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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

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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.

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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

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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.

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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-

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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

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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-

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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~.

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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).

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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.

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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~.

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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

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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

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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.

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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

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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.

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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

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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-

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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.

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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

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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-

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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.