Testimony
	New York City Department of Health & Mental Hygiene Office of Communications

Good afternoon, Chairwoman Lopez and members of the Committee, I am Dr. Lloyd Sederer, Executive Deputy Commissioner for Mental Hygiene at the New York City Department of Health and Mental Hygiene. I am here today to testify about the mental health services provided to the residents of New York City following the tragic events of September 11, 2001. In particular, I will describe Project Liberty, discuss what we have learned about the continuing mental health needs of New Yorkers following this terrorist attack, and address the next steps and challenges that we face.

Project Liberty is the name chosen by New York State for the crisis counseling and assistance program that was established following 9/ll. Typically, following major disasters, the Federal Emergency Management Agency or FEMA provides funding directly to states to mitigate the effects of the disaster, including funding for a mental health response. FEMA's Crisis Counseling Assistance and Training Program or CCP is subject to precise federal rules. A Presidential disaster declaration must precede application for CCP funds and only a State mental health authority can apply for CCP funds. There are two types of CCP programs: the Immediate Services Program which as a rule provides funds for up to 60 days immediately following the disaster, and the Regular Services Program which as a rule makes funds available for up to 9 additional months. The only allowable categories of service under CCP are short term individual and group crisis counseling, outreach, education services, and referrals to other types of services (when needed).

On September 11th, after President Bush declared a disaster emergency for New York City, New York State also identified 10 other counties in close proximity as also greatly impacted. The State Office of Mental Health (SOMH), as required under federal law, completed a needs assessment that determined that the existing resources in the City and surrounding counties were not sufficient to meet crisis counseling needs, and submitted an application to the federal government for CCP funds. New York State was initially awarded $22.7 million, of which $14 million was targeted to New York City, for the Immediate Services Program, and $132 million, of which $111 million was for New York City, was subsequently awarded for the Regular Services Program. These combined awards represent the largest public, crisis counseling program in the history of the United States. Notably, over the course of this grant over a million New Yorkers have been served, an impressive and unprecedented degree of public service. At our request, FEMA's usual time limit on CCP funding was extended until December 31, 2003, for most providers. Only the Fire Department and Department of Education continue to provide counseling and education to their respective communities through Project Liberty financial support at this time.

In New York City, FEMA's crisis counseling funding established New York City's Project Liberty program. Project Liberty's overall goal (in NYC and the surrounding counties) was to reduce or eliminate the psychological distress that large numbers of New Yorkers experienced as a result of the World Trade Center disaster. Project Liberty provided effective, community-based disaster mental health services that reached over one million New Yorkers and helped them regain pre-disaster levels of functioning. Today, after over two years of operation, all of the FEMA funds for New York City's Project Liberty have been expended -- except for the money now set aside for the Fire Department and Department of Education, which as mentioned continue to operate programs.

When NYC Project Liberty was created, in the immediate wake of the disaster, the thinking then was that the best and most expedient way to make these services available to the people of this large and diverse city was to work directly with existing community-based agencies. Over the course of two years, Project Liberty provided funding to 106 community agencies throughout the five boroughs. The agencies participating in this historic effort included mental health clinics, public and private hospitals, settlement houses, community based organizations and workplace-based service centers. These agencies provided services at hundreds of sites throughout New York City. In what was also groundbreaking work, most of the counseling sessions were provided outside of traditional mental health settings in environments in which recipients reported being more comfortable, such as in homes, parks, libraries, union halls, schools, temples, churches and mosques.

Over one million individuals and their families received counseling services from Project Liberty providers. Although FEMA guidelines are very restrictive about what type of data can be collected, we do know some of the characteristics of the people we served. Specifically, 32 percent of the individuals receiving services were Black, 29 percent were White, 26 percent were of Hispanic origin, 10 percent were Asian and Pacific Islanders, and 2 percent were Middle Eastern. The outreach and counseling was available in almost any language requested and culturally informed. In fact, 20 percent of services were provided in languages other than English, specifically, 11 percent were provided in Spanish, 6 percent in Chinese and 3 percent in other languages including Farsi, Cantonese, Mandarin, Fujanese, Tagalog, Russian, Polish and American Sign Language. One of the important characteristics of Project Liberty was that it was available to immigrants, regardless of their legal status. The recipients of services included families of those who lost a loved one on 9/ll, those injured in the disaster, uniform service personnel, children at public and private schools, senior citizens, those evacuated from the towers as well as many others who where affected by the tragedy.

Provider outreach efforts were reinforced by three separate media campaigns involving television and radio spots in English and Spanish, as well as bus and subway print campaigns in English, Spanish and Chinese. Media campaigns were intensified prior to the first and second anniversaries. All of the various media campaigns encouraged individuals to call 1-800-LIFENET if they wished to take advantage of the program. 1-800-LIFENET counselors were familiar with all of the Project Liberty agencies and the agencies' language capacities. LIFENET made thousands of referrals.

The police and fire departments hired peer counselors who were retired firefighters and police officers to provide outreach and help de-stigmatize counseling. They also worked to reassure members of the anonymity of the program. Providers focusing on trade union members, mental health consumers, providers serving those with disabilities and non-uniformed city employees also employed peer counselors.

An immediate and continuous priority for Project Liberty providers was ensuring that those most directly affected by the events of 9/11 were made aware of the program. We established relationships with various family groups such as Tuesday's Children, Voices of September the 11th, and WTC United Family Group. In addition, one Project Liberty program specifically was responsible for providing counseling to all those visiting Memorial Park, which is adjacent to the Office of the Chief Medical Examiner where the unidentified remains of the victims of the tragedy are housed.

In addition to administering the general program, Project Liberty staff were responsible for organizing and managing Project Liberty counseling and support coverage at memorial events and anniversaries, including those for Flight 587. Project Liberty counselors were also present when families of the deceased provided impact statements to the Department of Justice (DOJ) and FBI for the trial of Zacarias Moussaoui.

Training was also an important aspect of Project Liberty. Staffs were trained in the basics of crisis counseling. A large percentage took advantage of additional training opportunities offered by the program, such as community mapping, presentation skills and compassion fatigue. Many individual agencies also offered training customized for their specific program.

Throughout the course of Project Liberty, we were constantly reminded that the crisis counseling model, as defined by FEMA, limited the scope of Project Liberty services to short term crisis counseling, outreach, education and referrals. At about the midway point (August 2002), we approached FEMA with information that we were gaining from our experience in seeing thousands of New Yorkers who had experienced the terrorist attacks. Our providers were finding that, although most people needed only one session, a significant percentage required additional counseling time. While these people did not need long-term mental health treatment they were likely to benefit from additional counseling sessions. We made a case for this in Washington, DC, in the summer of 2002, and were able to obtain from FEMA permission to slightly expand our services to include brief therapeutic interventions. This was the first time that a CCP was granted permission to provide this type of extended intervention to those impacted by a disaster. FEMA also responded to our appeal to develop activities that promote community resilience.

It is with great pride that many Project Liberty provider agencies speak about their experience with the program. Many staff report that the outreach aspect of the program made them more acutely aware of the people living in their communities and what they need. The outreach enabled Project Liberty staff to develop relationships with key stakeholders and numerous institutions that had not been significantly engaged in community outreach and disaster response. Provider staffs have reported that many of the paraprofessional staff who were hired as indigenous outreach workers have decided to further their education and pursue counseling related careers. Most of the Project Liberty provider staff have secured positions elsewhere in their respective agencies, thereby constituting a well trained and experienced cadre of staff available should future responses be necessary.

So we can see that although the project itself is no longer functioning at its previous levels, it has changed the nature of mental health services in NYC. We now have expertise in crisis counseling throughout the City, have helped to destigmatize mental disorders, and created the capacity to mobilize a credible mental health response to any future disaster.

Although New York State has discontinued most Project Liberty service delivery activities, there are two highly affected populations who continue to receive Project Liberty services: the New York City Fire Department and New York City's Department of Education (DOE). In response to New York City's request, SOMH has requested from FEMA another extension to continue their work at least until September 30th, 2004, for the Fire Department and we have asked that SOMH request from FEMA an extension of services for DOE through the next full school year. In addition, it is important that we recognize that the Red Cross and 9/ll Fund continue to provide funding for counseling for those who meet specified eligibility criteria based on the degree of their exposure to the attack.

We want to emphasize, however, that Project Liberty has not been the Department's only response to 9/ll. In addition, we have been very active in organizing New York City's mental health disaster preparedness and response activities, as we face the possibility of future disasters of many kinds, including terrorist attacks. We have established an Office of Mental Health Disaster Preparedness and Response, which maintains regular communication with mental health responders, and our City, State and Federal government partners. This office has:

• Developed response plans and protocols for voluntary disaster mental health providers in a tiered, function-based manner;
• Introduced best practices and outreach to targeted communities and involved non-traditional psychosocial providers, particularly members of the clergy;
• Established a Mental Hygiene Incident Response Team of essential staff to maintain critical core mental hygiene services should a disaster occur;
• Developed a hospital training program to educate emergency medical personnel on the psychosocial aspects of disasters secondary to weapons of mass destruction;
• Trained community mental health staff to respond to incidents involving weapons of mass destruction; and
• Provided public information on disaster mental health and risk communication training seminars to mental health responders.

As we take these next steps in the post- 9/ll and now largely post-Project Liberty environment, we do so with greater knowledge of the mental health needs of New Yorkers. We have learned that those people most at risk of developing post-traumatic stress disorder symptoms immediately after a disaster are those who were directly involved in the disaster, particularly if they were injured, lost loved ones or their home or job, or were a rescue worker. Among these people, most recover. However about a third, most likely those who have suffered further loss or trauma, will have persistent PTSD symptoms. For example, people who subsequently lose a job, develop a medical illness, are a victim of a violent crime, or have an automobile accident. In addition, there is also a group who develop symptoms many months or years after the event. These are people who also experience a subsequent trauma or stressor. For example, a firefighter who later responded to a devastating fire with mortalities or whose parent dies from illness. Thus, over time, those people who will suffer with post-traumatic stress symptoms are a combination of those who developed symptoms immediately after the disaster that became persistent and those who developed symptoms later on.

In addition to this knowledge, we expect that we will learn more about the effects of terrorist attacks from the information we will gather in the upcoming years from the World Trade Center Health Registry. The Registry is a critically important effort to evaluate the physical and mental health effects of those who were exposed to the 9/ll disaster. Over 30,000 people have enrolled in the Registry. DOHMH intends to contact participants every 2 to 3 years and inquire about their health as well as undertake focused studies. We believe that this Registry will be vital to our ability to not only respond to the effects of 9/ll, but also to any possible future acts of terrorism.

As we move forward and seek to meet the mental health needs of New Yorkers following 9/ll, we want to reiterate that FEMA's crisis counseling program was not designed to address the continuing mental health needs we confront. It was established to support short-term interventions and assist those immediately impacted with the goals of restoring normalcy when possible and referring those in need of more services for specialty mental health care. More crisis counseling is not the answer to 9/11 over two and a half years after the event. We now need to be able to provide traditional mental health treatment for those with persistent PTSD and related anxiety and depression disorders. To help address these needs, the Mayor's federal legislative agenda includes a call to amend the Stafford Act, which is the law that governs FEMA's disaster assistance, including its crisis counseling program. We know that the ramifications of terrorism are more widespread, pervasive and long lasting than the effects of natural disasters such as floods, earthquakes and hurricanes. We also know that the most profound and lasting consequences of terrorist attacks are psychological in nature. The specific problems that Project Liberty encountered with the FEMA guidelines included the prohibition on reimbursing traditional mental health treatment (i.e., therapy and medication), the extremely short-term nature (i.e., crisis) of the counseling that is permitted, and the absence of payment for case management. The changes that are needed to modernize the crisis counseling section of the Stafford Act are part of the Mayor's overall proposal to Congress to update the entire Stafford Act so it can respond to both natural disasters and terrorist attacks.

We want to note, as well, that there was an effort to secure funding to address the continuing needs of New Yorkers. SOMH applied for a $22 million grant from the Victims of Crime program. This program was a significant source of continued funding for Oklahoma City's services after FEMA's funding ceased. This grant request was not successful. Although we were not directly a part of that effort we were supportive of the State's attempt to find additional funds. Given that many disasters affect more than one locality in a state and the fact that many localities do not have the means to compete for funding at the federal level, most federal funds flow only to state governments. When that is the case, we work to support New York State's efforts to obtain additional federal funds.

As you well know, New York City's need for mental health services has only increased since the events of 9/ll. Although disaster relief funding enabled us to respond to the crisis, the mental health needs that most people have at this point are in the domain of the traditional mental health system. So, please le me restate the now painfully familiar problem of the State's cap on Medicaid funding for outpatient mental health services. We continue to work on eliminating this discriminatory restriction on the expansion of mental health services throughout New York State. This cap presented a serious problem for the mental health system before 9/ll. It now presents a far greater problem.

Thank you for the opportunity to discuss the important issue of post-9/ll mental health services. I am pleased to take any questions.

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