2005 APA Silver Awards: Silver Achievement Awards

Silver Award: The Child and Adolescent Services Program of the World Trade Center Healing Services, Saint Vincent Catholic Medical Centers, New York—Providing Trauma-Related Treatment to Students After the Terrorist Attacks of September 11, 2001, and Other Traumatic Events

On September 11, 2001, Saint Vincent's Hospital Manhattan, as the closest level I trauma center to the World Trade Center (WTC), immediately provided emergency medical care to hundreds of injured victims in cooperation with New York City's police and fire departments. However, it soon became apparent that the overwhelming need was for mental health assistance to community members and rescue and recovery workers. During the first ten days after September 11, 2001, St. Vincent's Hospital staff saw more than 7,600 individuals seeking information and crisis counseling and responded to more than 10,000 telephone calls.

The department of psychiatry at St. Vincent's Hospital, which has a 20-year history of partnering with schools in this community, immediately deployed child therapists to the elementary and high schools closest to the WTC site. In addition, child and adolescent psychiatry leadership consulted with administrators in the local school district to assist them in their plans to address the many personal and organizational challenges they were facing to maintain the educational mission in the face of this monumental disaster.

Since then the hospital has offered several specialized mental health programs through WTC Healing Services for people affected by the terrorist attacks. The largest program is the Child and Adolescent Services Program, which provides school-based mental health care for students. During the past four years, the program has expanded to encompass 16 Lower-Manhattan elementary, middle, and high schools, where therapists have provided evaluations and expert, evidence-based trauma-related treatment to students with anxiety, depression, and stress-related conditions, including post-trauma syndromes and posttraumatic stress disorder (PTSD)—many of these conditions resulting from students' direct witnessing of the towers falling and people dying. Initially, many of the younger children were contending with painful feelings over the loss of life and sense of safety, whereas the older children expressed worries about ongoing danger, the air quality, biological weapons, and their own future.

In recognition of exemplary success in the provision of trauma-related treatment to students after the events of September 11, 2001, and other traumatic incidents, the Child and Adolescent Services Program of WTC Healing Services, Saint Vincent Catholic Medical Centers, have been awarded one of APA's Silver Achievement Awards for 2005.

The objective of the program is to provide direct services to children, parents, and school staff; provide expertise to school leadership on mental health issues; and offer evidence-based trauma-focused cognitive-behavioral therapy for treating PTSD and traumatic grief. This program is in great demand. As of June 30, 2005, close to 16,000 services, including individual and group counseling, have been delivered in schools through almost 24,000 contacts, primarily with students, family members, and teachers.

Before September 11, 2001, few mental health services were found in New York City's schools. After September 11, 2001, there was an almost overwhelming need to not only treat youths but also assess the efficacy of these services.

The program focuses on four areas to ensure success: outreach, identification, assessment, and treatment. Research has shown that 60 percent of all youths who receive services in their lifetime entered the service system by first receiving services in an educational setting and that schools are the optimal place to reach children to provide mental health services. Growing evidence shows that school mental health programs improve mental health outcomes by decreasing absences and discipline referrals and by improving test scores. Although many children became symptomatic as a result of September 11, 2001, children who have symptoms related to other traumatic events are also included in the program. The target population includes children exposed to events such as the traumatic loss of a loved one, physical abuse, domestic and community violence, motor vehicle accidents, fires, tornadoes and hurricanes, industrial accidents, and other terrorist attacks and regular terror alerts.

Initially, school personnel were not able to identify traumatized children for referrals. They were more likely to identify students' problems as school achievement deficiencies, truancy, lateness, or acting-out behaviors. Therefore, the program's clinical staff provided psychoeducation for all school personnel. Because many of the school personnel were traumatized as well, they frequently referred themselves for treatment after these presentations. With the school personnel alert to symptoms as well as behavior, there were many referrals to the clinical staff.

A partnership with the Columbia Teen Screen and the Mental Health Association allowed for screening entire classes or, in some cases, even schools. The Columbia Teen Screen is a model program of the Substance Abuse and Mental Health Services Administration (SAMHSA) that screens for depression and anxiety. WTC Healing Services was also able to add a PTSD screen to identify children who were suffering from trauma symptoms after September 11, 2001. For example, at Millennium High School, located near Wall Street, 30 percent of the students screened needed treatment.

In addition, the WTC clinical staff uses the PTSD-Reaction Index (PTSD-RI) for many children who were identified as part of the Child and Adolescent Trauma Treatment and Services (CATS) consortium research project through the New York State Office of Mental Health. Clinical staff also use the World Trade Center Exposure Measures, the Child Depression Inventory/Beck Depression Inventory, and other measures. This battery was then used to identify which children needed intervention and to provide verification of effectiveness through three- and six-month follow-up visits.

One of the strengths of the program is its link to all the behavioral health services, including the child and adolescent outpatient psychiatry clinic and inpatient program located at the hospital. When children are not functioning well in school or other domains, psychiatric consultations are therefore easily arranged. These evaluations often lead to intensive treatment, as appropriate; follow-up; and, in some cases, medication.

In treatment, the program uses five trusted yet innovative treatment approaches: psychodynamic psychotherapy, trauma-focused cognitive-behavioral individual therapy, trauma-focused group therapy, group art therapy in school settings, and ad hoc emergency classroom interventions. In many treatment cases a combination of two or three modalities may be used, such as trauma-focused cognitive-behavioral therapy and play therapy.

It is recognized that optimal cognitive-behavioral therapy, as one of the program's innovative treatment approaches, has the following components: a combination of psychoeducation, stress inoculation, and development of a trauma narrative. Coping and resilience is a result of the stress inoculation techniques and narrative processing that are part of trauma-focused cognitive-behavioral therapy. The development of a trauma narrative ensures support and safety for children to create a narrative of the events that occurred and cognitive reprocessing for children who develop negative self-images. Two manualized group trauma treatment models are currently being used in the schools. Skills Training in Affective and Interpersonal Regulation and Structured Psychotherapy for Adolescents Responding to Chronic Stress are two evidence-based group models that provide opportunities to intervene with larger groups of students.

A second program innovation was use of a group art therapy project at the two high schools adjacent to Ground Zero. The students in these schools were evacuated on September 11, 2001; they had problems returning to the school and in subsequent months, and even years in many cases, had difficulty in progressing to the next grade and exhibited irritability and anger. A group art therapy project, Hope for the Future, was developed for the September 11 anniversary in 2002. This intervention was so effective that it has become an annual occurrence as a central part of the schools' efforts to honor the experience, cultivate a sense of community renewal, and help students work through any lingering issues.

A third treatment innovation is classroom interventions for emergencies. Once the program was in the schools, it became apparent that a means for students to process traumatic events was needed. One type of event was news of terrorism in another part of the world, which could trigger memories of September 11, 2001—for example, the Madrid subway bombing. The tsunami disaster and Hurricane Katrina created much generalized anxiety, because New York City is on the coast as well. In addition, individual schools had their own traumas, such as the death of one student in a skiing accident and another while subway "surfing." Clinical staff processed these incidents for as long as necessary after they occurred.

The Child and Adolescent Services Program also developed ways of overcoming funding barriers. One example is the program's approaching community leaders to get funding for services in the schools. Geographically, the work took place in schools in Lower Manhattan, so many of the downtown (Wall Street) businesses were approached and provided with some initial funding. A mark of the program's contribution is that the New York Times Foundation and other philanthropic institutions have been major supporters of the program's efforts.

The WTC Healing Services participates in the CATS program, which serves primarily the neighborhoods most affected by the WTC disaster. The CATS program is a cooperative treatment and service project funded by SAMHSA and conducted by seven independent teams in collaboration with the staff of the Office of Mental Health of the State of New York. The program has monitored outcomes since its involvement in the CATS program beginning in December 2003.

To determine the necessity and course of treatment, the PTSD-RI was administered to youths on the initial visit. It was then readministered at three-month intervals to verify the efficacy of the treatment and to reassess areas of strength and weakness. A criterion score of 26 or higher was required for inclusion in this research study. From 2003 to 2005 PTSD-RI scores were gathered for 81 youths at baseline, 39 youths at three months, and 18 youths at six months. The average score at baseline was 28.6 (moderate PTSD), all scores ranged from 0 to 64. At three months, the mean PTSD-RI score declined to 17.6 (mild PTSD), and at six months, the mean was reduced further to 14.8 (mild PTSD). This decrease in PTSD-RI scores was significant.

Currently the WTC Healing Services cannot serve all the Lower Manhattan schools that want and need services. However, the program is providing expertise to other schools throughout the country as part of the Schools Working Committee of the SAMHSA-funded National Child Traumatic Stress Network. This program clearly provides care for a large number of students who might not otherwise be served and serves as a model for other schools throughout the country.

For more information contact Susan E. Sabor, L.C.S.W., at WTC Healing Services, 144 West 12th Street, New York, New York 10011; e-mail, [email protected], or Carole Patterson, L.C.S.W., 170 Broadway, Suite 1208, New York, New York 10038; e-mail, [email protected].

Silver Award: Police Organization Providing Peer Assistance (POPPA), New York City—Helping Police Officers Cope With On-the-Job Pressure

Police officers, as a consequence of their extremely stressful work environment, suffer from high rates of posttraumatic stress disorder, alcohol abuse, marital and family problems, and suicide. But because they fear stigmatization and job-related consequences, police officers are reluctant to seek assistance from departmental services. They are conditioned to maintain emotional control and tend to see themselves as problem solvers rather than as people who are themselves in need of assistance. Distrust of the mental health system very often prevents officers from seeking outside assistance as well. But police officers, just like everybody else, need to mentally process what they experience.

The Police Organization Providing Peer Assistance (POPPA) is an independent, autonomous agency that offers, in partnership with the New York City Police Department (NYPD), completely confidential assistance to police officers who are suffering from work-related stress or other personal problems. POPPA has been awarded one of the APA's Silver Achievement Awards for 2005 in recognition of its success in encouraging NYPD officers to seek help for such problems.

POPPA was created in 1996 by union leader Bill Genet in response to 26 suicides in the NYPD over the two-year period 1994 and 1995. Genet, a 30-year veteran of the NYPD at that time and a Trustee of the Patrolmen's Benevolent Association (PBA), had become aware that police officers needed a program that was independent of the NYPD that the officers could turn to, voluntarily, and receive support without fear of jeopardizing their careers. City Council hearings on police suicides confirmed his long-time belief. He knew that the only group that police officers would trust to conduct such a program was other police officers.

Initially the organization was run literally from Genet's home with a small amount of funding from the City of New York and the police unions. Then, up until September 2001, POPPA was run from a small space of less than 600 square feet that was donated by the PBA. Genet contracted a counseling and psychotherapy group to train the first 25 officers who had volunteered to become peer support officers (PSOs) and set up a 24-hour help-line (888-COPS-COP, or 888-267-7267) that has been in existence since POPPA's founding.

When terrorists attacked the World Trade Center on September 11, 2001, 23 police officers were killed. Their fellow officers continued to work amid the chaos and horror. By mid-2002, an estimated 20,000 to 25,000 officers had worked at Ground Zero, the city morgues, or the Staten Island retrieval operation.

Forced to vacate its office near the World Trade Center after the terrorist attacks, POPPA established a temporary crisis center in the Federal Reserve Bank lobby, three blocks from Ground Zero. From there POPPA deployed teams of PSOs for outreach to rescue workers, recruited additional volunteers in the mental health professions, and coordinated the deployment of more than 300 volunteer counselors who came to New York from across the United States and from abroad. The situation demanded new response techniques, and POPPA proved it could meet the challenge. It organized small groups of officers to undergo "defusing" and "debriefing," enabling them to process their experiences in the aftermath of the terrorist attacks. By late September, POPPA was counseling about 100 officers per day. Every officer who called the help-line received one-on-one support, even though the number of callers had increased threefold.

Since its inception, POPPA has recruited and trained more than 200 volunteer NYPD officers to man the help-line. These volunteers have enabled the organization to penetrate the resistance to seeking assistance for personal problems that had been endemic in the department. An officer can call the help-line about any personal or job-related stress problem. Within 24 hours the PSO will meet with the officer face-to-face to provide an empathic ear and screen for major safety risks, such as suicidal or homicidal ideation, alcohol abuse, or risk of violence. The volunteer meets with the caller at any location of the caller's choosing. First meetings often take place in a car or coffee shop. Stress-related problems are discussed as a natural consequence of police work. Seeking assistance is presented as a sign of strength, not weakness.

PSOs do not provide ongoing individual counseling—POPPA believes that that is best left to a professional. When necessary, the officer is given a referral to a mental health professional who is trained and experienced in working with police officers. The PSO helps to alleviate fears and misconceptions about the mental health professionals who will later be working with the officer. By the time an officer meets with a professional, the officer is ready to work on his or her problems. The availability of a clinical panel is a unique feature of the program. Many police assistance agencies use only peers or offer only short-term crisis intervention—they do not have a clinical panel available to treat officers.

PSOs work for free, on their own time, to respond to help-line calls. This cadre of peers who give their own time to help fellow officers is an essential ingredient of the program. And POPPA's volunteer spirit is infectious. Although members of the clinical panel are paid for individual treatment provided in their offices, their training and their work in response to September 11 was voluntary. In the event of a future terrorist attack, POPPA's clinicians and PSOs will again give their time to respond when needed.

The confidentiality agreement between POPPA and the NYPD is another unique and critical component of the program's success. Officers can receive treatment that is clinically appropriate to their needs with expectations of complete confidentiality. While POPPA's clients receive care from psychiatrists, psychologists, and social workers, they continue to work full duty unless there are rare circumstances that the professional believes would place the officer or others at risk. POPPA also has an agreement with the NYPD to place severely ill officers on confidential sick leave and to return them to full duty without restriction when they are ready for it.

Although the help-line is POPPA's key intervention, the organization's PSOs and mental health professionals have started additional programs to address the needs of police officers and families. As a result of the September 11 experience, POPPA concluded that outreach and trauma response are needed over the long term, not only in the wake of disaster. POPPA recently developed new peer-based outreach programs and trauma response teams to respond to the "ordinary" police traumatic incidents, such as shootings, homicides, suicides, and child abuse. It is believed that such assistance will help officers deal with everyday traumatic events that are part and parcel of police work and allow for early identification and referral for severe stress reactions. In addition, this ongoing trauma response initiative means that a large, well-trained, and experienced team of peers and professionals will be available to respond in the event of another terrorist attack or disaster.

POPPA has the following full-time paid staff: A director oversees the development and operation of all programs (the help-line, PSO recruitment and training, outreach teams, trauma response teams, suicide postvention, and liaison with NYPD administration). A clinical director is responsible for the development, training, and coordination of the clinical panel, PSO and clinician training, monitoring of severely symptomatic cases, and assisting the director. A director of development is responsible for supervision of administrative staff, fundraising and program development, public relations, and management of finances. A medical advisor (part-time) serves as a consultant to the director and clinical director, provides education to PSOs and members of the clinical panel, conducts fitness-for-duty evaluations and consultations on complex cases and high-risk cases, monitors the mental health of all staff, and is responsible for the implementation of self-care groups for POPPA personnel. Finally, the clinical panel is staffed by mental health professionals (M.D.s, Ph.D.s, C.S.W.s, and C.A.S.A.C.s) who work in private offices throughout New York City and surrounding areas. These individuals are trained and experienced to work with police officers. Mental health professionals are essential for detox and psychiatric admissions, medication consultation and management, fitness-for-duty evaluations, and urgent assessments. The staff also includes administrative and support staff.

The principal funding sources for POPPA's programs are the American Red Cross ($650,000) and a grant through the New York City Mayor's Office from the Department of Justice ($650,000). All other operational and administrative costs are funded jointly by the New York City Police Department and the New York City Police Unions.

The number of calls to the help-line has increased from 250 in 1996 to between 900 and 1,200 calls per year over the past four years. Since its inception in 1996, more than 8,000 officers have called the help-line. Recent help-line data show that officers are calling for stress or anxiety (30 percent), marital problems (21 percent), traumatic stress (16 percent), alcohol-related problems (14 percent), depression (13 percent), and bereavement (7 percent). About 40 percent of callers receive a referral to a mental health professional. By the end of 2004, a total of 2,811 officers had received a referral from POPPA.

More than 28,000 officers benefited from outreach and crisis counseling during POPPA's September 11 efforts. Although more than three-quarters of the NYPD personnel had significant exposure to the September 11 attacks, there were no suicides in the NYPD for more than a year after that. Project Liberty, the Red Cross, and several other programs have cited POPPA as a model peer program and a model emergency services assistance program. In addition, police assistance programs from around the United States—and even other countries—have sought advice from POPPA on police assistance strategies.

Of significant note, since 1996 the organization has assisted and monitored 319 Blue-Line sick cases—involving officers whose symptoms were so severe that they had to take confidential sick leave. More than 88 percent of these officers (282 officers) have made a successful return to full duty with their weapon and with no other restrictions.

Since POPPA's inception, the average number of suicides in the NYPD has been reduced to five or six per year—a dramatic reduction from the 26 in 1994-1995. More than 70 police officers have firmly stated that they would have committed suicide if POPPA's assistance had not been available. POPPA's clients attest to the positive outcome of working with the agency: "This program is truly a Godsend, and I now wake up looking forward to every day instead of dreading it." And "Your support and genuine concern helped me to get through one of the darkest storms of my life."

For more information contact Frank Dowling, M.D., Medical Advisor, 26 Broadway, Suite 1640, New York, New York 10004-1898; e-mail, [email protected].