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.     

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.     

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.     

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.     

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.     

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.     

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.     

Awareness and perceptions of a communitywide mental health program in New York city after September 11

The Project Liberty program was established after the terrorist attacks of September 11, 2001, to offer free mental health services to New York City residents. The authors used data from a random-digit-dial telephone survey to assess public awareness of and willingness to make use of Project Liberty's services. They found that 24 percent of the New York City residents surveyed (480 of 2001 respondents) had heard of Project Liberty four months after September 11. Persons with lower socioeconomic status and those who had psychological symptoms consistent with posttraumatic stress disorder were more likely to say that they would contact Project Liberty. The results of the study suggest that although awareness of this public mental health services was low, Project Liberty was well received among the people who may be most likely to need its 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.     

Outreach to homeless mentally ill people: Conceptual and clinical considerations

This paper describes a model of outreach predicated on developing a trusting, meaningful relationship between the outreach worker and the homeless person with mental illness. We describe five common tasks inherent in this model of outreach (establishing contact and credibility, identifying people with mental illness, engaging clients, conducting assessments and treatment planning, and providing ongoing service). Other issues discussed include: (a) Responding to dependency needs and promoting autonomy; (b) setting limits while maintaining flexibility; (c) resistance to mental health treatment and follow-up service options.Dr. Morse is with the University of Missouri-St. Louis, the Missouri Institute of Mental Health, and Community Alternatives; Mr. Miller, Mr. Rosenberg, are with Community Alternatives; Dr. Calsyn is with the University of Missouri-St. Louis; Ms. West is with the Adapt Institute, and Ms. Gilliland is with the St. Mary's Health Center.The authors would like to thank a number of individuals who contributed useful suggestions about outreach for this paper, including Vince Estrada, Steve Laffoon, Gitry Hydebrand, Linda Harmann, James Steffen, Loretta Haggard, Susan Morse, Christy Estrada, Chris Lhotak, Lou Kimmell, and Fred Osher. We also appreciated the editorial and word processing assistance provided by Dorothy Gano and Marnice McLean.     

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.     

Outreach services to clients with severe mental illness in the Okayama Prefectural Mental Health and Welfare Center

The community mental health system in Japan is being adversely affected by diminishing public mental health services, including those provided by public healthcare centers and the mental health divisions of municipal governments. It seems reasonable to expect that this will lead to the inadequate detection, assessment, and treatment of the population with mental health problems, and thus to the flooding of psychiatric hospitals with excessive numbers of severely mentally ill patients. In this article, the author suggests the utility of a 'network-based outreach team' as a possible remedy for the current situation. The Okayama Prefectural Mental Health & Welfare Center is running a network-based outreach team on a trial basis to work with individuals with serious mental illness who are disengaged from mental health services. The team is composed of members from the Mental Health & Welfare Center, public mental health services, and human service agencies. The main aims of this team are two-fold: to enhance support for clients with severe mental illness who are overwhelmed with multiple complex problems, through collaborative intervention within the framework of a network-based outreach team; and to develop the qualities and skills of public mental health service and human agency personnel in order that they better assist people with severe mental illness, by providing joint training with mental health specialists of the Mental Health & Welfare Center in community settings. The author suggests that the team structure of the network-based outreach team will benefit public mental health services by reintegrating currently fragmented services into coordinated ones.     

Assessing the service needs of people with mental handicaps: THE JAY PROJECT PHASE 1

The Jay Project was set up to devise a method for assessing the needs of individuals with mental handicaps, with particular reference to the services that they were then receiving and to identify future service needs. It presented service needs from the point of view of the individuals, rather than trying to fit them into current service provision. Assessments covered all the major areas of life. Findings were presented to a Steering Group whose members were drawn from all the relevant local statutory and voluntary agencies. It was hoped that the Project would be able to inform service planning both for the individuals assessed and on broader planning levels, would create a multi-agency forum and approach to services, and would help to improve inter-agency contact and cooperation.     

Socioeconomic status and self-reported barriers to mental health service use.

OBJECTIVE: Socially disadvantaged individuals are at high risk for having their mental health service needs unmet. We explored the relations among education level, income level, and self-reported barriers to mental health service use for individuals with a mental illness, using data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). METHODS: Our sample group comprised the 8.3% of adult respondents who met the CCHS 1.2 criteria for an anxiety or affective disorder in the past 12 months (n = 3101). We examined the association between education and income levels and self-reported accessibility, availability, or acceptability barriers to mental health care. RESULTS: Accessibility, availability, and acceptability barriers were reported by 3%, 5%, and 16% of our sample, respectively. Individuals with a high school diploma were less likely than individuals without a high school diploma to report acceptability barriers to care (odds ratio 0.65; 95% confidence interval, 0.45 to 0.93). Higher-income individuals were less likely than lower-income individuals to report acceptability barriers to care (odds ratio 0.69; 95% confidence interval, 0.50 to 0.96). Employment, distress level, age, and family structure were also associated with acceptability barriers. CONCLUSION: Issues related to acceptability explain most of the unmet need for mental health services. Program planners should consider the development of targeted approaches to service delivery and outreach for low-income, working individuals who have not completed high school.     

Increasing the Repertoire for Depression Care: Methods and Challenges of a Randomized Controlled Trial of Peer Support for Vulnerable Older Adults

ObjectiveLow-income White and older adults of color face barriers to depression care. Our purpose is to describe the methods and challenges encountered during the implementation of a randomized controlled trial to test the effectiveness of a peer support depression care intervention for low-income White and older adults of color during the COVID-19 pandemic.MethodsPeer Enhanced Depression Care (Peers) is an 8-week community-based intervention that uses peer mentors who are trained and supervised to provide social support and self-care skills to depressed older adults. The effectiveness of the intervention in reducing depression will be evaluated by following a sample of older adults recruited in the community over a 12-month period. Target enrollment is 160 older adults. We hypothesize that participants randomized to the Peer Enhanced Depression Care intervention will experience greater decrease in depressive symptoms compared to participants randomized to the social interaction control. We provide lessons learned regarding the recruitment of BIPOC and White low-income older adults and peer mentors during the COVID-19 pandemic.ResultsRecruitment challenges occurred in primary care clinics that were unable to accommodate recruitment efforts during the pandemic. This led to focused outreach to community-based organizations serving older adults. Challenges to participant recruitment have included barriers related to stigma, distrust, as well as unfamiliarity with research. Peer mentor recruitment was facilitated by existing government-supported resources.ConclusionsThis study will provide knowledge regarding the effectiveness, mechanism, and processes of delivering an informal psychosocial intervention such as peer support to a vulnerable older adult population.     

Assessing the service needs of people with mental handicaps: METHOD USED IN THE JAY PROJECT

This article sets out the method used in the Jay Project for assessing the service needs of people with mental handicaps over the major areas of life. Detailed interviews were conducted with the individuals themselves, their close family and/or friends, and the professional workers who knew them well. Available records were also consulted. A summary of the perceptions and opinions of the people interviewed was drawn up and presented under key headings, followed by a list of “service needs” as seen from the point-of-view of the service users. The assessments were discussed by the Project's multi-agency Steering Group where recommendations for action were made, the aims being to try to obtain better services for individuals and to indicate to service planners the degree of service need in a geographical area. The method demonstrated that broad-based assessments could be produced in a relatively short time. The structure of the Project created a forum for multi-agency dialogue and helped to foster inter-agency cooperation.     

Employing people with psychiatric disabilities to engage homeless individuals through supported socialization: the Buddies Project

This article describes the Buddies Project, a small time-limited grant that employed two part-time formerly homeless persons on a community-based mental health outreach team to participate in social activities with "difficult to engage" homeless individuals. We offer clinical examples that point to the success of this small supported socialization project. We suggest that employing people with psychiatric disabilities to participate in social activities with homeless persons with psychiatric disabilities can be an important tool to decrease homeless persons' social isolation and engage them into mental health treatment and independent housing.     

Ethics of assertive outreach (assertive community treatment teams)

Purpose of review: Assertive outreach, also known as assertive community treatment, is a well established service model in several countries for people with severe and enduring mental health problems who do no engage with psychiatric services. However, it has been criticized for being coercive and paternalistic. The present review considers a number of recent contributions to the debate concerning the ethics of assertive outreach. Recent findings: Assertive outreach brings into sharp focus a number of ethical issues that affect most mental health services, but it also generates new ones, primarily whether delivery of a service to people who are refusing it and are not legally bound to accept it can be justified. Several authors have grappled with these issues, mainly through using traditional principles of ethical treatment based on professional values, and this paper reviews such attempts at resolving those dilemmas. In so doing, it reveals the limitations of such approaches. Summary: In conclusion, the present review suggests an alternative ethical basis for supporting delivery of assertive outreach services to a reluctant client group, which focuses more on the client's values and areas of assistance with which they express genuine appreciation and satisfaction.