October 29, 2014, marks the two-year anniversary of Hurricane Sandy, the second most powerful Atlantic Hurricane on record and the second most economically costly hurricane in the USA, with Katrina having the dubious distinction of first.
"Superstorm Sandy," as it was called, rained vast devastation along the northeastern coast of the United States. Mental health problems (as well as the abuse of alcohol and drugs) in the wake of a disaster are well known. This is because disaster, however generated, threatens to undermine both the physical and emotional underpinnings of a community. Perhaps some of the greatest knowledge about disaster mental health was sadly gained after the attacks of 9/11 (1). In the 13 years since then, because of Katrina and other natural disasters in this country, a great deal more has been learned about what to expect and what can be done to help disaster ravaged people and communities (2). Yet too many of the lessons learned have not been adopted to the extent their scientific evidence warrants.
The NYS Office of Mental Health (OMH), very shortly after submitting extensive documentation to FEMA, received an $8.2 million, 60-day initial services grant to provide mental health services to impacted individuals and communities (3). This was followed by a second award for continued services. Together, the two FEMA grants, totaling nearly $50 million, funded mental health disaster services for Hurricane Sandy survivors in New York City, Nassau and Suffolk Counties (Long Island), and Westchester and Rockland Counties (up the Hudson River) for 16 months before closing down on February 28, 2014. We called the mental health disaster program Project Hope. I was the principal investigator on both grants.
At the heart of a FEMA mental health grant is what is termed the CCP, or Crisis Counseling Program. The CCP delivers: 1) outreach in the impacted communities, 2) education on common disaster reactions and coping skills, and 3) brief crisis counseling. There is no treatment of mental health conditions covered by the CCP, nor has there been in the decades this program has been in existence. Nor does the CCP use field-based electronic means of collecting information and consequently, gathering live-time information and thus providing immediate, informed triage capability for impacted individuals in the disaster zone.
Within weeks of OMH receiving the FEMA grant, approximately 800 crisis counselors (representing approximately 600 full-time equivalents) were hired by local, not-for-profit community agencies, trained, and then deployed to impacted communities. Project Hope served over 406,000 individuals. Over 50 percent of those served sought individual or family crisis counseling. Just under 20 percent of individuals participated in group crisis counseling sessions. Approximated 30 percent participated in group public education sessions.
New York State has been the fortunate beneficiary of FEMA CCP funding totaling approximately $213 million since 9/11. These grants have provided great humanitarian and lifesaving support. Because the CCP is a statutorily defined federal program, even needed changes are difficult to achieve. Yet responsible government needs to overcome bureaucracy and inertia when so much is at stake. The two-year anniversary of the storm is a time to advocate further for the disasters that surely lie ahead. Here, I offer ideas on how to improve upon what has been done to date, thereby enhancing the services that future impacted communities throughout the country might receive.
This article describes a set of technology and mental health service enhancements to the federal Disaster Crisis Counseling Assistance and Training Program proposed by New York State to FEMA (and SAMHSA as its advisor) after Hurricane Sandy, but were not approved and thus not implemented. To our knowledge, no such collection of new and necessary services had been sought by other states or Federal agencies at that time, or since.
What more Could Have Been Done?
The NYS county and state governments and participating providers have much to be proud of in terms of the massive scope and volume of Project Hope services delivered. But too many questions remain: Were impacted individuals adequately identified? Was onsite information collected by counselors promptly and accurately collected and disseminated? Were the mental health and substance use disorders triggered by the disaster properly detected to allow immediate triage to care? What were the rates of these conditions and the demographics of those who became ill? Did those in need of treatment engage and remain in care, and what were their clinical outcomes? How can we begin to consider the costs and benefits of the various components of disaster mental health, especially in term of enabling impacted individuals to return to their everyday lives and functioning?
The enhanced services we proposed for Project Hope were meant to answer these questions and concerns. They fell into two main categories: technology enhancements and clinical service enhancements. The latter included what could be done by crisis counselors embedded in impacted communities as well as what could be provided in mental health clinics and schools serving those communities.
Technology Enhancements
To date, crisis counselors still collect all CCP service information the old-fashioned way -- by paper and pencil. The information they collect records the number of services provided, so the government knows how many people were served in each of the three approved services noted above. The continued services grant allows for collecting additional information on the degree of distress experienced by adults and youth who are seen (in fact, these forms were developed by New York in the 9/11 crisis program, Project Liberty). This paper-based system requires the additional step of manually inputting the data into electronic databases, with its extra burden, cost, and potential for error.
OMH proposed that Project Hope, instead, employ smart phones or wireless pads to record services, with protections to ensure confidentiality. This basic technology advance has been used in disaster and other health delivery settings in low resource countries -- so why not ours? Moreover, in partnership with the New York City Department of Health and Mental Hygiene (DOHMH), we proposed that crisis counselors use a brief, feasible triage set of questions (special thanks to Dr. Carol North) to determine the degree and nature of exposure by the survivor, followed by brief screening instruments for clinical depression, PTSD, and alcohol and drug abuse for those whom the triage questions identified. Screening tools can determine the type of stress a person has experienced and help in referral for care. Furthermore, by electronically tracking the referral participating government agencies could also determine, for the first time, to degree to which potentially disabling conditions were treated and the outcomes of care.
Field-Based Enhanced Services
Mental health (and health) professionals know how difficult it can be for impacted individuals to seek services as well as stay in treatment. Lack of engagement and retention as well as lack of adherence with treatment may be the greatest reasons why people do not get well. The use of problem solving and motivational enhancement interventions to individuals and families has been shown to increase rates of people going to and adhering with medical treatments. Hence, we proposed that Project Hope crisis counselors receive proper training, and under the supervision of licensed professional staff, deliver these interventions in their field work.
OMH also proposed that crisis counselors be permitted to sustain contact with impacted individuals and families who screen positive for a disorder; we suggested modified (i.e., limited) care management until referral is completed and a person engaged in care. The important relationship established with a field-based counselor can be used to help people get to and stay in care that we know often does not happen.
Disaster experts also know from Katrina as well as international work that interested individuals and families can benefit from a feasible and effective mind-body intervention in which a simple breathing technique is taught to survivors. Controlled breathing at six breaths a minute, with mild resistance on exhalation, can be taught to adults and even young children producing substantial reductions in the stress response (by reducing heart rate, blood pressure, and the fear response); this is accomplished by activating the parasympathetic nervous system (which counteracts the adrenergic -- 'fight/flight' -- nervous system). This technique would be taught only to those interested.
Clinic/School-Based Enhanced Services
Previously, with the support of FEMA and SAMHSA, OMH already had implemented a limited set of cognitive behavioral therapy (CBT) services during Project Liberty, the 9/11 grant. More was needed. Project Hope proposed enhanced services for those individuals, adults and youth, whose needs could not be adequately served by field-based crisis counseling services alone.
For adults, Project Hope sought to deliver CBT for depression, PTSD, and complicated grief. We also proposed Screening, Intervention and Referral for Treatment (SBIRT), an evidence-based intervention for problem drinking and substance abuse; SBIRT has been used in primary care and emergency settings with notable results (4). We also wanted office-based mental health professionals to be trained to offer the Mind Body Breathing technique described above.
For youth, Project Hope sought to deliver CBT for trauma as well as CBT for depression -- both evidence-based practices for youth, but are not in sufficient supply to meet the needs of this disaster impacted population. OMH also proposed Teen Intervene, a program to help youth with emerging substance use problems. A limited program for 22 pre-school programs, delivered by Bank Street, NYC, was also a part of the enhanced services proposal to meet the needs of these children affected by Hurricane Sandy.
What More Needs to Be Done for Disaster Mental Health
The enhanced technology and clinical services OMH proposed to FEMA (and SAMHSA) were grounded in scientific evidence and experiences elsewhere. We were unable to advance the levels of disaster mental health care to better meet the needs of survivors and communities -- actually, what they are owed. OMH and the New York City DOHMH were not successful in gaining approval for technology and service enhancements. An important opportunity to improve the landscape of mental health disaster response in this country was not accomplished.
To honor those impacted by Hurricane Sandy at this two year mark, as well as those impacted by many other natural and human-made disasters since 9/11, government agencies need to do more of what is proven -- and needed. When, not if, the next disaster strikes, may this article serve as a record of what can be done.
Despite the nearly $50 million spent on Project Hope (5), we do not know what disorders emerged, nor what treatments were delivered -- and with what outcomes. Government is not meeting the basic standard of any industry, which requires assessing and reporting on the cost benefits of its substantial investment. Moreover, that services known to work for impacted individuals were not delivered seems clinically irresponsible. Finally, an unusual opportunity was missed to harness the expertise of New York City, State, and national experts to build and implement the capacity for electronic capture of field-based information, leaving us still with paper and pencil approaches in 2014, and shockingly behind third world countries that already are using smart phones.
Science has a long-standing black eye for what is called the "science to practice" gap: the extraordinary time delays in closing the gap between what we know and what we do. There is a still a prominent gap to be closed for disaster mental health care.
Let the Project Hope experience, and its recommendations, be a guide for when the next catastrophic event strikes.
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Acknowledgements: This work was done with a remarkable team that included Ken Gnirke, Sheila Donahue, Carol Lanzara, Carol Packard, and Joseph Bucci.
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References:
1.Sederer, LI, Lanzara, CB, Essock, SM, Donahue, SA, Stone, JL, Galea, S. Lessons learned from the New York State mental health response to the September 11, 2001 terrorist attacks. Psychiatric Services 62:1085-1089, 2011.
2.Sederer LI. Mental Health and Hurricane Sandy: What can we expect, what can we do? The Columbia University Mailman School of Public Health. November 5, 2012, Reprinted in The Huffington Post on November 7, 2012.
3.Sederer, LI. FEMA Approves $8.2 Million for Post-Sandy Mental Health Outreach, TheAtlantic.com, November 19, 2012.
4.Sederer, LI, Goplerud, E: Problem Drinking, The Huffington Post, October 9, 2009.
5.Crisis Counseling Assistance and Training Program Regular Services Program Final Report
May 29, 2013 -- February 28, 2014 FEMA (Available upon request from the NYS OMH).
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Dr. Sederer is a psychiatrist and public health physician. The views expressed here are entirely his own. He takes no support from any pharmaceutical or device company.
www.askdrlloyd.com -- Follow Lloyd I. Sederer, MD on Twitter: www.twitter.com/askdrlloyd