Characteristics of Project Liberty clients that predicted referrals to intensive mental health services.

OBJECTIVE: The authors describe characteristics of Project Liberty crisis counseling recipients that predicted referral to more intensive professional mental health treatments over the two-year period after the terrorist attacks on the World Trade Center. METHODS: Random-effects ordinal regression models were applied to data from 684,500 logs of Project Liberty service encounters for individual counseling sessions. RESULTS: Overall, about 9 percent of individual counseling visits ended with a referral to professional mental health services. Individuals needing intensive mental health treatment continued to enter Project Liberty for two years after the World Trade Center attacks. The strongest predictor of referral was having reactions to the attack that fell into a greater number of the four domains assessed-behavioral, emotional, physical, or cognitive domains. Individuals with reactions in four domains were most likely to be referred. Those who had greater attack-related exposure were also more likely to be referred. CONCLUSIONS: It is important to provide long-term access to brief counseling and triage services and to target these interventions specifically to individuals displaying greater distress or impairment and having more traumatic exposure.

Demographic characteristics of individuals who received Project Liberty crisis counseling services.

OBJECTIVES: This article describes demographic characteristics of service recipients and their patterns of use of crisis counseling services provided under Project Liberty during the 27 months after the September 11, 2001, attacks on the World Trade Center. It also examines the extent to which service recipients reflected the demographic characteristics of their home communities. METHODS: A total of 753,015 service encounter logs submitted by 177 providers were analyzed to determine rates of use by different demographic groups and to evaluate patterns of use over time with goodness-of-fit and logistic regression models. RESULTS: A total of 687,848 individual crisis counseling sessions were provided to an estimated 465,428 individuals, including large numbers of persons from racial or ethnic minority groups and non-English-speaking individuals. Most of these services were provided to residents of the five New York City boroughs, with a small percentage of services to residents from the ten surrounding counties. Most services were provided in community settings rather than provider offices. African-American and Hispanic individuals showed the greatest increase in rates of accessing services over time. Follow-up visits were significantly more likely to be by Caucasians than by non-Caucasians, and children were more likely than adults to receive follow-up visits. Demographic characteristics of individuals using Project Liberty crisis counseling services generally were representative of the five boroughs and ten other counties constituting the greater metropolitan region and representative of estimated need. CONCLUSIONS: Project Liberty provided services that were accessible to individuals of diverse racial and ethnic backgrounds.

Use of Project Liberty counseling services over time by individuals in various risk categories.

OBJECTIVE: The authors examined temporal changes in the rates at which people sought access to Project Liberty services after the attacks of September 11, 2001, according to risk category (family of missing or deceased, persons directly affected, uniformed personnel, other rescue or recovery workers, schoolchildren, displaced employed and unemployed workers, persons with disabilities, and the general population). METHODS: First visits to individual counseling services, as determined from logs of 465,428 service encounters, were proportioned among risk categories and plotted across 27 months. RESULTS: Individuals who lost family members accounted for 40 percent of visits in the first month but dropped to 5 percent or fewer visits by five months. Uniformed personnel used disproportionately larger percentages of services after the first year. Occupationally displaced and unemployed workers sought counseling at relatively steady rates. CONCLUSIONS: Postdisaster counseling should be made available for extended periods, with shifting emphases to meet the changing needs of high-risk groups.

Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001.

OBJECTIVE: The authors surveyed a sample of Project Liberty crisis counseling recipients approximately 1.5 years after the terrorist attacks on September 11, 2001, to determine the proportion of respondents who screened positive for complicated grief, a recently identified condition marked by symptoms of continuing separation distress and accompanying bereavement-related traumatic distress. METHODS: A total of 149 service recipients drawn from eight high-volume providers responded to a telephone survey that included questions to screen for complicated grief. RESULTS: Approximately half of the recipients knew someone who had been killed in the attacks. Of those recipients, 44 percent screened positive for complicated grief. Individuals who lost a family member were more likely than those who lost an acquaintance to screen positive for complicated grief. Positive screens were associated with functional impairment independent of the presence of symptoms consistent with full or subthreshold major depression or posttraumatic stress disorder (PTSD). Thirty-two percent of those who screened positive for complicated grief did not meet even subthreshold criteria for major depression or PTSD. CONCLUSIONS: Results affirmed the importance of complicated grief as a unique condition and indicated the need to attend to the psychological consequences of bereavement in disaster-related mental health services.

Outcomes of enhanced counseling services provided to adults through Project Liberty.

OBJECTIVE: Project Liberty provided brief crisis counseling to 753,015 residents of New York City and surrounding counties after the attacks on the World Trade Center. Most regained predisaster functioning after counseling. For those who did not, Project Liberty provided enhanced services by specially trained, licensed mental health professionals. Individuals receiving crisis counseling and enhanced services responded to confidential telephone interviews about 18 and 24 months, respectively, after the attacks. Impairment was compared between groups to determine whether enhanced services recipients reported improved functioning and fewer symptoms of depression, posttraumatic stress, and complicated grief. METHODS: Crisis counseling recipients (N=153) were interviewed once and enhanced services recipients (N=76) were interviewed twice about symptomatology and daily functioning. RESULTS: The samples did not differ in age or gender. Significantly greater proportions of enhanced services recipients reported knowing someone who died as a result of the attacks, having been involved in rescue efforts, or having lost their job because of the attacks. Compared with crisis counseling respondents, enhanced services recipients at their first interview reported significantly more symptoms of depression, grief, and traumatic stress and significantly poorer daily functioning in five life areas. At follow-up, enhanced services respondents reported significant improvement in three of five functioning domains, significantly fewer symptoms of depression and grief, and marginally less traumatic stress. CONCLUSIONS: Recipients of enhanced services were more impaired than people who received only crisis counseling. On the basis of reports from service recipients, meaningful improvements in functioning and symptoms may be associated with the receipt of enhanced services.

Did Project Liberty displace community-based medicaid services in New York?

OBJECTIVE: This study analyzed how the introduction of Project Liberty services after the September 11, 2001, terrorist attacks affected agencies' provision of community-based Medicaid mental health services in the New York metropolitan area. METHODS: Provision of Medicaid mental health services was tracked between January 2000 and June 2003 for provider agencies participating in Project Liberty (N=164) and for a comparison group of mental health provider agencies that did not participate in this program (N=94). RESULTS: Overall, participation in Project Liberty did not significantly affect the volume of Medicaid services provided. However, for agencies with one site, a statistically significant difference was seen; compared with agencies in the comparison group, agencies that participated in Project Liberty claimed a mean+/-SE decrease of $4.66+/-3.57 less in Medicaid services per month per Project Liberty visit. CONCLUSIONS: Project Liberty permitted rapid expansion of the total volume of services provided by community-based organizations without interfering with the provision of traditional services, although a modest effect was seen for smaller agencies. Although the results do not imply that "supply side" planning for disaster needs would not improve system response, they do imply that implementation of flexible "demand side" financing can call forth a large volume of new services rapidly and without interfering with other community services.

Clients' satisfaction with Project Liberty counseling services.

OBJECTIVE: Satisfaction with 11 aspects of service quality and four domains of effectiveness was assessed for counseling services offered through Project Liberty after the September 11, 2001, attacks on the World Trade Center. METHODS: A total of 607 Project Liberty service recipients completed anonymous questionnaires, telephone interviews, or both. The 11 aspects of quality were counselor respect for client, willingness to listen, cultural sensitivity, speaking the same language as the client, amount of counseling time, convenience of meeting time and location, information received, whether the service would be used again, whether the service would be recommended to friends or family, and overall quality of service. The four effectiveness domains were daily responsibilities, relationships, physical health, and community involvement. RESULTS: At least 89 percent of service recipients rated Project Liberty as either good or excellent across 11 service quality dimensions and four effectiveness domains. The counselor's respect for clients and his or her cultural sensitivity were rated particularly favorably. CONCLUSIONS: These ratings suggest that, from the viewpoint of these recipients of counseling services, Project Liberty counselors were largely successful in providing accessible, acceptable, and useful services after the World Trade Center disaster. Such evaluations can be conducted in a cost-effective manner and integrated with evidence-based practice to ultimately ensure that recipients of counseling receive the most efficient and effective interventions.

Use of clients' self-reports to monitor Project Liberty clinicians' fidelity to a cognitive-behavioral intervention.

OBJECTIVE: This study examined outcomes associated with clinicians' fidelity to key elements of a cognitive-behavioral treatment intervention developed for Project Liberty's enhanced services counseling program. METHODS: In telephone interviews 60 individuals reported how often their clinicians provided six components considered central to the intervention by the intervention developers. Respondents received services at sites where some (25 to 50 percent) or all clinicians had received training in the intervention. RESULTS: Compared with respondents who received services where only some clinicians had received training (N=19), those who received services where all clinicians had received training (N=41) were significantly more likely to report that their clinicians applied techniques central to the intervention (p<.01). Additionally, those who received services from sites where all clinicians were trained were significantly more likely to report that they had been given homework (p<.05). CONCLUSIONS: Brief questions to service recipients are a useful and cost-effective way to monitor intervention fidelity.

Effectiveness of two methods of obtaining feedback on mental health services provided to anonymous recipients.

OBJECTIVE: The authors examined alternative methods for obtaining feedback from people receiving anonymous mental health services via Project Liberty, an initiative that provided free counseling to residents of the New York City area after the 2001 attacks on the World Trade Center. METHODS: Counselors offered all English-speaking and Spanish-speaking adults who used Project Liberty crisis counseling services the opportunity to evaluate Project Liberty via a telephone interview (eight sites) or a brief questionnaire (four sites). RESULTS: A total of 107 service recipients provided feedback via a brief 32-item questionnaire, and 153 gave feedback via a 45-minute telephone interview. Although the overall participation rates were modest (less than 20 percent), nearly three-quarters of those who volunteered to participate in the telephone interview (for which they received $20) did so. Neither gender nor racial or ethnic group was associated with a greater likelihood of participating in one method over another. CONCLUSIONS: Responses to items on the brief questionnaire and in the telephone interview were similar, and offering multiple response methods increased participation rates. Although telephone interviews were more costly than the questionnaire to administer, they provided important additional information about ongoing symptoms and problems that individuals experienced after the attacks. The modest response rates obtained in the evaluation indicate that future evaluations of postdisaster services need to use methodstomaximizeresponse rates and provider adherence to administrative tasks that are critical to the evaluation.

Clusters of event reactions among recipients of Project Liberty mental health counseling.

OBJECTIVE: This study aimed to determine a pattern in the frequency with which individuals who manifested distress reactions resembling diagnostic syndromes of posttraumatic stress disorder (PTSD) and major depressive disorder accessed services provided by Project Liberty. METHODS: Hierarchical cluster analysis was applied to 31 reactions to stress (event reactions) shown by 465,428 recipients of Project Liberty counseling, to determine how well event reactions mapped onto traditional diagnostic criteria. Service recipients were tracked when they first sought Project Liberty counseling during the 27 months after the attacks. Those who reported three or more reactions associated with these clusters were characterized as having possible diagnosable conditions. RESULTS: Strong consistent clusters corresponding to traumatic stress and depressive symptoms emerged, with 26 percent, 16 percent, and 8 percent of service recipients rated as having possible PTSD, major depressive disorder, or both, respectively. Taken together, this group constituted over 40 percent of service recipients served by Project Liberty almost every month throughout the 27 months of its existence. CONCLUSIONS: Event reactions, as reported by Project Liberty crisis counselors, many of whom were nonclinicians, mapped coherently onto diagnostic syndromes, suggesting that a checklist of such reactions may be useful to disaster counselors as a cost-effective screening and planning instrument. The steady entry over time into Project Liberty counseling by a substantial number of individuals experiencing high levels of distress underscores the need for providing long-term access to mental health services postdisaster.

Service utilization and event reaction patterns among children who received Project Liberty counseling services.

OBJECTIVES: This study examined service utilization and event reaction patterns among children who used crisis counseling services provided under Project Liberty for 27 months after the September 11, 2001, terrorist attacks on the World Trade Center. METHODS: The authors analyzed logs of 681,318 service encounters submitted by Project Liberty counselors, paying particular attention to demographic characteristics and reported event reactions. RESULTS: Nine percent of service recipients reached by community-based Project Liberty providers were children, whereas census data for the 15 counties and boroughs served by Project Liberty indicated that children constituted 25 percent of the population. Service use as a function of race or ethnicity and of gender was consistent with census data. Similar to findings for adults, the most common emotional event reactions reported for children were experiencing sadness and tearfulness, being anxious and fearful, having difficulty concentrating, experiencing irritability and anger, having intrusive thoughts or images, and having difficulty sleeping. Behavioral event reactions listed on service logs suggested that older children (12 to 17 years) were more likely to use drugs whereas elementary school-age children were more likely to display signs of anxiety, isolation and withdrawal, and difficulties with concentration and memory. CONCLUSIONS: Sensitivity to differences in the event reaction patterns shown by younger and older children may be useful in refining treatments to help reduce the psychological impact of children's trauma after terrorist incidents.

The road back: predictors of regaining preattack functioning among Project Liberty clients.

OBJECTIVES: This study determined the likelihood and predictors of Project Liberty counseling recipients' reporting their return to satisfactory life functioning 16 to 26 months after the September 11, 2001, attacks. METHODS: Using anonymous brief paper-and-pencil questionnaires or structured telephone interviews, 452 respondents provided retrospective ratings of their functioning in five life domains during the month before the World Trade Center attacks and the month immediately before the assessment. Information on demographic characteristics and exposure to risk during the World Trade Center attacks also was obtained and used in logistic regression models. The 153 respondents who were interviewed by telephone also rated helpfulness of various coping strategies. RESULTS: In the five domains, 77 to 87 percent of the sample reported good to excellent functioning in the month before the attacks; 55 to 68 percent reported returning to at least the same level of daily functioning after the attacks. African Americans were two to four times more likely than respondents of all other races to report a return to good or excellent functioning after the attack in four domains. Compared with respondents who did not lose their job as a result of the attacks, those who did lose their job were less likely to return to good preattack functioning in two domains. Project Liberty counseling reportedly helped 90 percent of respondents return to predisaster levels of functioning. CONCLUSIONS: Responses to future terrorist attacks should consider demographic characteristics and the impact of the attack because they can affect return to preattack functioning. Counselors should support activities that facilitate positive responses and ameliorate negative psychological responses.

Impact of a media campaign for disaster mental health counseling in post-September 11 New York.

OBJECTIVE: After the September 11, 2001, terrorist attacks on the World Trade Center, the New York State Office of Mental Health (NYOMH) initiated a three-phase multifaceted, multilingual media campaign that advertised the availability of counseling services. This study evaluated the association between patterns of spending within this campaign and the volume of calls received and referred to a counseling program. METHODS: Spending on television, radio, print, and other advertising was examined, as was the corresponding volume of calls to the NetLife hotline seeking referrals to counseling services. RESULTS: From September 2001 to December 2002, $9.38 million was spent on Project Liberty media campaigns. Call volumes increased during months when total monthly expenditures peaked. Initially, flyers, billboards, and other material items accounted for most monthly expenses. Over time, spending for television and radio advertisements increased, whereas other advertising declined. Temporal patterns show that in periods after an increase in media spending, call volumes increased independently of other sentinel events such as the one-year anniversary of the attacks. CONCLUSIONS: Sustained advertising through multiple media outlets appeared to be effective in encouraging individuals to seek mental health services.

A psychometric analysis of Project Liberty's adult enhanced services referral tool.

OBJECTIVES: Project Liberty was the first federally funded crisis counseling program to offer evidence-informed treatments to crisis counseling recipients in need of more intensive clinical intervention. The Adult Enhanced Services Referral Tool was developed as a screening instrument for making and monitoring referrals to enhanced services. This study aimed to examine how well the tool functioned for identifying persons who would perceive a need for professional treatment. METHODS: A one-page tool was created that assessed demographic characteristics, risk categories, and psychological reactions to the focal event, September 11, 2001. Psychosocial reactions were assessed by the 12-item SPRINT-E, which is an expanded version of the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). The SPRINT-E was embedded in the Adult Enhanced Services Referral Tool. Data were collected from 788 clients who received crisis counseling between June and October 2003. RESULTS: The SPRINT-E is a unidimensional measure of distress and dysfunction. Internal consistency was excellent for the total sample (alpha=.93) and subsamples. Among the 543 clients offered referral, 71 percent accepted. Among those offered referral, the number of intense reactions (score of 4, quite a bit, or 5, very much) was by far the strongest predictor of referral acceptance. CONCLUSIONS: The SPRINT-E was successfully integrated into the crisis counseling program and provided an apparently successful, empirical basis for referral from counseling to professional treatment. Results of the brief psychological assessment provided a stronger basis for referral to treatment than membership in a risk category (for example, family member of deceased) alone.

Using staff focus groups to refine a feedback process for people who used Project Liberty.

Project Liberty provided free counseling services to those affected by the September 11th attacks. Focus groups were conducted with Project Liberty provider staff to gain feedback on their participation in the process of evaluating Project Liberty individual crisis counseling services. Focus groups provided information regarding barriers to eliciting feedback from people who used Project Liberty services that informed planning for the next phase of the evaluation. Focus groups proved to be a valuable method for collecting data from service providers across provider sites that differed geographically, culturally, ethnically, and organizationally, as well as in methods of offering services to individuals with mental health problems related to the attack on the World Trade Centers.

Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II.

OBJECTIVE: To develop treatment recommendations for the use of antipsychotic medications for children and adolescents with serious psychiatric disorders and externalizing behavior problems. METHOD: Using a combination of evidence- and consensus-based methodologies, recommendations were developed in six phases as informed by three primary sources of information: (1) current scientific evidence (published and unpublished), (2) the expressed needs for treatment-relevant information and guidance specified by clinicians in a series of focus groups, and (3) consensus of clinical and research experts derived from a formal survey and a consensus workshop. RESULTS: Fourteen treatment recommendations on the use of atypical antipsychotics for aggression in youth with comorbid psychiatric conditions were developed. Each recommendation corresponds to one of the phases of care (evaluation, treatment, stabilization, and maintenance) and includes a brief clinical rationale that draws upon the available scientific evidence and consensus expert opinion derived from survey data and a consensus workshop. CONCLUSION: Until additional research from controlled trials becomes available, these evidence- and consensus-based treatment recommendations may be a useful approach to guide the use of antipsychotics in youth with aggression.

The kids oneida project: what happened to services when the payment rules changed.

Community-based systems of care may provide high quality, cost-effective alternatives to institutional care for children and adolescents. This report examines Kids Oneida (KO), a not-for-profit managed care entity established in upstate New York in 1998 to serve such children and their families. Changes in payment rules that established the program allowed KO to contract with a wide array of providers to provide and be reimbursed for non-traditional and formerly unreimbursable services, such as mentoring and supervision. By design, emphasis was on highly individualized plans of care in which traditional office-based services played only a small part. During the first 30 months of KO's operation, 228 children, whose severity of emotional disturbances was comparable to those of children placed in residential treatment centers, had average monthly expenditures for first admissions of 2,734 dollars for services and 228 dollars for administrative fees. Median length of stay in the program was 13.5 months, yielding an estimate of 39,987 dollars for typical length of stay. Length of stay and treatment costs were not related to children's gender or race. Length of stay was significantly longer for children with diagnoses indicating attention deficit hyperactivity disorder and behavior disorders. Treatment costs were significantly higher for children with behavior disorders and/or substance use and children who had had prior contact with the juvenile justice system.