Highlights of the 2002 Institute on Psychiatric Services

The 2002 Institute on Psychiatric Services, held October 9-13, 2002, in Chicago, drew 1,750 participants to a varied program of more than 300 lectures, symposia, workshops, debates, and poster sessions. Attendance was the third largest in the 54-year history of APA's annual fall conference on clinical care and current issues in service systems—largely public-sector systems. The strong attendance underscores the long-standing commitment of psychiatrists to improving care in the public sector and helping to shape the systems that serve vulnerable populations.

The unifying theme of the meeting, "Community Counts: Creating and Supporting Systems of Care," was also the overriding message of APA president Paul S. Appelbaum, M.D., in his address at the institute's opening session. He called on psychiatrists and patient advocates to aggressively fight the "systematic defunding" of services in their communities, which has resulted in a national crisis in mental health care. "If we don't take action," he said, "there are a lot of others who will—on the opposite side—and they will win." He described the treatment system as "a system in name only," crumbling and fragmented. Unless society is willing to invest more resources in treatment of mental illnesses, he warned, programs and services across the country will continue to shut down and the middle class will begin to experience problems in gaining access to care that are now chiefly faced by the poor and uninsured.

Dr. Appelbaum outlined a five-step action plan that he urged APA members to devote time to each day. First, they should gather data that document the crisis in their state by working with APA district branches and advocacy groups. Armed with real numbers—on provider reimbursement rates that fall below the costs of care, on hospital and clinic closures, and on the high costs of skyrocketing emergency room visits by people with mental illness—they will be ready to sound the alarm. Second, they should meet with local media organizations, such as community newspapers, and show them the numbers, urging them to alert people to the problems in their community.

Third, because not all problems can be solved at once, Dr. Appelbaum recommended the creation of a priority list in each state. Fourth, he urged APA members to find strong allies for the fight, such as the National Alliance for the Mentally Ill and other advocacy and interest groups. The fifth step is to meet with state legislators and local business leaders and show them the data on the true costs of defunding services. Dr. Appelbaum stressed that it is important for business leaders to understand that "the people they are paying to provide care are pocketing the profits while their employees cannot find anyone to treat them."

By taking the five steps, APA members and advocates will prepare a climate for the changes that are needed, Dr. Appelbaum said. The purchasers of care in each state—state governments and major employers—will begin to pressure the insurance and managed care industries for change. He referred his listeners to the APA "Take Action Tool Kit," which he urged them to learn more about on the APA Web site.

Psychiatry as a partner in social change

If the theme of the 2002 institute— "Community Counts"—is of critical importance, then what is the relationship between the psychiatrist and the community? Can psychiatry be reconceptualized as a public health discipline? How can psychiatrists play a role in social change? These questions were the focus of a presentation by Kenneth S. Thompson, M.D., associate professor of psychiatry and public health at the University of Pittsburgh.

To address these questions, Dr. Thompson said that psychiatrists must ask another question: Why are some people healthy while others are not? Research on genes may be a top priority, but the most robust epidemiological finding is that socioeconomic class predicts the burden of mental illness in a community. Remedicalization may have initially gained resources for psychiatry, he noted, but as psychiatry has backed away from engagement in the social world, it has lost resources—and the cuts will continue until psychiatry rejoins "the struggle to speak truth to power" and allies itself with other disciplines and groups that have already begun to undertake social change initiatives.

Dr. Thompson outlined the seven patterns of a healthy community observed by researchers in the new public health movement. A healthy community is a place where there is ongoing dialogue, where diversity is embraced, and where leadership is generated everywhere. The healthy community knows itself and its history. It develops a vision for shaping the future, connects people and resources, and creates a sense of belonging in which each person understands the value of his or her role. These ideas are not incompatible with the efforts psychiatrists undertake with individual patients, Dr. Thompson noted.

Important national and international initiatives to create such communities, to develop "social capital," and to address inequities in health care are under way, but without the participation of psychiatry. Dr. Thompson lamented that psychiatry residents not only are not informed of these efforts but are told not to get involved in social change—perhaps because their teachers remember embarrassing interludes in the 1960s and 1970s when psychiatrists made promises about changing society that they had no expertise to fulfill.

Psychiatry today has little input into important projects such as the creation in many states of "health action zones," Dr. Thompson said. Millions of dollars are being spent on a national movement to tear down and redesign public housing, but psychiatry has no connection to the Department of Housing and Urban Development. Psychiatrists' expertise in helping people to realize their strengths and to find common ground where they can begin to trust and talk to each other and develop long-term meaningful relationships is particularly needed at the community level, where psychiatrists have a natural role to play in bringing groups together for social change.

Dr. Thompson then described community development efforts in Pittsburgh's impoverished Hill District. Many such projects begin with a detailed community health assessment, which departments of public health in every state are required to conduct with local samples of 5,000 residents. When psychiatrists became involved in Hill District neighborhoods, they realized that health departments in every state must have a wealth of information about the health of U.S. communities. However, many departments are afraid to release information, Dr. Thompson explained, because they are small operations. If they made information public showing that a community is near the bottom of every list of health indicators, "the messenger would be killed. The department would be held responsible for fixing all the problems." In addition, only quite recently—and in only two cities—have mental health departments partnered with public health departments to ensure that the mandated surveys include questions about behavioral health.

One way that psychiatrists can work to effect social change, Dr. Thompson said, is to obtain the release of public health data about their communities and "advocate with these data." Let the information "percolate" through the community and become an irritant to planners and legislators, reminding them that addressing problems in impoverished neighborhoods must be part of any plan for a city's future. For examples of ways to use such data, Dr. Thompson suggested that psychiatrists visit the Web site of the University Center for Social and Urban Research (www.ucsur.pitt.edu) and examine the three "black papers" developed by the center. For those interested in creating and participating in social change, he recommended two books by Ronald Heifetz, a psychiatrist at the Kennedy School of Government: Leadership Without Easy Answers and Leadership on the Line.

Cultivating youth resiliency

Carl C. Bell, M.D., president and chief executive officer of the Community Mental Health Council and Foundation, Inc., and director of community and public psychiatry and clinical professor of psychiatry and public health at the University of Illinois School of Medicine in Chicago, gave a lecture on cultivating resiliency among youths. He began by defining resiliency as "the capacity to bounce" and said that he would address the question, What conditions foster resiliency?

Biological, psychological, emotional, cognitive, social, environmental, and spiritual factors all play a part in an individual's resiliency. Dr. Bell pointed out that resiliency, or "toughness," can be cultivated. A person can learn to perceive events as challenges rather than as threats. Learned helplessness can be replaced with learned helpfulness—an example of an adaptive ego defense. Other such defenses include anticipation, being proactive, and having a sense of humor.

Whether a person is internally or externally motivated is another important component of resiliency, Dr. Bell noted. Internal motivation, or locus of control, can also be cultivated. Children and adolescents can be engaged in activities that reinforce their motivation, such as sports. Interpersonal skills are valuable, and they too can be taught. These are all central issues in childhood socialization that continue to be relevant throughout a person's life.

A person's "explanatory style," or causal attribution, also influences resiliency and outcomes. Dr. Bell highlighted research showing that people who have an external rather than an internal causal attribution have more heart attacks and are less likely to change their behaviors in response to health setbacks and other adverse events—for example, changing one's diet after a heart attack. Resolution of trauma is easier for persons who accept blame rather than blaming others, and transforming blame into forgiveness may promote growth.

Dr. Bell noted that resiliency can also be enhanced by optimism, which has various other benefits, including health benefits. Although stress and trauma can take their toll on optimism and its benefits, positive events have the reverse effect. Studies have shown that "ego-brittle" children tend to come from homes characterized by conflict and discord but that a good relationship with at least one parental figure can have a protective effect.

Self-perception is also important. A traumatic experience can provide an individual with a great deal of information about his or her level of self-reliance and may improve the person's ability to cope with future traumatic events or stressors. The posttraumatic growth literature suggests that trauma enhances coping skills and can bring a new perspective on life and a changed sense of self. Also, studies suggest that perception of self may be related to level of resistance to suicidal behavior.

Dr. Bell suggested that we can learn a lot about resiliency from other cultures: for example, the Hindu concept of atman, or true self; the Japanese term kokoro, or heart; and the Chinese concept of chi, or internal energy.

In summarizing, Dr. Bell offered a seven-principle model for cultivating resiliency. First, "reestablish the village." Second, provide access to health care—having health insurance is important to resiliency and happiness. Third, encourage bonding. Fourth, build self-esteem. Fifth, improve social skills. Sixth, re-establish the "adult protective shield." And finally, minimize the residual effects of trauma.

CBT-oriented approach to treating schizophrenia

Peter J. Weiden, M.D., presented a lecture highlighting the findings of several active research programs in the United Kingdom that are demonstrating the effectiveness of an approach to the treatment of schizophrenia that is a modified version of cognitive-behavioral therapy (CBT). In addition to showing a significant reduction in both positive and negative symptoms, studies that compare the CBT-oriented approach with supportive therapy have yielded larger effect sizes than those in U.S. studies that compare atypical and conventional antipsychotics. Yet, Dr. Weiden observed, few of his colleagues in the United States have heard of the U.K. studies.

In offering an explanation for the resistance of U.S. practitioners to the use of psychotherapy in treating psychosis, Dr. Weiden, who is director of the schizophrenia research program at SUNY Downstate Medical Center in Brooklyn, briefly reviewed some historic studies conducted during what he termed "the scorched-earth war" between psychoanalysis and psychopharmacology, which began after the introduction of chlorpromazine in the 1950s. The earliest studies unequivocally demonstrated the effectiveness of medications and even seemed to suggest that medicated patients who also received psychoanalytic treatment fared worse than patients on medication alone. Although advocates of the psychoanalytic approach were able to show in a few subsequent studies that a strong therapeutic alliance did make a difference for some psychotic patients, the same studies showed that the type of psychotherapy did not matter. Medication won, psychoanalysis lost, and, according to Dr. Weiden, these studies effectively ended U.S. investigations of psychotherapy for patients with schizophrenia.

Since the ascendancy of biological psychiatry, the Kraepelinian model, which characterizes schizophrenia as a degenerative brain disorder, has dictated the treatment approaches used, Dr. Weiden noted. Not long ago, when he and a colleague were asked to update some psychoeducational material for patients with schizophrenia, they were struck by a passage instructing clinicians to tell patients that they have a brain disorder "like Alzheimer's disease." What is at issue, Dr. Weiden said, is not whether that statement is true or false, but the implications for patients when their problems are described to them in this way.

Before discussing the CBT-oriented approach, Dr. Weiden noted some cautions. First, the findings are mixed, and the research is ongoing. Second, standard CBT has been extensively modified for patients with schizophrenia. He then described the key assumptions of the approach. First, using the diagnostic label "schizophrenia"— "the S-word"—is not necessary and may be harmful to patients. Second, even though diagnostic assessment requires a clinician to record psychosis as absent or present, viewing psychosis as being on a continuum has profound implications for how the clinician addresses the patient. The third assumption, which Dr. Weiden called the cornerstone of CBT-oriented treatment, substitutes the "stress vulnerability model" for the brain disorder model. The former posits that psychosis is a universal reaction to extreme stress and that people with schizophrenia have a much lower threshold to stress.

The fourth ingredient is to accept patients' delusional expressions as true expressions without contradicting them, which can be done in most cases without colluding with patients, Dr. Weiden explained. The clinician attempts to understand how the delusion might be true and to find an example that permits a general confirmatory statement, which helps normalize paranoid fears. Dr. Weiden described a highly paranoid African-American patient he treated in a New York City emergency room who believed that racist police were tracking him to do him harm. Rather than telling the patient that he was experiencing a delusion for which he needed treatment, Dr. Weiden observed that court cases had shown that some police officers are racists who harm people and discussed with the patient the difference between his being a specific target of racist police and police racism in general.

Dr. Weiden then showed numerous slides summarizing the findings of the U.K. studies. He encouraged his listeners to familiarize themselves with this literature and with the CBT-oriented approach, the theoretical underpinnings of which, he said, are cogently described in a book by Kingdon and coauthors entitled Cognitive-Behavioral Therapy of Schizophrenia, originally published in 1997 and available from Guilford Press.

Trauma and loss among children after September 11

Francine Cournos, M.D., discussed lessons learned about trauma and loss among children in the aftermath of September 11, 2001. Dr. Cournos is professor of clinical psychiatry at Columbia University and director of the Washington Heights Community Service, a comprehensive program for people with severe mental illness in New York City. She pointed out that, since September 11, there has been a dramatic shift in attitudes toward trauma. In particular, the intensity of the concern for children after the events of September 11 has led to an increased interest in trauma.

Dr. Cournos explained how responses to childhood trauma are mediated by adults' capacity to define an occurrence as traumatic. She suggested that, as a traumatic event, September 11 was "less difficult" to respond to than are private tragedies, because it was a defined public event. However, trauma that occurs more "routinely," such as child neglect and abuse, is often more difficult to conceptualize.

Dr. Cournos noted that the traumatic impact of an event is related to the degree of exposure to the event as well as a person's level of vulnerability—for example, history of trauma, history of psychiatric illness, and loss of supports. People who have had multiple previous traumas experience trauma very differently from other people; a subsequent traumatic event can reactivate previous trauma. An association has also been found between trauma and television exposure to traumatic events. Betrayal is another important factor in trauma: trauma occurs within the context of existing relationships and results in loss of trust; when children feel betrayed—for example, by an adult—trauma is more likely.

The children who were most affected by the events of September 11 were not characterized by their proximity to the World Trade Center but by whether they lost a relative in the attacks. Dr. Cournos noted the similarity between this finding and Anna Freud's observation that, during the London Blitz, children who were sent to the countryside without their parents felt less safe than those who remained in London with their parents, despite their proximity to the bombings.

It can be difficult to distinguish between psychopathology and a normal response to an event, Dr. Cournos cautioned. Reactions range from initial and universal responses (such as fear and anger) to longer-term problematic states of mind (such as rage, mistrust, and withdrawal) to psychiatric disorders—for example, posttraumatic stress disorder, which was more prevalent in New York City after September 11 than in other U.S. cities.

Childhood trauma needs to be considered in the context of the child's stage of development. During early childhood, attachment issues, concept of self, and affective regulation are paramount. During middle childhood, peer- and school-based opportunities and concerns emerge. By adolescence, the child has developed a sense of his or her place in the world as well as reliance on internal controls and values, although even adolescents are still dependent on their parents for their emotional base.

Dr. Cournos noted that children develop an understanding of death at an early age. Children as young as two years old have some cognitive and affective comprehension of death. Between the ages of six and 11, they have an understanding of the universality and finality of death. By age 12 to 14, they have the cognitive capacities of adults. The extent to which death is traumatic depends on the extent to which it overwhelms the child's—or adult's—coping strategies. Other important contributors include whether the death was sudden rather than the result of a chronic illness and whether the person tends to be vulnerable or more resilient.

In responding to trauma, it is important to remember that trauma is processed before grief. Child's play is an important means of coping and communicating. A parent can underestimate a child's level of distress by misinterpreting play as a sign that the child is not upset. But children grieve differently from adults; their grief is intermittent. Children may be preoccupied with specific aspects of how a person died and may ask questions that make adults feel uncomfortable.

Dr. Cournos reminded her audience that one of the basic principles of trauma intervention is "First, do no harm." Interventions for trauma include school-based interventions; structured interventions, such as bereavement groups; and longer-term relationship-focused treatments.

She summarized by emphasizing that the community fails to respond to trauma among children. Although adults could relate to the events of September 11 and showed appropriate concern for children, in more routine traumatic events, they cannot relate. She expressed hope that the experience of September 11 will enable us to improve the care provided for children who suffer trauma.

Debate on psychiatrists' obligations to their patients

The topic of one of two debates held during the institute was "A Psychiatrist's Obligation to His or Her Patient Is to Advocate for the Best Care for That Patient Regardless of Cost Considerations." The debate was organized by the American Association of Community Psychiatrists and was moderated by Anita S. Everett, M.D., inspector-general in the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services. In opening the debate, Dr. Everett noted that psychiatrists are not natural debaters, given that their profession encourages a consensus-based approach, and she encouraged audience participation in the debate. In keeping with this spirit, the debate had a more friendly, less argumentative tone than is sometimes the case.

The affirmative perspective was presented by Ranganathan Ram, M.D., of East Amherst, New York. Dr. Ram pointed out that while psychiatric illness is the most costly form of illness to treat, it can also be the most disabling. Persons with mental illness are subject to social inequality and often have impaired judgment. Thus psychiatrists need to act as their advocates to a greater extent than for other patients, Dr. Ram suggested. He reminded the audience that the Hippocratic oath makes no mention of cost, which would imply that psychiatrists are obliged to advocate for the best possible care for their patients.

Dr. Ram warned that the current economic recession threatens the quality of mental health services that psychiatrists can provide to their patients. In addition, the physician's role has become diminished in a climate of maximizing company profits. Insurance, which used to be a way of managing risk, has become a tool for containing costs and restricting access to care. The individual patient has become pitted against patients as a group—care is sacrificed in order to make resources available to the larger population. In such a climate, it is difficult to make the distinction between cost containment and plain incompetence.

Dr. Ram asked, "How does one distinguish between a cost consideration and a saving?" Some savings may be false savings: money that is not spent today could mean higher costs tomorrow as a result of untreated substance use disorders and serious mental illness. Patients often have no option but to come to the emergency department for treatment, yet emergency treatment is a very expensive form of care.

The negative case was argued by Nada L. Stotland, M.D., M.P.H., speaker of the APA Assembly, who, in line with Dr. Everett's comments on consensus, predicted that the debate's participants would end up agreeing. However, she acknowledged that the topic of the debate was an important one for discussion. She opened her argument by describing the feelings of guilt and dissatisfaction that psychiatrists often experience as they complete each patient encounter, knowing that they can never do as much as they would like to do for the patient, yet feeling obliged to provide the best possible care. She reminded the audience of the television program Marcus Welby, M.D. The program's title character seemed to devote all his attention to one patient per weekly episode. This patient usually had both a medical problem and a psychosocial problem, and the cost of treatment was never mentioned. No third party would pay anything close to what would be required to provide the level of care depicted in Marcus Welby, Dr. Stotland observed.

She pointed out that sacrificing the individual good for the good of the whole, as Dr. Ram mentioned, can be a positive thing—for example, routine immunization of children. In addition, sometimes the physician has obligations to the patient's family. Dr. Stotland pointed out that these broader obligations are often forgotten with the current focus on patient autonomy.

Although it would be possible for physicians to diagnose and treat all kinds of conditions, the assessment necessary to make such diagnoses would take hours, Dr. Stotland noted. Every minute spent with one patient is time that could be spent with other patients. Psychiatrists' sense of obligation can be taken too far—for example, are they violating their obligations when they are asleep, because they could be using that time to treat patients?

Dr. Stotland proposed that there is no such thing as "basic care." She asked, "At what point does basic care become luxury care?" Physicians often deceive themselves in thinking that there is a scientific basis to everything they do, she said, but there is not. There is no absolute. She proposed that the real harm lies in the fact that some people receive zero care while others have access to every test and treatment imaginable. She suggested that mental health care workers need to face up to the system they are participating in and try to achieve balance.

During the rebuttal segment of the debate, Dr. Ram pointed out that macro decisions such as the allocation of financial resources are not among physicians' strong points. But Dr. Stotland urged psychiatrists and other physicians to play a role in such decisions, because their opinions carry a lot of weight in the community. She warned that unlimited advocacy for individual patients produces inequality and misallocation of resources and that it is important to direct funds toward actual care rather than toward company profits—care will be provided in the areas to which the money flows. Dr. Ram wondered whether it is just large amounts of money that make a difference to the quality of care a person receives, or is it something else? For example, in poorer countries such as India, Cuba, and Costa Rica, life expectancy is not much different from what it is in the United States, despite far smaller health care expenditures in those countries. In any event, he concluded, it is not acceptable that psychiatrists have access to such a small piece of the pie.

Consequences of stigma and strategies for change

Participants in a symposium entitled "Psychiatric Stigma: Consequences and Strategies for Change" reported on current and completed projects of the Chicago Consortium of Stigma Research (CCSR), a research infrastructure support program funded by the National Institute of Mental Health and based at the University of Chicago Center for Psychiatric Rehabilitation. The CCSR was formed in response to the lack of strong evidence of effective ways of alleviating stigma. Its goal is to apply concepts and methods from social psychology to better understand the causes and consequences of stigma surrounding mental illness and to uncover methods for eradicating it. The consortium has been meeting for the past three years, initially building models of what stigma is.

Amy C. Watson, Ph.D., gave a presentation on stigma and police decision making. She noted that studies have shown that older police officers are more likely to rely on informal approaches in dealing with a person with mental illness, whereas younger officers are more likely to go "by the book" and arrest the person. She highlighted Weiner's attributional model as a useful framework for her discussion. Under this model, a person who is viewed as being responsible for his or her condition is more likely to incite anger, resulting in punishment and neglect, whereas a person who is seen as not responsible is likely to engender pity and thus to receive help.

Dr. Watson presented the results of a 4 × 2 vignette survey of police officers that was designed to assess how attitudes varied according to whether the mentally ill person was viewed as a suspect, a witness, a victim, or a person in need of assistance and whether the police officer knew the person had schizophrenia. A significant effect of the mental illness label and of the role of the mentally ill person was found. For example, a person who was viewed as needing assistance was more likely to engender pity than was a person in the role of suspect, victim, or witness.

Colleen Mahoney, M.A., presented a conceptual framework for studying the impact of stigma in the consumer-case manager relationship, which she hopes to test in a future study. Ms. Mahoney noted that the relationship between the consumer and the case manager depends on a combination of consumer characteristics, case manager characteristics, and outcome indicators (such as quality of life, social relationships, functioning, and community tenure). Case managers often attribute problems in the relationship to the client rather than to themselves. However, individual case managers differ in their level of training, experience, skills, knowledge, demographic characteristics, attitudes, and personality traits. Even case managers with similar skill levels do not necessarily offer all those skills and resources to clients on an equal basis. And the nature of the relationship changes during the course of treatment.

The client-case manager relationship is a complex one that can have both positive and negative attributes, Ms. Mahoney observed. Two Assertive Community Treatment Working Relationship Scales (a positive scale and a negative scale) have been developed for studying the relationship, based on the attributional model. Various scenarios of consumer behaviors and corresponding case manager responses—for example, a request by the consumer for a reduction in medication dosage—are to be tested.

Beth Angell, Ph.D., discussed stigma in the clinical decision-making process. She noted that mental health care workers are just as likely to stereotype as are members of the general public. In fact, mental health care workers tend to be less optimistic about outcomes, she said, and it is important to understand their attitudes and attributions.

Dr. Angell's research has focused on issues of coercion in addressing conflict and noncompliance, describing the range of compliance strategies used in assertive community treatment and other intensive community programs. She pointed out that some professionals consider formal approaches to be too restrictive and bureaucratic and rely on less formal approaches. Such approaches include persuasion; "use of the relationship" (evoking an emotional component, such as an appeal to trust or reminders about past positive outcomes); use of bargaining, rewards, and leverage (for example, withholding resources if the client does not comply, although clinicians are generally reluctant to use this approach); and use of force (which is extremely rare).

Dr. Angell observed that providers' decisions are affected by paternalism, perceptions of the client's ability to control his or her behavior, and diagnosis. Clinicians see the patients who are the most severely ill, so they may develop the view that clients never get better or, if they do, only get better through receiving intensive services.

Patrick W. Corrigan, Ph.D., proposed strategies for changing public attitudes that create stigma. He pointed out the enormous challenges that face persons with mental illness, who, even if they meet the goals of rehabilitation, still face being stigmatized by employers, landlords, and other members of the community. The one major stigma is the belief that persons with mental illness are dangerous. In addition to "fixing" the mentally ill person, it is necessary to "fix" the community the person lives in, he said.

Dr. Corrigan highlighted studies that have been conducted of three different approaches to addressing stigma: education, protest, and contact. Protest has been shown to have a rebound effect: when people are told not to stigmatize, they are more likely to do so, except in the very short term. Education has been shown to have some impact. However, a CCSR study has shown that the most effective strategy is contact—that is, meeting a person who has a mental illness.

Dr. Corrigan raised the question of why providers can be so stereotyping, given the potential benefits associated with contact. To help answer this question, he noted that the level of disconfirmation is also important—that is, the extent to which the mentally ill person's story differs from the stereotype. He then introduced Robert K. Lundin, who suffers from bipolar disorder and who filled the role of the "contact" person in the CCSR study.

The Illinois School Crisis Assistance Team Project

In addition to its work with persons with serious mental illness, the Mental Health Association (MHA) in Illinois has a history of providing prevention services. In this capacity, it was approached by the state attorney-general's Safe-to-Learn Task Force to develop a state program of school crisis assistance teams. Jan Holcomb, B.S., R.N., chief executive officer of the MHA in Illinois, and Carol Wozniewski, M.A., director of development and special projects at the MHA, gave an overview of the Illinois School Crisis Assistance Team (SCAT) project and described how the teams have been recruited and trained.

Although most school communities have emergency and disaster plans in place, they lack the services of trained crisis responders to identify and treat emotional trauma. This is of concern, Ms. Wozniewski noted, because crisis interrupts a school's primary mission of educating America's children and can traumatize both children and adults, sometimes causing them to be destructive to themselves and others.

The mission of the SCATs is to serve as consultants to the leaders and caregivers of Illinois school communities, to provide crisis intervention services in the immediate aftermath of a critical incident at a school, to help local leaders and caregivers identify at-risk individuals to ensure that they are provided with necessary mental health services, to enhance public awareness of the effects of trauma, and to provide necessary information and assistance to Illinois schools and their communities on how to cope with a traumatic incident.

Examples of crises that SCATs have responded to are the sudden death of a student or faculty member, suicide, serious car accidents, threats to the school, wakes and funerals (at which SCAT members provide "companioning" services), and natural disasters. Car accidents are the most common event that the teams respond to. According to the Centers for Disease Control and Prevention, 31 percent of all deaths among youths aged ten to 24 years result from motor vehicle crashes, 18 percent from homicide, 12 percent from suicide, and 11 percent from unintentional injuries, Ms. Wozniewski noted.

The SCAT program follows the crisis-response model of the National Organization of Victim Assistance, which focuses on prediction and preparation. The model is educational and community based—responders do not need to be mental health professionals.

Currently, there are 44 SCATs in Illinois and more than 700 trained SCAT volunteers, of whom 150 have successfully completed advanced training and 36 are certified trainers. Volunteers include teachers, school administrators, principals, nurses, social workers, counselors, psychologists, truancy officers, community mental health workers, police officers, and firefighters.

The main tasks of SCAT volunteers are to aid local decision makers in identifying children and adolescents who may be at risk and to provide them with crisis intervention and supportive counseling services. Crisis intervention involves helping people to begin to feel safe and secure, helping people develop an understanding of what happened and how it is affecting them, and helping people cooperatively develop plans for dealing with problems caused by a tragedy. Supportive counseling involves education (both on mental health issues and on issues surrounding the event, such as the dangers of drunk driving), encouragement of physical and mental health, and development of problem-solving skills and coping strategies in an attempt to put the tragedy in perspective.

The SCAT project has become a major player in the area of disaster response. In Illinois, it has a bigger network than the Red Cross. In fact, Ms. Holcomb and Ms. Wozniewski noted that the program sometimes gets referrals from the Red Cross for activities not covered by the Red Cross, such as sexual assault counseling.