A VA Health Care System Two Years After September 11, 2001

The two years that have passed since September 11, 2001, have demonstrated that mental health care workers play a critical role in disaster response. Future challenges for health care systems that respond to disasters include meeting the needs of a traumatized community, maintaining an educated and able workforce, and developing long-range plans.

The Veterans Integrated Service Network for New York and New Jersey (VISN 3) has remained actively engaged in emergency planning since September 11. The Mental Health Executive Board (MHEB) has implemented a mental health emergency preparedness team to integrate services with hospitalwide emergency preparedness practices. In the immediate aftermath of September 11, the MHEB identified populations most likely to need enhanced services, including known veteran patients, veterans in the community who were not currently receiving Department of Veterans Affairs (VA) services (particularly first responders), and medical center staff. We identified veterans with histories of posttraumatic stress disorder, depression, or suicide attempts as high-risk individuals.

We developed and mailed educational brochures to more than 10,000 veterans with these disorders. Staff telephoned high-risk veterans on their caseloads, provided psychoeducational and support groups in psychiatric inpatient and outpatient settings, and distributed informational flyers to veterans in medical settings and the community about how to gain access to VA services. We are continuing to develop services and strategies to educate these populations about obtaining care.

The MHEB identified staff as a group that needed support to help them cope with fears and uncertainty during a disaster period. In the event of a chemical or biological incident, stress may be increased as a result of extended operational periods and fear of hazardous exposure. Frontline medical response staff may need support to alleviate the psychological impact of their experiences. Support should be offered in a nonstigmatizing manner so that participation does not imply inability to perform duties. If staff feel that their participation communicates emotional fragility to management, they may decline services. In addition, incident review, education, and personal safety training can help staff cope with the stress of a traumatic event and enable them to master increased job demands.

Immediately after the September 11 attacks, each facility in VISN 3 implemented psychoeducational and supportive services for staff. At one site, leadership requested the assistance of experienced debriefing counselors through the VA Readjustment Counseling Service (RCS). The evidence base for the effectiveness of debriefing is mixed. Studies suggest that in some cases critical incident stress debriefing may be more harmful than helpful. The value of psychoeducational debriefings, which teach participants about normal reactions to stressful events and healthy coping skills, has not been established. However, anecdotal evidence suggests that employees find these debriefings beneficial. Below we describe the debriefings conducted by RCS and results of a postdebriefing survey.

RCS staff met with groups of employees during two weeks in November 2001. Employees were invited to voluntarily meet with "stress teams" available during each shift. Groups were as large as 80 participants. A psychoeducational format was used. We conducted a survey during March 2002 to evaluate the debriefings. Because of a low response rate (77 of approximately 700 attendees, or 11 percent) and a delay in implementing the survey, the results must be interpreted cautiously. However, the findings were consistent with those reported for a non-VA site in New York by Herman and colleagues in the Frontline Reports column in the April 2002 issue.

Among the 77 respondents, 56 (73 percent) said that they watched the events of September 11 on television, 51 (66 percent) reported feeling emotionally affected, 21 (27 percent) had a friend or relative who was near the World Trade Center at the time of the attacks, six (8 percent) knew someone close to them who was killed, and five (7 percent) witnessed the events in person. A majority (52 respondents, or 68 percent) said that they felt better after attending the debriefing, 23 (30 percent) that they felt the same, and two (3 percent) that they felt worse. Most participants attended the debriefings because they wanted to attend (59 respondents, or 77 percent) rather than because they felt pressured to. Participants rated the content of the debriefings as "good" (a mean score of 3.14 on a scale of 1, poor, to 4, excellent). Ways in which respondents reported that the sessions were helpful included "learning I was not alone," "sharing experiences," "better understanding of how events affected self," "learning ways to speed recovery," and "receiving support." The vast majority of respondents (more than 90 percent) said that they would attend a session in the future and would recommend debriefings to others.

In summary, debriefings based on a psychoeducational model were well received and were generally experienced as helpful. Future research should examine what elements of the sessions are most efficacious, and integration of these elements in an employee assistance plan during and after a disaster should be considered. It can be difficult to perform rigorous studies at the time of an emergency, but, to the extent possible, agencies should document interventions and conduct assessments of what works so that we can build on experience.

Ms. Kushner is mental health care line business manager and Dr. Weissman is associate director for evaluation and health services research, Mental Illness Research, Education, and Clinical Center, of VISN 3 in the Bronx, New York. Address correspondence to Dr. Weissman at the Mental Illness Research, Education, and Clinical Center, Bronx VA Medical Center (OOMH), 130 West Kingsbridge Road, Bronx, New York 10468 (e-mail, [email protected]).