solutions and planning future responses. Training and Supervision Reciprocal licensing across states is a concern. Red Cross Disaster Mental Health Services providers are required to be licensed, and other volunteers often have training and credentials but may not have licensure in the states where a disaster occurs. The practice in NDMS, in which
94 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM providers are automatically federalized when activated, is a potential model to adopt. It would be necessary to have a reliable and comprehen- sive system for tracking mental health professionals; this system would have to consider specific training or experience in disaster response. The specific training of providers has also been identified as a prob- lematic issue. Mental health professionals responding to terrorism events frequently do not have disaster training or experience. This results in a shortage of skilled mental health providers and increases the likelihood of ineffective, inadequate, or even harmful treatment for survivors. In addition, the FEMA-CMHS CCP generally relies on unlicensed provid- ers. There is a need for structured supervision of such individuals (APA Task Force, 1997~. Care should be taken to ensure that any tracking sys- tem and/or standards that are implemented remain flexible enough so that they do not impede a rapid response to psychological needs. Public Communication and Dissemination of Information Communication activities are especially problematic in the area of pre-event public education; because this type of intervention must occur prior to an event, it cannot be made part of disaster response plans. Com- munication will also be essential during and after chemical, biological, radiological, and nuclear terrorism events. Because of shared jurisdictional responsibility, the central authority for communication may be unclear, and it is therefore necessary to coordinate communication efforts to di- minish mixed messages and confusion on the part of the public. This co- ordination of communication efforts will be most effective if the neces- sary relationships are established prior a terrorism event. Furthermore, evidence-based strategies should be used to design public communica- tion messages and mechanisms in some cases, the evidence-base is lack- ing and research in the area should be encouraged. Pre-event public education should not only focus on minimizing panic reactions, but also contain useful information about risk assessments, ap- propriate action, and need for prophylaxis. As described in Chapter 2, events are more traumatic when they are unexpected, which implies that increased public awareness could mitigate the psychological conse- quences of terrorism events. However, a tension exists between transmit- ting useful information, and raising unrealistic fears or promoting com- placency in the event of a terrorist attack; additional research is needed in this area. Strategies for successfully increasing public awareness prior to an event include hotlines; prepared statements containing facts, plans, and risks; and pre-event identification of a respected spokesperson (HHS, 2002~. The Internet is also increasingly used by government agencies and other organizations for public communication about terrorism prepared-
CURRENT INFRASTRUCTURE 95 ness. One example of pre-event public education aimed at reducing psy- chological distress took place recently in Iowa. In collaboration with the Iowa Department of Public Health, on February 16, 2003, all newspapers in the state included a six-page supplement on smallpox with their Sun- day paper (or in a later issue if no Sunday paper was distributed by that newspaper). Financing The potential of financial support for responding to the psychological consequences of terrorism has increased recently. For example, the Public Health Security and Bioterrorism Preparedness and Response Act, signed into law on tune 12, 2002, provides $4.6 billion to address bioterrorism issues; $1.6 billion of that amount comprises grants to states to improve bioterrorism and public health emergency response, and some portion of those grants will be used for counseling and training in disaster response. However, mental health is not included in any of the focus areas for the new bioterrorism funding, making it difficult for states to concentrate sig- nificant resources on preparedness for psychological consequences. In addition, neither SAMHSA or NIMH received new funding in fiscal year 2003 designated for preparedness and planning for the psychological con- sequences of terrorism.7 Government funding for mental health care is time-limited and fund- ing for the evaluation of interventions has been specifically excluded. In addition, much federal support is limited to counseling interventions. Some individuals will require longer-term care that is beyond the scope of the crisis counseling traditionally provided after disasters. This type of care should be part of the overall response plan. The provision of care in Oklahoma City continued for a number of years with support from foun- dations, charities, and the American Red Cross. Special provisions have similarly been made for the World Trade Center to extend the period of funding for care. Yet in the event that terrorist attacks become more fre- quent, these unstructured and somewhat unsystematic ways of dealing with the financing of psychological needs will be inadequate. Further- more, current plans for response fail to address prevention strategies in a systematic way. Currently, funding often flows through contracted agencies due to familiarity and accountability. Outreach is then limited to an agency-af- filiated community base, which may exclude important nontraditional 7 Congressional Consolidated Appropriations Resolution and Accompanying Conference Report, 2003. U.S. 108th Congress, 1st session. H.J. Res. 2.
96 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM providers such as faith-based workers. In addition, some private practi- tioners, who may have the relevant experience, are unaffiliated and can- not access grant monies. The assumption is often made that long-term mental health services will be provided largely as charitable contributions, through either probono volunteers or extremely low reimbursement. It is more realistic, however, to ensure that funding for long-term mental health care following terrorism events be available to a range of providers at reasonable reimbursement rates. This will make it more practical for many with appropriate skills to be included in the pool of providers. Knowledge- and Evidence-Based Services One of the most critical problems in designing a plan to respond to the psychological consequences of terrorism is that the knowledge and evidence base to inform planning, policies, and practice is sorely lacking. We do not know conclusively what interventions work and thus what to recommend as best practices. In some cases, practices that are known to be ineffective or inaccurate continue to be recommended. Specific areas in which evidence is lacking include the following: · Models for community recovery and resilience building are lack- ~ng. · Early interventions after disasters and terrorism events require further development and evaluation. · Many preparedness programs and responses are driven by patho- logical models of mass panic in reaction to crisis. Some research has dem- onstrated that this likely is not accurate and results in a missed opportu- nity to call upon community members to enhance responses. · Additional evidence is needed to ensure that all public communi- cation strategies and education or training programs are effective. · There is a lack of knowledge on how to prepare and "vaccinate" a population against the fear that results from a terrorist attack. · The psychological impact of a terrorist attack with weapons of mass destruction remains largely unknown, and current response capa- bilities for such an event are likely to be inadequate. SUMMARY Although a variety of programs and services are in place to respond to psychological issues in a crisis or disaster, issues regarding the coordi- nation of agencies, organizations, and services; training and supervision of providers; communication and dissemination of information; financ- ing of services; and lack of an evidence base to direct these services pose
CURRENT INFRASTRUCTURE 97 serious challenges to the nation's ability to effectively and efficiently pro- tect the public's mental health. The infrastructure is not currently focused on planning and preparedness for the psychological consequences of ter- rorism in the United States. Systematic surveillance for psychological con- sequences in the population and other strategies for preparedness are not conducted as they are for other important public health issues. The lack of universal preparedness is due, in part, to the traditional lack of importance placed on mental health issues, a predominant focus on response to incidents rather than preparation for them, and a lack of clear evidence about what can be done to prepare effectively. An increased recognition that the psychological consequences of terrorism constitute a serious and immediate public health issue should help to shift efforts to- ward preparedness and planning. This new focus not only must include those traditionally seen as responsible for responding to psychological needs, but also must include the range of systems and providers respon- sible for the health and well-being of the public, such as primary care, schools, the workplace, and others that currently are not fully included in responses. A terrorism event will have broad impact on the public from those directly to those remotely affected. The focus of response must move beyond traditional clinical services that most people do not require, which are too costly and time consuming to provide, to a broad public health approach that will increase resilience and prepare individuals psycho- logically for terrorism events. Finding 3-1: Many mental health professionals do not have specific knowledge with regard to disaster mental health. Training and edu- cation emphasizing psychological consequences and methods for response should be provided to professionals within mental health fields, including school-based mental health practitioners such as school counselors, school psychologists, and school social workers. Finding 3-2: A broad spectrum of professional responders is neces- sary to meet psychological needs effectively. Those outside the mental health professions, who may regularly interface with the public, can contribute substantially to community healing. These professionals include, but are not limited to, primary care provid- ers, teachers and other school officials, workplace officials, govern- ment officials, public safety workers, and faith-based and other community leaders. However, these professionals will require knowledge and training in order to provide effective support. Basic knowledge of psychological reactions, as well as training in sup-
98 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM port techniques and recognizing serious symptoms that necessitate referral, should be provided. Finding 3-3: The workplace is a newly recognized and important environment in which to address public health planning for the psy- chological consequences of terrorism. Some examples of new occu- pationally exposed groups include construction workers, postal workers, utility workers, public health workers, and children and teachers in schools. Implementation of universal preparedness is required for the workplace, but specific considerations will be needed for critical occupational sites. Recent terrorism events have created new workplaces and categories of responders and have ex- posed traditional first responders to new levels of job-related stress and risk. Finding 3-4: Research following terrorism events presents a multi- tude of practical and ethical challenges. Utilizing findings from re- search on other traumatized populations is not an adequate substi- tute, and support of disaster-specific and terrorism-specific research is necessary to provide information pertinent to the population and its needs for intervention. This research can be facilitated by im- proving cooperation and coordination among federal funding and regulatory agencies as well as by developing the high-quality meth- odology necessary for the conduct of these investigations.