Dr. Sederer, Ms. Lanzara, and Ms. Donahue are affiliated with the New York State Office of Mental Health, Albany, New York, where Mr. Stone was formerly affiliated.
Dr. Essock is with the Department of Psychiatry, Columbia University, New York City, and the New York State Psychiatric Institute.
In the aftermath of the September 11, 2001, attacks on the World Trade Center, the public mental health system in New York City and neighboring counties mounted the largest mental health disaster response in history. The programs and services delivered fell under the organizational umbrella of what the New York State Office of Mental Health (NYSOMH) called Project Liberty. In this report, we first summarize the development of Project Liberty, as funded by the Federal Emergency Management Agency (FEMA). Second, we describe what worked and what did not in Project Liberty, citing published reports as well as describing our collective and firsthand experience as the primary New York State (NYS) and New York City officials and scientists who led the disaster response and its analyses. Third, we offer what we consider the lessons learned for future mental health disaster responses. Although every disaster—and every community and governmental entity—is unique, there are clear and universal lessons that can be derived from the events of September 11, 2001, and the supports and services offered by Project Liberty. A formal report on Project Liberty has already been published (1), making this Open Forum a complementary reflection on this disaster and the associated mental health response.
Immediately after the September 11, 2001, attacks, President George W. Bush declared New York City and its ten surrounding counties (where many commuters to the city live) a federal disaster area. The declaration made these areas eligible to receive FEMA-funded programs, including the Crisis Counseling Assistance and Training Program (CCP), which supports short-term interventions for individuals and groups experiencing psychological sequelae of large-scale disasters. FEMA awarded Project Liberty, New York's CCP, over $155 million, of which $137 million was expended over three years. NYSOMH oversaw the design, implementation, and evaluation of Project Liberty, with services administered through the city, ten surrounding county governments, and more than 200 nongovernmental mental health provider organizations (NGOs). Project Liberty was implemented in two phases: the emergency Immediate Services Program from September 12, 2001, to June 12, 2002, and the nonemergency Regular Services Program from June 15, 2002, until December 31, 2004.
Overall, Project Liberty's immediate and regular services programs provided direct crisis counseling, education, and outreach services to nearly 1.5 million affected individuals diverse in age, race, culture, education, primary language, socioeconomic status, other special needs, and levels of psychological distress. More than 750,000 individuals received crisis counseling, and nearly 740,000 individuals were served with public education. Approximately 89% of those served were in New York City, where 9.7% of all Project Liberty services were delivered to direct victims (family members of the deceased and individuals who were injured or evacuated or whose homes sustained major damage), 11% to World Trade Center rescue workers, and 6.3% to disaster-displaced employed or unemployed.
Children represented 20% of those who received Project Liberty counseling services (2). Project Liberty community-based agencies provided nearly 40,000 children with individual counseling at schools and in other community settings. Project Liberty also funded counseling and other services to an additional 36,337 New York City schoolchildren through a crisis counseling program that was operated by the city's Department of Education. Through collaborations with the NYS Office of Children and Family Services and the NYS Office of Temporary and Disability Assistance, the project attempted to reach children and families in welfare and foster care settings, families with youths remanded to the juvenile rehabilitation system, and children in youth development programs.
All Project Liberty services were provided at no cost to recipients (3). Because some of those affected developed serious and persistent mental disorders, beyond the normative and transient distress and stress that follows a disaster (4), Project Liberty requested and obtained federal approval in 2002 for expanded trauma-related services (referred to as enhanced services) that were brief, intensive, and evidence-informed interventions (5).
Enhanced services for adults included cognitive-behavioral and grief interventions designed to target an array of disaster-related problems (5). The cognitive-behavioral intervention for adults included techniques for recognizing postdisaster distress; developing skills to cope with anxiety, depression, and other symptoms; and teaching cognitive reframing. The bereavement and grief program included information about natural grieving processes and traumatic grief symptoms (6). Both interventions were supported by manuals, included homework materials, and were designed to consist of ten to 12 sessions.
Enhanced services for children included two treatment manuals (7). For children ages five to 12, the Child and Parent Trauma-Focused Cognitive-Behavioral Therapy Treatment Manual was adopted, a treatment with a high level of empirical support (8,9). For adolescents (ages 13–21), the Trauma/Grief-Focused Group Psychotherapy Program (10) was modified for individual use. Both treatments included psychoeducation, affect regulation, relaxation training, cognitive restructuring, and gradual exposure techniques.
High level of interagency collaboration
The magnitude of the attacks required substantial interagency collaboration at the municipal and state levels. This collaboration was facilitated by two principal factors. First, there was a remarkable shared sense of purpose in the aftermath of the attacks. Second, the interagency work of Project Liberty was built on years of collaboration among city and state governments and NGOs. NYSOMH also had established effective relationships with federal agencies from earlier disasters, such as plane crashes and floods.
In NYS, each county (New York City includes five counties) has a mental hygiene commissioner (encompassing mental health and addictions) who is a mental health professional. County commissioners and their respective staff met regularly with NYSOMH to build Project Liberty; these mental health leaders also had frequent joint public appearances with local providers as well as with political and civic leaders. Issues such as funding and service delivery were addressed openly and publicly, avoiding suspicion of “back room deals” and supporting new policies and procedures needed to serve the unique affected populations that the disaster created. Also instrumental to success was immediate and central control. NYSOMH opened a command center in Albany (the state capital, located 150 miles north of New York City). This center, staffed 24 hours a day from the morning of September 11, 2001, and sustained for four weeks, processed all requests, contacts, and activity of any sort, establishing the foundation for what followed.
Engagement of local NGOs to provide services
Project Liberty quickly became a complex collaboration among the state mental health authority, local governments, and nearly 200 NGOs. NYSOMH held monthly technical assistance meetings with New York City and county project coordinators to review provider planning and operations, contracting and budgeting, crisis counselor recruitment and training, and federal program requirements. New York City and other county project coordinators working for Project Liberty then communicated information from these meetings to the NGOs.
Through these new and often uncharted mechanisms, city and county mental health departments developed and implemented local plans of service and recruited, engaged, and oversaw the NGOs that provided services throughout the disaster area. Priority target populations—defined geographically and demographically—were identified early on, and providers who demonstrated access, capacity, and cultural competence to work with them were brought into the project as quickly as possible. Some providers were included because of their links to specific cultural, ethnic, or racial groups, and others because of their expertise in working with specific populations such as children, elderly persons, or people with physical or mental disabilities. Providers who could effectively reach uniformed officers, rescue and recovery workers, and family members were particularly recruited, including the New York City Fire Department and the Mayor's Office of Labor Relations, which worked with city employees and their families.
Media and public education
Awareness of the potential psychological effects of large-scale traumatic events and understanding how to cope with these events were low in the general population in 2001. The stigma associated with mental illness, and by extension mental health services, in American society added to the problem of delivering services to those in need (11). NYSOMH therefore launched a media campaign to raise public awareness of disaster distress and inform the public that free counseling services were available and not stigmatizing (“Even Heroes Need to Talk” was one campaign slogan). State and local multilingual media campaigns were implemented. The city disseminated messages in subways, on buses, and in newspapers and magazines; the state supplemented the city's efforts with Internet, radio, and television advertising (12). Messaging alerted the public to counseling and referral services through 1-800-LIFENET, a preexisting toll-free, 24-hour, multilingual mental health hotline. The campaign also conveyed that postdisaster stress symptoms can appear not only immediately after a disaster but many months later. This message was, in retrospect, an important tool in reaching out to secondary victims such as disaster rescue-and-recovery workers.
Surveys conducted after the attacks support the success of these mass media efforts. By January 2002, one in four New Yorkers reported knowing about Project Liberty, with a majority reporting a positive image of the program (13). By the one-year anniversary of the attacks, over 50% of New Yorkers surveyed reported knowing about Project Liberty, and 33% reported that they had called or were considering calling LIFENET (13). Notably, program “branding,” now a part of the CCP, was innovative and used extensively in Project Liberty; it had a clearly recognizable program name and logo, a Project Liberty Web site, and tailored psychoeducational materials.
Project Liberty was the first of FEMA's CCPs to include an evaluation component to improve mental health disaster response capabilities, document the program's implementation, and enhance accountability. FEMA now routinely includes program evaluation in the CCP model; moreover, its recommended staffing includes evaluation and data entry coordinators. Forms and processes developed by Project Liberty also have been incorporated into the CCP, including encounter logs. In addition, a participant feedback survey, adult assessment and referral tool, and service provider feedback survey have been added to the CCP data toolkit, although they are optional for current grant recipients. Project Liberty also introduced using service delivery data to improve ongoing program operations. These evaluations and their findings were published on the five-year anniversary of the attacks as part of the September 2006 issue of Psychiatric Services (3,5,14–25).
Mental health professionals' experience working with trauma.
The prevalence of trauma in a population unaffected by disaster is known (26), but only in the past decade has trauma become a widely recognized factor contributing to the pathogenesis, maintenance, and treatment of a broad range of mental disorders. Project Liberty thus encountered widespread lack of experience in crisis intervention and trauma-informed care among mental health professionals. Although this limitation has no doubt lessened, trauma-informed care needs to be a core competency in disaster response. Similarly, there were limits on the number of trained, available, and linguistically and culturally capable mental health professionals with experience in trauma-related care. This slowed the expansion of existing mental health services for specific populations.
Flow of funding and provider payment for staff and services.
Critical and prompt decisions had to be made about how to fund a large number of service providers across many locations. NYSOMH and the New York City Department of Health and Mental Hygiene decided that a fee-for-service payment method, with existing rates for defined services, was the only viable option for the CCP. Program contracts were thus executed with NGOs only five weeks after the disaster. However, the fee-for-service model required services be delivered before payment could be made. The result was that NGOs had to incur expenses to hire and train staff without startup funding, which posed a cash flow problem, particularly for small not-for-profit agencies. This situation was subsequently eased somewhat by special authorization of advance payments but not without already having substantially strained some agency resources.
Exclusion of coverage for treatments.
What became disturbingly clear in the wake of the September 11 attacks was that treatment was not covered by FEMA. Although this may seem implausible, the model extant was that of crisis response and public education, with FEMA then rapidly transitioning out of an affected community. The September 11 attacks and subsequent disasters (like Hurricane Katrina) have shown how inadequate this model is for executing the tasks required after a major disaster.
Basic treatments, such as sedatives for sleep, tranquilizers for severe anxiety or stress, or antidepressants for more severe depression prompted or exacerbated by the stress of the disaster were not covered by the FEMA grant. Short-term cognitive therapies known to be effective with anxiety, depression, and trauma were not possible to deliver within FEMA's constraints. This substantially limited emergency care that New Yorkers could obtain, although the enhanced services subsequently permitted some cognitive treatments. Treatment remains absent to this day in FEMA-supported services and continues to be an important focus of efforts to change guidelines regulating the CCP program.
Duration of clinical program and follow-up of long-term conditions.
The FEMA model of crisis counseling and public education was, in part, founded on the view that individuals needing additional services would be served by the public (and perhaps private) systems of mental health care. That assumption was wrong. The existing public mental health system in the United States had then, and continues to have, serious limitations in the following areas: access to services, training of the mental health workforce, reliable and comprehensive assessments, provision of evidence-based treatments, continuity and collaboration of care, and a person-centered response (27,28). Individuals whose illnesses require more than the CCP offers—who become persistently ill or disabled as the result of a disaster—will have ongoing treatment (and rehabilitation) needs that the existing mental health system is ill equipped to meet.
Although most individuals will show distress in response to a disaster such as September 11, a proportion of the population will develop a serious mental or addictive disorder (26,29). These disorders, in turn, will demonstrate varying severity and duration. No program mounted in response to a disaster will be able to rely on crisis counseling and public education to suffice for the mental health needs of those affected. Nor can any such program expect long-standing federal funding. An effective public health (and mental health) response to a disaster will therefore require the capacity to identify those at risk of developing a serious or persistent mental illness and ensure their effective referral to existing (albeit overburdened) community-based mental health services (30).
Limitations of existing needs assessment methodologies.
Project Liberty was required to use the federal Center for Mental Health Services (CMHS) needs assessment methodology in grant applications for funding. The methodology aims to estimate the number of victims who will require crisis counseling based on levels of disaster exposure and impact, including number of fatalities, the hospitalized and nonhospitalized injured, and degree of social dislocation (employment and housing losses). However, the September 11 attacks quickly highlighted the limitations of any one formula in anticipating need. The Project Liberty needs assessment could not rapidly determine the numbers of deaths, injuries, and evacuations or the physical and economic damage and destruction. NYSOMH staff conducted extensive research on the number in each loss category, making modifications in the methodology with federal guidance. These data were ultimately cited in the CCP applications and final reports. In fact, the Project Liberty final report concluded that the CCP needs assessment formula cannot effectively predict the impact of a catastrophic, human-made disaster in a densely populated and diverse metropolitan area, nor can this formula be used as a measure of individuals who might benefit from CCP services, particularly the needs of unique populations (1).
Project Liberty was a massive and invaluable resource during the years of rebuilding in the wake of the September 11, 2001, attacks on the World Trade Center. The lessons learned were many, and the following five are of generalizable import for other large-scale crises.
First, the mental health impact of organized large-scale attacks is substantial, varied, and, for some of those affected, persistent. Therefore, an adequate public mental health response needs to be broad based and comprehensive, anticipating a wide range of individual and collective reactions ranging from acute distress to the development of new or recurrent cases of mental and addictive disorder. An organized public mental health response thus must reach large numbers of people in the population whose needs are likely to be heterogeneous and changing in the days, weeks, and months after events of this magnitude.
Second, disaster-related mental health services must include funding for treatment (including focused therapies and medication) in light of the needs of those affected. Education and crisis counseling are not sufficient to meet the needs of those affected. This was probably the central challenge faced by Project Liberty providers.
Third, the mental health community is already limited in its capacities to provide accessible, good-quality care for existing high-prevalence, high-burden disorders, such as mood, anxiety, traumatic, and psychotic disorders, as well as addictions. Therefore, without expanded resources, the baseline mental health system is not capable of meeting the needs after such an event. Because Project Liberty was able, with prompt and fair payments over time, to build on existing mental health system capabilities, an expandable base of financial support is needed to adequately meet the mental health needs of a population affected by disaster (20).
Fourth, ongoing performance evaluation linked to immediate course corrections and additions or changes in programming is essential to disaster responses. The evaluation of Project Liberty, designed early in the process as a key part of the program, proved to be invaluable, clearly pointing to including performance evaluation and improvement in future disaster response programs.
Finally, in our view, Project Liberty, the largest disaster-related mental health effort to date in the United States, was as much of a social effort as it was a clinical one. It was the people who led and delivered the services, and it was the communities, the organizations (government and NGO), and the individuals affected who were determined to keep on going and keep on living despite the damage done that stand as a truly remarkable testimony to people's resilience after such an event. In some respects, appreciating this phenomenon suggests that future public mental health programs may well benefit from including efforts to enhance community resilience (31).