[Senate Hearing 110-481]
[From the U.S. Government Publishing Office]
S. Hrg. 110-481
POST-CATASTROPHE CRISIS: ADDRESSING
THE DRAMATIC NEED AND SCANT
AVAILABILITY OF MENTAL HEALTH CARE
IN THE GULF COAST
=======================================================================
HEARING
before the
AD HOC SUBCOMMITTEE ON DISASTER RECOVERY
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
OCTOBER 31, 2007
__________
Available via http://www.gpoaccess.gov/congress/index.html
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
__________
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii TED STEVENS, Alaska
THOMAS R. CARPER, Delaware GEORGE V. VOINOVICH, Ohio
MARK L. PRYOR, Arkansas NORM COLEMAN, Minnesota
MARY L. LANDRIEU, Louisiana TOM COBURN, Oklahoma
BARACK OBAMA, Illinois PETE V. DOMENICI, New Mexico
CLAIRE McCASKILL, Missouri JOHN WARNER, Virginia
JON TESTER, Montana JOHN E. SUNUNU, New Hampshire
Michael L. Alexander, Staff Director
Brandon L. Milhorn, Minority Staff Director and Chief Counsel
Trina Driessnack Tyrer, Chief Clerk
AD HOC SUBCOMMITTEE ON DISASTER RECOVERY
MARY L. LANDRIEU, Louisiana, Chairman
THOMAS R. CARPER, Delaware TED STEVENS, Alaska
MARK L. PRYOR, Arkansas PETE V. DOMENICI, New Mexico
Donny Williams, Staff Director
Aprille Raabe, Minority Staff Director
Amanda Fox, Chief Clerk
C O N T E N T S
------
Opening statements:
Page
Senator Landrieu............................................. 1
Senator Stevens.............................................. 10
WITNESSES
Wednesday, October 31, 2007
A. Kathryn Power, M.Ed., Director, Center for Mental Health
Services, Substance Abuse and Mental Health Services
Administration, U.S. Department of Health and Human Services... 10
Anthony H. Speier, Ph.D., Director, Disaster Mental Health
Operations, Office of Mental Health, Louisiana Department of
Health and Hospitals........................................... 18
Jan M. Kasofsky, Ph.D., Executive Director, Capital Area Human
Services District, Baton Rouge, Louisiana...................... 20
Kevin U. Stephens, Sr., M.D., J.D., Director, New Orleans Health
Department..................................................... 22
Ronald C. Kessler, Ph.D., Professor of Healthcare Policy, Harvard
Medical School, and Principal Investigator of the Hurricane
Katrina Community Advisory Group............................... 29
Howard J. Osofsky, M.D., Ph.D., Kathleen and John Bricker Chair
of Psychiatry, Department of Psychiatry, Louisiana State
University Health Sciences Center.............................. 31
Mark H. Townsend, M.D., DFAPA, Professor and Vice Chairman for
General Psychiatry, Director of Psychiatry, Medical Center of
Louisiana at New Orleans....................................... 33
Alphabetical List of Witnesses
Kasofsky, Jan M., Ph.D.:
Testimony.................................................... 20
Prepared statement........................................... 71
Kessler, Ronald C.:
Testimony.................................................... 29
Prepared statement with an attachment........................ 100
Osofsky, Howard J., M.D., Ph.D.:
Testimony.................................................... 31
Prepared statement........................................... 113
Power, A. Kathryn, M.Ed.:
Testimony.................................................... 10
Prepared statement with attachments.......................... 41
Speier, Anthony H., Ph.D.:
Testimony.................................................... 18
Prepared statement........................................... 58
Stephens, Kevin U. Sr., M.D., J.D.:
Testimony.................................................... 22
Prepared statement with attachments.......................... 93
Townsend, Mark H., M.D., DFAPA:
Testimony.................................................... 33
Prepared statement........................................... 117
APPENDIX
``Trends in mental illness and suicidality after Hurricane
Katrina,'' September 2007, by Ronald C. Kessler, Sandro Galea,
Michael J. Gruber, Nancy A. Sampson, Robert J. Ursano, and
Simon Wessely.................................................. 120
Michael A. Zieman, FACHE, Administrator of Memorial Behavioral
Health, Memorial Hospital at Gulfport, Mississippi, prepared
statement...................................................... 152
Lafayette Parish School System, prepared statement............... 155
East Baton Rouge Parish Schools, Baton Rouge, LA, prepared
statement...................................................... 156
Monroe City School District, Monroe, LA, prepared statement...... 157
World Health Organization, December 2006, Bulletin............... 159
``The Louisiana Model for a Local System of Care,'' report from
the Capital Area Human Services District....................... 169
Chart entitled ``Mental Health Resources in New Orleans,''
submitted for the Record by Senator Landrieu................... 175
Chart entitled ``SAMHSA Funding to Gulf Coast in Fiscal Year
2006,'' submitted for the Record by Senator Landrieu........... 176
POST-CATASTROPHE CRISIS: ADDRESSING
THE DRAMATIC NEED AND SCANT
AVAILABILITY OF MENTAL HEALTH CARE
IN THE GULF COAST
----------
WEDNESDAY, OCTOBER 31, 2007
U.S. Senate,
Ad Hoc Subcommittee on Disaster Recovery
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:35 p.m., in
Room SD-342, Dirksen Senate Office Building, Hon. Mary
Landrieu, Chairman of the Subcommittee, presiding.
Present: Senators Landrieu and Stevens.
OPENING STATEMENT OF SENATOR LANDRIEU
Senator Landrieu. Good afternoon. The Subcommittee on
Disaster Recovery will come to order.
When I became Chairman of the Subcommittee on Disaster
Recovery at the beginning of this year, I promised that this
Subcommittee would work to create the most effective disaster
response and recovery system possible, streamlining current
processes, designing brand-new tools, where necessary,
promoting better coordination between government at all levels,
the private sector, and the nonprofit community, particularly
as it relates to dealing with catastrophic disasters.
With the help of my Ranking Member, Ted Stevens, this
Subcommittee has held five hearings since its inception in
March 2007. Our first hearing was basically an overhead
snapshot of the current situation, urgent steps toward fixing
the recovery process led off by testimony from GAO. The second
was a hearing entitled ``Beyond Trailers: Creating a More
Flexible, Efficient, and Cost-Effective Federal Disaster
Housing Program,'' examining a more efficient, cost-effective
way to handle the Federal disaster housing program. Our third
hearing was ``Repairing the Road Home Program,'' trying to help
literally hundreds of thousands of homeowners and renters get
back to their communities and their neighborhoods. Our fourth
was a hearing on problems with FEMA's public assistance program
entitled ``FEMA's Project Work Sheets: Removing the Most
Obvious Obstacles to Our Recovery.'' And, last, just less than
a month ago, I had the privilege of hosting a field hearing in
Anchorage, Alaska with Senator Stevens actually looking at a
pending disaster of coastal erosion on the northwestern shore
of Alaska at a small fishing village, Shishmaref, where the
impacts of coastal erosion were clear and dramatic.
Through these hearings, we have been able to create a
narrative that tells a story that I think is very compelling
and one that this country needs to hear and absorb, and that is
that our country's disaster response mechanism lacks the muscle
and the flexibility necessary to prevent and ward off disasters
as well as to facilitate the long-term recovery of impacted
communities, particularly from catastrophic disasters.
Only last week, we saw the heroic efforts of first
responders in California as they battled the massive fires that
destroyed over 500,000 acres. The dramatic images of this fire,
as well as this morning's 5.2 magnitude earthquake in the Bay
Area, reminds us that disasters can and will strike anywhere,
that no place in the United States is immune.
The Federal Government appears to have applied some of the
lessons learned from the 2005 hurricane and subsequent levee
failures. However, we have to understand that putting out those
fires, as horrible as they are, and which tragically claimed
1,676 homes, 250 businesses, and it took 16 lives, which is
horrific to even think about those numbers, but the comparison,
if you will, to Hurricanes Katrina and Rita that destroyed
266,000 homes, 18,000 businesses, and killed nearly 1,700
people, is what this Subcommittee has focused a good bit of its
time and attention on.
The common thread, however, between these two events,
despite their difference in their magnitude, is the fact that
survivors of these fires and the survivors of the floods are
both suffering right now from severe emotional and mental
impacts. These impacts will be long lasting for California
survivors, and they are long lasting for the survivors along
the Gulf Coast.
Many of you who watched the coverage of the wildfires saw
reports of distress, nightmares, and emotional disturbances in
evacuees as they camped out in shelters awaiting news on the
status of their homes and their loved ones. Unfortunately for
them, I know that this is only the beginning. Even 2 years
after our terrible 2005 hurricane season, hurricane survivors
along the Gulf Coast continue to suffer emotionally as they
ride out the slow recovery process.
For Hurricanes Katrina and Rita survivors from all walks of
life, the stress from the storm and rebuilding has hit a high
level that can only be described as a crisis. The loss of
homes, jobs, and loved ones, together with the separation of
family and the slow, painful pace of recovery has left, I
think, emotional scars.
The mental health situation has emerged as one of the most
critical issues facing our recovery, and that is the focus of
the hearing today. From our police force, our firefighters, and
other first responders, who themselves were victims, to our
young children, to the elderly, from everyday men and women
trying to provide for their families, the mental health crisis
in the Gulf Coast has left no segment of society untouched.
Between May 2005 and February 2006, 668 first responders
were surveyed by the LSU Health Sciences Center: 19 percent of
police officers exhibited symptoms consistent with post-
traumatic stress disorders (PTSD); 26 percent exhibited
symptoms of major depression; 1 in 5 said their alcohol
consumption had increased. A survey of 2,757 children returning
to New Orleans within a year of Hurricane Katrina found that 20
percent had been touched by a hurricane-related death or
injury; 33 percent had been temporarily separated from parents
or guardians; 1,638 school children grades 4 through 12 were
also surveyed by LSU; 54 percent met criteria for PTSD or
depression. During the same period of time, 31 percent of
children preschool to age 5 demonstrated symptoms meeting
criteria for mental health referrals.
We always have a challenge in our community for mental
health. There never seems to be enough resources or enough
services. But the situation along the Gulf Coast and the
potential long-term impacts of the fires in California warrant
some attention and our focus today.
The city of New Orleans currently has just five active
emergency rooms. As of August 2006, only 77 out of 460 pre-
Hurricane Katrina beds, inpatient psychiatric beds, are
available in New Orleans. This has forced hospitals to turn
away even suicidal patients. Recent surveys have found that
only 140 out of 617 primary care physicians have returned. An
American Psychiatric Association survey found that 22 of 196
psychiatrists--only 22--are still practicing in New Orleans.
Now, when I say New Orleans, I mean the regions: St.
Bernard, parts of St. Tammany, Jefferson, and Orleans Parishes.
We still have major destruction in Cameron on the western side
of our State, and along the Mississippi Gulf Coast, the
communities of Waveland and Biloxi and other places--Pass
Christian, MIssissippi--are still very significantly impacted.
[The prepared statement of Senator Landrieu follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Landrieu. So I thank Senator Stevens for joining
me. He has been a real champion in this effort. I would like
now to ask for his opening statement, and then when he finishs,
I will be introducing our first witness.
We do have three panels, but we intend to move this hearing
quickly, and we do anticipate other Members showing up, and
when they do, they will be recognized and their statements
submitted for the record. Senator Stevens.
OPENING STATEMENT OF SENATOR STEVENS
Senator Stevens. Well, thank you very much, Madam Chairman.
I do not have an opening statement. I look forward to hearing
the statements of the witnesses. We have a conference on
defense at 3:30 p.m., so I will have to leave at that time.
That is why I would just as soon move long.
Thank you very much.
Senator Landrieu. Thank you, Senator Stevens.
Our first witness will be Kathryn Power, Director of the
Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration (SAMHSA). Prior to her
appointment, she served for over 10 years as the Director of
the Rhode Island Department for Mental Health, Retardation, and
Hospitals. She has also served in the capacity as community
health director there.
Ms. Power, you have a tremendous amount of responsibility
and authority over this Federal program, and we thank you for
being here today and look forward to your testimony.
TESTIMONY OF A. KATHRYN POWER, M.ED.,\1\ DIRECTOR, CENTER FOR
MENTAL HEALTH SERVICES, SUBSTANCE ABUSE AND MENTAL HEALTH
SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Ms. Power. Thank you very much, Madam Chairman and Members
of the Subcommittee. I am really appreciative of the honor to
appear before you today, and I thank you for the opportunity.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Power with attachments appears in
the Appendix on page 41.
---------------------------------------------------------------------------
I am going to be brief in my oral response to the questions
that you had asked me to address, and I would ask that you make
the full test of my remarks a part of the hearing record.
As a mental health professional, I have a special lifelong
interest in trauma responsive care. As I started my career as a
rape crisis counselor, I learned about the powerful effects of
trauma--how trauma could psychologically devastate a person,
how the damage from trauma could spill into a person's entire
social network, including partners, family, friends, and
children. But it does not take an expert in trauma or mental
health care to know that times of crisis leave indelible marks
etched on our psyches, we need only to look inward. I also
learned that healing and recovery are possible and do take
time.
Some 50 years ago, I still remember Hurricane Hazel, a
deadly and tremendous storm of enormous power that made an
enduring impression on my young mind.
I remember the nuclear accident on Three Mile Island on the
Susquehanna River in Pennsylvania. I lived a mere 8 miles away
from that accident with my two sons and husband.
And I remember the night of the Station Night Club fire in
West Warwick, Rhode Island, in which 100 people lost their
lives, and at that time I was the State Mental Health and
Substance Abuse Authority. Today, 4 years later, the community
and the State are still recovering.
I am forever changed by these events. I am sure that each
of you has had significant similar transforming experiences.
Some events propel us forward; others test our mettle.
Hurricane Katrina did both. While challenges remain, I am
convinced that already Hurricane Katrina has taught community,
State, and national citizens and leaders ways in which to
effect fundamental change in how we understand and approach
disaster preparedness and response, particularly in behavioral
health, and above all, for the most vulnerable victims of these
events.
Effective disaster preparedness and response are an
essential part of SAMHSA's public health mission in building
resilience and facilitating recovery. That is why, in September
2005, SAMHSA focused all of its resources to assist the
affected communities along the Gulf Coast deliver an effective
behavioral health response. That is why today we are still
responding to the behavioral health needs and outcomes for
those still struggling to heal and to recover.
Based on our research early on, we estimated that over
500,000 women, men, and children might be in need of crisis
assistance. Our understanding of the risk and protective
factors mandated that our work at that time proceeded along two
courses that were parallel that emphasized the principles of
collaborating with the local and State authorities. The first
path was to lower the psychological distress and build
resilience for those otherwise healthy individuals for whom the
disaster might have increased their risk of behavioral health
problems; and, second, ensuring continuity of care for those
individuals who had mental and substance abuse disorders
already.
SAMHSA alone has provided more than $170 million in mental
health and substance abuse funding, including $64 million in
2007. Those funds are also in addition to the Crisis Counseling
Program, which is funded by FEMA and administered by SAMHSA, as
well as the SAMHSA staff costs that were associated with the
mobilization of over 900 Federal and civilian staff that
provided mental health disaster services in the region. They
include discretionary and block grant mental health and
substance abuse treatment and prevention funds.
While much physical and emotional rebuilding remains to be
accomplished, the work that SAMHSA undertook in collaboration
with Federal, State, and local officials in the affected Gulf
Coast regions stand as a testimony of what can be done and what
can be done well to help rebuild the emotional health and well-
being of a proud population. The process and outcomes of our
work to reach out to people through the Crisis Counseling
Program, whether to assure them that their feelings were normal
and healthy or to urge them toward further evaluation and
treatment, were the subject of and intensive cross-site
evaluation in July 2007. And, Madam Chairman, that is one of
the studies and objective evaluations that you had asked me to
bring, and I brought a copy of that with me today.
While we could say that our work is complete and life in
the Gulf Coast today approximates what it was in the days
before Hurricane Katrina and her sister hurricanes, we cannot
say that. However, it is not for want of effort on the part of
SAMHSA and on the part of HHS and on the part of the
Administration. The work of building resilience and
facilitating recovery begins with individuals in families, in
neighborhoods, and in communities themselves. What SAMHSA can
do best is to provide state-of-the-art tools, state-of-the-art
resources to our colleagues on the ground, and I believe that
is precisely what we have done over the many months since
Hurricane Katrina.
Today, I believe that the resources and the knowledge are,
in fact, placed squarely in the hands of the States, to use as
they determine to the best interest of the behavioral health of
the women, men, and children throughout the Gulf Region, and
all of those who have been affected. In just these past 3
weeks, SAMHSA has offered to continue to work with leaders of
the Gulf State Region to bring greater transparency to the
process through which resources can be best allocated to meet
the behavioral health needs of Hurricane Katrina survivors.
I would be very pleased to answer any questions you may
have, and thank you again for the opportunity to speak before
you.
Senator Landrieu. Thank you.
Let me begin by commenting that clearly your background
more than adequately prepares you for the job that you are
doing now, and I appreciate the sincerity with which you are
approaching it. One of my questions has to do, though, with the
law that seems to restrict some funding or most of the funding
of FEMA going to crisis counseling as opposed to treatment.
Could you comment about whether you agree with the status
of the law? If not, have you recommended a change? And how does
that narrow interpretation affect you from actually delivering
treatment? Because I understand that the crisis counseling is
actually limited to five visits only and no real treatment in
terms of mental health needs.
Ms. Power. Thank you for the question, Senator. I think it
is a very important one, and I think that we need to focus on
the Crisis Counseling Program (CCP), which really was
originally entitled the Crisis Counseling, Training, and
Assistance Program when it was started 30 years ago. And I
think that even if we just talk about the semantics of that,
the origination of the program was basically designed to really
be short-term interventions. It was not intended from its
origin to be long-term mental health treatment.
One of the things that we have found over the past several
years, particularly in working with the Gulf States, is that
the component parts of the Crisis Counseling, Training, and
Assistance Program are sometimes hard to understand, and we
need to explain a little bit more clearly what the particular
programs are under the CCP.
So under one program of the CCP, which is the Immediate
Services Program, that is the program that is available for a
60-day period that is really designed to hopefully support
public education efforts after disasters about behavioral
health reactions, and really the phenomena--and, actually, the
upside of what has occurred post-Hurricane Katrina is that for
the first time--and I think your Subcommittee is evidence of
this. For the first time, people are really paying attention to
mental health and substance abuse issues in a disaster. And I
really do think that that is such an important step in the
right direction from a public health perspective.
The other part of the Counseling Program is the longer-term
program, which is 9 months, and that program is really
designed, again, for public education campaigns, for short-term
interventions, for hotline services, and for individual crisis
counseling in the outreach to homes.
What we did do in this particular iteration is that we did
create, working with FEMA and working with both Louisiana and
Mississippi, another classification of service called
Specialized Crisis Counseling Services. And that was, frankly,
Senator, the first time that they were able to take the Crisis
Counseling Program and say, wait a minute, we think that there
might be another level of need that needs to be reviewed; and
if the State can justify the need in catastrophic disasters,
there was a specialized crisis counseling service that was
provided.
Senator Landrieu. Do you know how much money was allocated?
Because I see here that the total amount awarded to the
immediate crisis counseling--I think this is just Louisiana
numbers--was $20 million.
Ms. Power. In the Immediate Services Program?
Senator Landrieu. In the Immediate Services Program for
declared parishes. Then it looks like there is about $1.2
million for undeclared parishes.
Ms. Power. OK.
Senator Landrieu. Do you know how much of that money was
carved out for actual treatment the way you have just
described?
Ms. Power. Well, I think your question actually talked
about the fact that there are longer-term treatment needs that
are not necessarily being met by the Crisis Counseling Program.
Senator Landrieu. Correct.
Ms. Power. And I think that is true because the Crisis
Counseling Program was really expected to meet short-term
interventions. The individuals from the State I am sure can
verify this. The longer-term treatment was really, I think,
identified as being supported through the social services block
grant dollars that Louisiana received. So that was what I
understand were the plans to use those funds for.
Senator Landrieu. Correct, and we received, according to
this, $64 million. But my point is since you have testified
that it came to your attention, or the administrator's, that
perhaps the crisis case program that was crafted 30 years ago
was missing maybe an important third level of treatment, say
again what you all did.
Ms. Power. What we did was we had conversations with FEMA
and with both the State, both Louisiana and Mississippi, and
developed what we called an expanded service through
Specialized Crisis Counseling Services, and that was basically
intended to try to address some of the needs that you had
articulated around substance abuse screening and referral,
suicide risk assessment and intervention, teaching stress
management techniques and coping techniques and the
prioritization and triaging of particular anxiety symptoms,
assisting with the coordination of care, and doing focused
interventions with a licensed mental health professional and
resource coordinator.
So that was the expanded Specialized Service Counseling,
and both Louisiana and Mississippi took advantage of that.
Senator Landrieu. Great. And, again, I am trying to get to
what percentage of the allocation was directed to that new
approach, generally.
Ms. Power. We will have to get that for you.
Senator Landrieu. If you could get that for me, because I
appreciate the movement to be flexible and try to respond to
the situation, and I think for the record it would be important
to know what resources followed that action, because it brings
me to--and then I will turn it over to my colleague for any
questions. And this is a small program, but it is somewhat
indicative. And, again, this is not to be overly critical of
you personally or your department, but recently, as you know, I
had to, with the help of my colleagues, reinstate funding for a
$400,000 grant that was one of the few operational grants in
the entire Gulf Coast, very small amount of money but
significant to us, $400,000, that was actually eliminated this
year in the SAMHSA budget. And I had to, with the help of the
other Members of the Senate, reinstate that last week in an
appropriations process.
So it leads me to believe that while your testimony seems
to be that you are all leaning forward, evidently there is some
part of the agency that is cutting back funding when another
part of the agency is trying to support additional funding.
Now, we fixed that, and I thank the Senators for stepping up.
But I cannot keep fixing every $400,000, $300,000, and $200,000
grant. We have got to see some real action, I think, within the
Department to make changes that are necessary and recommend
things to us for improvement.
Senator Stevens.
Senator Stevens. Thank you.
Ms. Power, if you think about the national scene with the
hurricanes in the Southeast, violent storms in the West, the
fires in California, and floods up in New England, isn't it
true that there is this problem of adjustment throughout the
country today, notwithstanding on top of that we have two wars
going on? How do you allocate your resources under those
circumstances?
Ms. Power. Well, Senator, we have certainly through our
discretionary grant portfolio and through those programs
particularly focused on systems of care for children,
particularly focused on the child trauma network, as the
Senator had mentioned, and we have a fairly wide portfolio of
discretionary programs that we know we will hear from and
receive applications from those areas that have been affected
by these disasters.
We have seen the effects of the expansion of the Garrett
Lee Smith suicide program take effect and take root within
college campuses. We have seen expansion of the National
Suicide Hotline, which we actually have created another hotline
for purposes of response. So we try to use our discretionary
program, even though it is not huge, we try to make sure that
discretionary program can appropriately respond to the mental
health and substance abuse needs of populations. It is very
huge, and particularly because you as leaders in the Senate and
in the House are saying mental health is really important, the
emotional lives of people is very important, and it is finally
being given the same level of attention as physical health
care. We applaud that and think that is wonderful. And as
people become more attuned to and understand what psychological
first aid is, what resiliency factors work well for people, we
hope that education and training and awareness are going to go
a long way for people to be able to understand what they can do
for their own mental health in terms of traumatic reactions,
what they can do to support their families and themselves in
ways we have learned from September 11, 2001. We are learning
from Hurricanes Katrina, Rita, and Wilma. We are learning from
each disaster what are some of those risk and protective
factors that we need to educate people more about so that, in
fact, people can be armed with much stronger personal tools and
techniques to be able to handle what is really quite
unrelenting pressure. With one crisis after another, the
environment in which we live, with the status of life today, it
has been very difficult to try to react.
So we try to use our discretionary portfolio, and we are
also trying to get information out about how do you assess your
own mental health, what is good psychological first aid, what
are good tools and techniques that you need to have as an
individual. Nobody ever taught us that when we were growing up,
and we are finally learning that is an important part of our
educational system and an important part of our family-
strengthening system.
Senator Stevens. Well, my comment would be that I am from
the generation where we did not have that luxury, but beyond
that, it does seem to me that we are not doing enough in our
educational process. You just said we used to learn it at home,
and if we are not going to learn it at home, we have got to
learn it in school. What are we doing about putting us into the
educational system and dealing with prevention rather than
reaction?
Ms. Power. One of the things that I did, Senator, in my
life is that I taught elementary school. I taught fifth and
sixth grade, and then I taught high school math for several
years. And as a parent and as a teacher, I have always believed
that we have not necessarily used our schools and the
opportunities in our schools to build mental toughness and
mental competency. And so we have adopted an emotional
competency agenda using work that is well researched in terms
of bringing emotional competency skills into the classroom and
helping students build their sense of mastery in terms of their
own emotions. And we have some selected programs that we use
with our Safe Schools Healthy Students grantees that we work
with, with the Department of Education. We have anti-bullying
programs. We have a number of focused school mental health
programs that really do reflect and, I think, show an
appropriate way to encourage our teachers, our family members,
and our students to become much more knowledgeable about their
own competency and their own emotional level of mastery for the
way they are, the way they think, the way they behave, and the
way they function. And I think that there is very powerful work
going on in our schools that are selected sites to teach us
more about how do we get better at that and how can we push
that out further and make not just centers of excellence but
have it across the United States in all of our school systems.
Senator Stevens. Thank you very much.
Senator Landrieu. Thank you.
I would like to follow that up now because my question
would be specific. As you know, we lost--probably close to 50
schools were destroyed just in Orleans Parish, another 7 in St.
Bernard, and any number of schools throughout the Gulf Coast,
elementary and high schools were destroyed, and that whole
system is being rebuilt and revamped.
Does SAMHSA right now have any current initiatives with the
school boards or parishes or counties along the Gulf Coast, any
extra support that you all are doing directly, not through
social service block grants, to help with mental health
counseling in the schools? And if so, where? And if not, why
not? Is it a lack of resources?
Ms. Power. I am not familiar, Senator, with anything
specific. I will go back and offer you my review of, if we have
any specific grantees that may be receiving some of our
prevention and school mental health promotion grants, and I
will take a look at that and make sure that you have that
information. I did not look at that portfolio before I came
today. I apologize.
Senator Landrieu. If you could get that information to us.
Ms. Power. Absolutely.
Senator Landrieu. Because this is a real need in our
schools. The schools have become a potential stabilizing force
in the community.
Ms. Power. Absolutely.
Senator Landrieu. Stabilizing to the children that have no
home, no church, no playground, no neighborhood, and
stabilizing to the parents who can put their children in school
during the day and manage to either gut their home, rebuild
their home, or go back to work, or all of the above. And
schools are becoming in this recovery the sort of necessary and
essential anchor.
Now, hospitals are anchors, too, and churches are anchors,
and synagogues, but schools, I am observing as a leader in this
community, are becoming sort of the central anchor. And it
seems to me that would be a good place of delivery to help and
counsel children who can be identified by their teachers and
administrators, and also a place where parents can be receiving
information about the state of their own mental health and
strategies or coping mechanisms as you have suggested. So I
would like you to look into that.
Just two more questions, and then we will move to the
second panel. According to my records, in 1995 and again in
2002, the FEMA Inspector General recommended that FEMA and
SAMHSA should collaborate to evaluate the overall effectiveness
of this Crisis Counseling Program that you have described and
we have talked about. Do you know if there has been an official
ongoing collaborative, either then or now, between FEMA and
SAMHSA to see if this program could be restructured to meet
some of the needs that we have identified in your testimony?
Ms. Power. I came to SAMHSA in 2003, Senator, and since I
have been there, we clearly have an ongoing cooperative
coordination arrangement with FEMA on a regular basis to talk
about the Crisis Counseling Program. We did have--and this is
the other piece that I brought--a final evaluation, outside
external evaluation on the Crisis Counseling Program done in
July 2007. So that I am delivering to you today so that you can
see that this is a formal evaluation of the Crisis Counseling
Program.
In that evaluation, they have made very specific
recommendations for FEMA and SAMHSA to sit down and have a
conversation about what is the next evolution on this program,
and, in fact, we are starting those discussions and have had
those discussions and are going to continue those discussions.
And as a matter of fact, in preparation for today's hearing, I
talked to the mental health commissioners and substance abuse
directors of the Gulf Coast States and said give me your ideas
about where we need to go, because we have this set of
recommendations, and we will be sitting down with FEMA and
having those conversations.
Senator Landrieu. OK. Thank you for your time and your
attention, and we will accept that report, and it is something
that our Subcommittee is going to spend some time focusing on
because we think the need is real, it is severe, and it needs
to be addressed.
Ms. Power. Thank you, Senator. I really wanted to just add
one other item which I did not get a chance to speak about some
of the other things that we have been working on. But I will
tell you that just recently we learned that the State of
Louisiana had spoken with the Department of Health and Human
Services about the need that they had relative to the shortages
of mental health professionals in the area, particularly in the
areas that you described, and that the shortages in those
mental health professionals were really a very significant
barriers to utilizing the existing resources that were
available for delivering care. And I wanted to just report--
which I think is good news--that the Department has offered to
assign Commission Corps officers who have mental health
expertise to fill vacancies in the State and local clinics
until full-time staff can be recruited in the areas. And we are
really excited about the opportunity to be able to have the
Department in discussions with the State Health Department on
the feasibility of that, and I think that is really a wonderful
step in the right direction.
Senator Landrieu. Well, I appreciate that, and I hope that
your remarks will be noted in this Subcommittee, but also when
monies are not expended, which sometimes happens in many of our
accounts, despite the ongoing efforts for recovery, sometimes
in most instances it is because of the shortage of personnel or
the complete destruction of the facilities that would normally
absorb the funding. And the Gulf Coast should not be penalized
for that, but the programs should be made more flexible so that
those resources can be used more slowly over time as our
personnel come back.
Thank you so much.
Ms. Power. Thank you very much, Senator.
Senator Landrieu. If our second panel would come forward, I
will do your introductions as you take your seats. Our first
witness will be Dr. Anthony Speier. He is the Director of
Disaster Mental Health Operations for the Louisiana Office of
Mental Health. Prior to Hurricane Katrina, Dr. Speier served as
Director of the Division of Program Development and
Implementation for the Louisiana Office of Mental Health. He
served as Chair of Adult Services and brings many years of
experience to his job.
Jan Kasofsky, our second witness, is Executive Director of
Capital Area Human Services, and let me thank her for her great
work. Many of the citizens of Orleans and St. Bernard fled to
the Capital Area, and her agency has done just a heroic job to
literally provide service and care for hundreds of thousand of
citizens as they fled to higher ground. She has any number of
experiences that give her the ability to do the job that she is
doing now.
Dr. Kevin Stephens, good to see you again. He is currently
the Director of the City of New Orleans Health Department. He
serves on the clinical faculty of Xavier University, Dillard
University, the LSU Medical School, and Tulane Medical School.
It should be noted that Dr. Stephens stayed at Charity Hospital
through the disaster, was there during and immediately
afterwards, and has been helping to lead the redevelopment of
our health care system in the region.
So I hope that you all will limit, of course, your remarks
to--I think we have 5 minutes each, and then we will open it up
for questions, and we will start with you, Dr. Speier.
TESTIMONY OF ANTHONY H. SPEIER, PH.D.,\1\ DIRECTOR, DISASTER
MENTAL HEALTH OPERATIONS, OFFICE OF MENTAL HEALTH, LOUISIANA
DEPARTMENT OF HEALTH AND HOSPITALS
Mr. Speier. Thank you, Madam Chairman, Senator Stevens, and
Members of the Subcommittee. I would like to spend a few
moments giving a little history about the mental health system
in Louisiana prior to Hurricane Katrina.
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\1\ The prepared statement of Mr. Speier appears in the Appendix on
page 58.
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Governor Kathleen Blanco and Senator John Breaux initiated
a health reform movement in Louisiana in 2004, of which mental
health reform was a major component. The storm came, challenged
us in many ways, but that process has moved forward. And we now
operate under a strategic plan for access to mental health
care, which is the State's plan to organize services, and it
goes beyond just what the Office of Mental Health provides. It
refers to services that occur throughout both the public and
private sector.
The basic principles of that plan is the use of evidence-
based practices, providing effective services for people of all
ages, provide accessible crisis services, provide combined
access to primary and mental health care, and provide
individualized supports for persons with serious and persistent
mental illness and people with serious emotional disturbance.
There is a very real crisis in Louisiana and the Gulf
Coast, as you both have mentioned. The mental health needs, as
we have seen them in people with serious and persistent mental
illness, are tremendous and have gotten only worse from the
storm. When you look at the general population, there have been
recent studies by both the Kaiser Family Foundation, by the
Louisiana Public Health Institute, and by Dr. Kessler's group.
They have indicated over and over how people can access health
care, people can access mental health care; the hospitals that
they were used to going to no longer exist. There is even
better evidence that people who have a more compromised
situation, people who have less resources available to them,
have a harder time accessing health care. This is true for
older adults, middle-aged people, and, most profoundly, our
children.
Since September 2005, I have directed the Crisis Counseling
Program, what we call ``Louisiana Spirit,'' and what we have
seen in that program is that we have people who never before
would have used mental health services are now desperately in
need of them. Just to give you all a few numbers that represent
the scope of work we have done, since September 2005, we have
made over 2.6 million contacts with people throughout the
State. Of those, we have made contacts with people in southwest
Louisiana and southeast Louisiana. We have provided over
400,000 more in-depth counseling sessions to a little over
239,000 individuals, of which 100,000 of those individuals are
in the greater New Orleans area. And what we are finding is
those numbers are not decreasing at this point in time. Recent
numbers from our crisis lines show a doubling of numbers since
August and September over June and July, and we think the
anniversary issues and the prolonged rate of recovery have had
a major impact on people and still has that impact.
You mentioned the Specialized Crisis Counseling Program,
which is one of the very positive things that we have been able
to accomplish with FEMA and SAMHSA, and in our program,
specialized crisis counselors are providing services to people
who are experiencing suicidal ideation, who are experiencing
senses of hopelessness and helplessness.
We find from our people that they are experiencing fear.
They are fearful for their children. They are fearful and
anxious about the next storm and living in a trailer. People
are sad, and when they get home, they find that they all of a
sudden experience loss and grief. So they get their home built,
and then that rush is gone, and all of a sudden the losses are
tremendous that they experience, and they need to be able to
deal and treat the grief they are experiencing.
In Louisiana today, instead of things resolving themselves,
we still have over 40,000 people in trailers, which we estimate
between 200,000 and 250,000 people are still in a displaced
status, both in Louisiana and in our neighboring States. People
who are still struggling with the early stages of disaster
recovery, which usually take place in the first 9 months after
a disaster--or 6 months after a disaster, and we have
experienced that with a number of storms. This storm is not
stopping.
Senator Landrieu. Could you try to wrap up in the next 30
seconds?
Mr. Speier. I will. The points I would like to make about
what we need to do: We need to meet the survivor needs. We need
a process of providing quick referral and treatment for trauma,
anxiety, and depression. We need to assist people with profound
feelings of loss and grief; ensure rapid response to
psychiatric emergencies; provide commitment to group
interventions to help survivors re-establish security in their
lives.
And what we need to do for future disasters is to provide a
national strategy where we do psychological first aid; we build
a mobile volunteer professional corps of mental health
professionals; we institute mitigation programs where we can
plan for disasters. Right now we are not able to plan for a
disaster through the FEMA process if it is a mental health
issue. We need opportunities to have continuity of operations
plans, and we need to be able to have 5-year cycles of funding
that are flexible and allow us to move the dollars as we so
need so that we meet the needs of the people rather than the
needs of the Federal regulations. Thank you.
Senator Landrieu. Thank you very much. Dr. Kasofsky.
TESTIMONY OF JAN M. KASOFSKY, PH.D.,\1\ EXECUTIVE DIRECTOR,
CAPITAL AREA HUMAN SERVICES DISTRICT, BATON ROUGE, LOUISIANA
Ms. Kasofsky. Madam Chairman and Members of the
Subcommittee, thank you for the opportunity to testify about
the mental and physical health needs and disaster response in
the greater Baton Rouge area. I am Dr. Jan Kasofsky, Executive
Director of Capital Area Human Services District, the publicly
funded mental health authority in the Baton Rouge area. The
impact of Hurricane Katrina far exceeds the geographic
destruction in New Orleans. As you have already mentioned, over
350,000 New Orleanians initially evacuated to the Baton Rouge
area, and the efforts by the provider community led the
groundwork for a best practice approach for normalizing access
to ongoing care.
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\1\ The prepared statement of Ms. Kasofsky appears in the Appendix
on page 71.
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Between 30,000 and 40,000 evacuees remain, some having
chosen to stay, while others are using it as a staging point to
return to their city. There is no question that the rate of
disabilities and homelessness in this population, particularly
mental illness, is much higher than in the typical population
and is reflected in the volume and acuity data in this region.
The public adult mental health clinics currently have a 65-
percent increase in new clients, more patients in crisis, and a
10- to 12-week wait to see a psychiatrist. The wait time for
children is now 6 to 10 weeks. Although the mental health
clinics have added social workers and streamlined intake
processes, we cannot meet the capacity expansion demands to see
and retain patients without adding psychiatrists. Although we
have the funding, we have not been able to recruit needed
psychiatrists. It is essential that the recruitment incentives
for physicians in the greater New Orleans area be available to
the greater Baton Rouge area to support capacity expansion.
The local private and public emergency departments have a
sustained 30-percent increase in behavioral health crisis,
totaling over 720 individuals per month, with all of these
individuals needing hospitalization. The large number of people
using the emergency departments is a clear indication of
increased trauma, the loss of public and private beds from the
greater New Orleans area, and a massively overwhelmed local
public outpatient clinic system. Clearly, increasing clinic
capacity will greatly assist the emergency departments.
A specialized psychiatric emergency department is being
established locally as one of nine components of a crisis
system. Services there will include administering medication,
counseling, referrals, and linkage to ongoing appropriate and
alternative services. This modular unit is being developed
while we await receipt of the funds into our budget.
Homelessness is now stable at a 15-percent increase, with
80 percent noting their disability as mental illness and
addictive disorders and 37 percent noting that they came to the
area due to Hurricane Katrina. With 876 FEMA trailers still
occupied, though scheduled for de-commissioning soon, and
additional families still receiving rental subsidies for market
housing, it is anticipated that, given their income levels,
many will enter the homeless population once subsidies end.
There must be acknowledgment of the levels of ongoing need by
the evacuees for accessible, affordable housing, especially for
those with disabilities.
Capital Area is newly contracting for housing and treatment
for individuals with addictive disorders and mental illness to
serve 120 individuals annually. Within the region, an
additional 50 to 75 transitional housing beds are under
construction, and permanent supportive housing has increased by
31 beds. There are an additional 162 units currently under
construction or in the development phase.
While primary care needs are being met, access to public
specialty clinics is extremely limited. There is an average 17-
week wait for life-sustaining treatments needed from
cardiology, pulmonology, endocrinology, and other clinics.
Access is limited by funding for additional medical
specialists.
I will briefly identify five recommended changes to the
Federal disaster response which hindered or complicated our
local response and recovery efforts.
One, psychiatric medicines, methadone, and pain management
medicines are crucial and must be included in the Federal
formulary in a disaster.
Two, a building from which to deliver care at congregate
settings is required for providers to deliver confidential
care, provide privacy, and be sheltered from the weather.
Three, FEMA must establish transportation to nearby service
delivery facilities from the non-commercial congregate sites to
avoid dependency on mobile teams.
Four, the Spirit teams must be able to make direct
referrals for people experiencing trauma and in need of an
immediate intervention to ensure service access. The Stafford
Act must allow this during the immediate disaster response.
Five, in a disaster, the locally delegated authority must
be allowed to lead one unified approach as identified by the
National Incident Management System.
In conclusion, I want to thank this Subcommittee for its
attention to our needs and its financial assistance on behalf
of the greater Baton Rouge area evacuee and provider community.
In this continuing crisis, we still have ongoing recovery
needs, especially for psychiatrists and medical specialists to
expand capacity and for accessible and affordable housing.
Thank you.
Senator Landrieu. Thank you very much, Doctor. Dr.
Stephens.
TESTIMONY OF KEVIN U. STEPHENS, SR., M.D., J.D.,\1\ DIRECTOR,
NEW ORLEANS HEALTH DEPARTMENT
Dr. Stephens. Good afternoon, Chairman Mary Landrieu and
Ranking Member Ted Stevens, distinguished guests, all of you
who are present here. I am Dr. Kevin Stephens, Director of the
New Orleans Health Department, a city that contributes greatly
to our culture and commerce in this country, and it is a city,
however, that is still facing a crisis in the availability of
mental health care after the worst natural and manmade
catastrophic disaster that occurred in the United States.
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\1\ The prepared statement of Dr. Stephens with attachments appears
in the Appendix on page 93.
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Thank you for providing this opportunity to share with the
Subcommittee the urgent mental health care needs of our
community, and we appreciate your continued concern about our
progress in rebuilding the mental health system.
Hurricane Katrina devastated our infrastructure, flooding
seven of the nine hospitals and many other medical facilities.
And so what I want to do, I want to focus on three things,
three critical problems: One, the lack of an adequate number of
available psychiatric hospital beds for citizens in our region;
two, the ongoing challenge of recruiting and retaining mental
health professionals, as we heard earlier in this hearing; and,
three, the criminalization of mental health patients that
system gaps are causing. I will outline what existed before
Hurricane Katrina, what is currently available, and, finally,
what we have to do to adequately serve our citizens.
Prior to Hurricane Katrina, we had over 350 public and
private psychiatric beds available in New Orleans, and that
included 152 beds at the Medical Center of Louisiana, 30 at New
Orleans Adolescent Hospital, and others at DePaul and the VA.
The beds at Charity were critical because they served our
large population of uninsured and underinsured citizens, and
that facility included 92 inpatient beds, as well as 20 dual
diagnosis beds for those with psychiatric and substance abuse
problems, and a critically important 40-person capacity Crisis
Intervention Unit. This specialized unit allowed for
individuals in psychiatric crisis to be observed for evaluation
in a safe place. The Charity CIU served as the single point of
entry or central triage station. First responders were able to
transfer care of mental health patients to a designated area
for medical clearance and psychiatric evaluation, which was
done within one hour. The proximity to the emergency department
provided the seamless and critical medical clearance for
patients to be moved to the CIU for evaluation, treatment, and
release or admission, depending upon their illness. The CIU
also accepted referrals from other facilities which depended on
Charity to appropriately triage the patients.
Currently, there is less than half the number of public and
private mental health beds in the city as we had prior to
Hurricane Katrina. This is a particularly acute problem since
public hospital beds are unavailable to the uninsured. Of the
two Medical Center of Louisiana campuses--University and
Charity--only University Hospital has reopened. It provides
emergency department services and has 10 beds in a temporary
mental health emergency room extension (MHERE) unit. University
Hospital also has approximately a 20-bed detox unit, and the
State has opened approximately 52 beds at the New Orleans
Adolescent Hospital and the DePaul sites, with plans to
increase the number by the end of this year.
Thanks to the perseverance of Congress on Hurricane
Katrina-related health issues and the recent hearing, Secretary
Leavitt gave the area $100 million for primary and mental
health. We think that these are critical dollars for the area,
but it is too early for us to determine their impact on mental
health because we just got these funds several weeks ago.
However, these funds will not increase the number of inpatient
psychiatric beds.
We are also very grateful to the Medical Center of New
Orleans because--at Charity, because they have expanded and
responded to the need. However, because of a steady stream of
people returning home and new people coming to the area, there
is an increasing prevalence of mental illness since the storm.
Recent reports, as you will hear later, have said that the
prevalence of serious mental illness has pretty much doubled
from pre-Hurricane Katrina. In fact, our EMS department
averages one call per day of suicide attempt, bizarre behavior,
or actual suicide. We average 190 police calls per month from
our 911 call log for serious mental illness and threats of
suicide.
The city has three things I will just briefly say: One, the
lack of a CIU in the area. However, the MHERE at University
Hospital does not accept referrals from other hospitals; it
does not serve as a single point of entry for mental health,
but does provide some services, but we are in need of more. If
you look in the presentation here, you can see that the ER time
for the EMS is very prolonged. Our police department has troops
that go and wait in the emergency room to get services because
the emergency departments are really clogged up with mental
health patients.
A centrally located CIU is also important, and I just want
to get to the shortage of personnel. We are working with the
Acting Surgeon General to temporarily help us shore up our
mental health professionals.
Last, we have to create a system that does not criminalize
the mentally ill who go into jail due to lack of services.
The Stafford Act does provide some resources for crisis
counseling after major disasters. However, the act does not
provide for psychiatric services or funding for prescriptions.
The lack of portability of Medicaid from State to State
also must be addressed to improve access to health and mental
health care following a disaster. States should be required to
give full faith and credit to the evacuating State's Medicaid
program for the time of the declared emergency. This is
critical for mental health patients, especially now as we go
through the next hurricane season and so forth, especially when
you evacuate to other States, you have to have your insurance,
or else you have no insurance, and then you are back in the
problem again. And these people have mental illnesses. That
makes it more difficult for them to navigate. So this
portability of Medicaid from State to State, especially during
a declared emergency, is really something that we think is
critical.
I would just like to thank you for this opportunity to
speak on our mental health status and as well as your
commitment to New Orleans. And though we face a historic
crisis, we are hopeful that with your assistance we can solve
the remaining problems and build a better and stronger
community for everyone. Thank you.
Senator Landrieu. Thank you very much.
I have asked my staff to walk over to the charts here
because I think it is an important place to start the questions
for this panel.
This is a chart of mental health resources in New Orleans
before Hurricane Katrina and after Hurricane Katrina,\1\ and I
want to say again that if time would have allowed, we could
have had the same testimony for every parish and county that is
affected. Please do not take that this hearing is just about
New Orleans. It is an attempt to show the needs in the region
as well as what I have started to refer to as the ``host
communities,'' led primarily by Baton Rouge, but Hammond has
been another host community; Lafayette, Louisiana, has been a
host community; Alexandria, Louisiana; Shreveport; where people
are still displaced in other places, and I am sure this is the
same for Mississippi. The people of the Gulf Coast just did not
disappear. They have gone somewhere else, either to north
Mississippi or central Mississippi or to Alabama, until they
can get back to their homes.
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\1\ The chart submitted by Senator Landrieu appears in the Appendix
on page 175.
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So this is a crisis that is going on throughout the whole
Gulf Coast, but these are just some numbers. If you can see the
psychiatric beds in New Orleans, there were 350. Now there are
77. In the greater New Orleans area, it was 668 and now it is
289. Physicians in New Orleans, 617; now 140. Psychiatrists in
New Orleans, 196; today it is 22. Doctors participating in
Medicaid was 400; today it is 100. And this Subcommittee
intends to give the statistics for all the parishes and
counties for the record. None will be as dramatic as this, but
I would say that they are all going to have a significant
reduction of beds, facilities, and professionals needed to
solve this problem. And we intend to not just continue to talk
about this, but to come up with solutions. And the Federal
Government has an obligation, in my view, to be part of the
solution, but we are not the only entity responsible, and that
leads me to the questions to you, Dr. Speier, for the State of
Louisiana.
I understand the legislature--and I am not sure if it was
last year or the year before--recently cut funding to your
office by 23 percent. Is that true? If not, was there any
decrease at all in funding? Was there an increase? And can you
explain your budget situation right now from the State level to
your office?
Mr. Speier. I am not aware of the 23-percent decrease. I am
primarily with the Crisis Counseling Program, so I have been
involved in that, Senator, and cannot really speak to that
shortfall. I can speak to that we have received an increase
this year in our budget funding, annualizing many of the funds
that were provided through the social services block grant,
programs the legislature did not have any idea that money would
continue. They had reviewed our mental health activities and
made strategic investments out of that many. Rather than that
block grant money just coming in and going out, it laid the
foundation for the State to then come in and build sustainable
programs. And so this year, we have received I know at least
$13 million towards those programs.
Senator Landrieu. Because you are saying the Federal
Government--if I can interpret what you are saying--allowed the
State to keep its social service block grant funding and not
have to return it at the end of the year, which is customary.
It allowed them time to build a basis of services. I do not
want to put words in your mouth, but is that what you are
testifying to?
Mr. Speier. The social services block grant money was one
year----
Senator Landrieu. They were one time, but they are allowed
to be kept, as I recall----
Mr. Speier. Correct.
Senator Landrieu. Didn't we extend the deadline?
Mr. Speier. Yes, and they extended the deadline, but it was
late in the extension of that deadline. And so we still have
those social service block grant monies, and the State used its
own resources to expand mental health services during this
fiscal year.
Senator Landrieu. Because it is very important as we try to
marshal better, more streamlined, more effective, more muscular
Federal response, that the Federal Government believes that the
States and the local governments are doing their fair share as
well in terms of finding solutions.
What is the State's most pressing mental health need? I
know you listed several, but if you had to say what is on the
top of your list from your perspective, what would it be?
Mr. Speier. The State's most pressing mental health need is
human resources and the resources necessary to deal with the
hurricane recovery population. The resources that come into the
State now through Federal funds for--non-disaster Federal funds
and State funds are targeting people with serious and
persistent mental illness, people with serious emotional
disturbance. Those are the primary populations, and the
populations mandated by the State.
The new population which has emerged and continues to
manifest itself in more significant ways is the hurricane
recovery population. The people who are worn out and are
becoming now symptomatic in significant ways, we do not have
the treatment dollars to address this population nor the
workforce. We have experienced a 23-percent shrinkage in the
mental health professional workforce, as your graphs indicate.
It is what we have experienced all over the State, having to
close admissions for the first time in clinics in north
Louisiana because of the loss of workforce.
So what we need, in my opinion, is incentives that the
Federal Government could help us establish to retain and
recruit a workforce and long-term funding for programs like the
Crisis Counseling Program that included--and include a flexible
use of the funds with treatment dollars so we can address
issues of trauma and clinical depression.
Senator Landrieu. I will just summarize the first part of
it because this is very interesting to me. In a catastrophic
disaster, or even a large-scale disaster, you are paralleling
your efforts to the population that had mental illness before,
and the current situation has exacerbated it, making their
treatment options more difficult, their places of service
sometimes destroyed, whole new systems have to be set up. But
what you are also saying is there is an emerging population of
people who were very healthy or relatively healthy mentally
before that are now showing symptoms of mental illness that
basically have no structure within the current framework to
basically be treated or dealt with.
Mr. Speier. That is absolutely correct.
Senator Landrieu. All right. Doctor, why don't you go ahead
and just take that question from your perspective, what would
be--and your testimony was excellent, and, again, let me thank
the Capital Area for everything that you all did to help, and
continue to do. And we, I believe--I have said this many times.
The Federal response has been not what it needs to be to our
host communities across the board, and we are continuing to
work on that.
But what would you say from your perspective is the most
immediate and the need of higher priority from your view?
Ms. Kasofsky. Well, I think the point you just summarized
that Dr. Speier said is very crucial. We are seeing more people
who are traumatized who actually do meet the State's criteria
for mental illness, and so I have been completely surprised
about the number of people that call for our services that
actually do meet the serious and persistent now. And so we have
to increase our capacity for those folks because they are so
unstable.
However, as you said, there is another population, there
has always been another population, that have very few options
of where they could go. It was typically other not-for-profits
that had set themselves up to see folks who are experiencing
mental health issues but hopefully never needing the services
that the government would provide for a serious mental illness.
That population was not served well prior to Hurricane Katrina
because there are just not enough providers that were offering
it. And now at this point we really do need to see that those
folks are seen so that they can get some services so that they
do not ever meet our criteria.
However, as I mentioned in my testimony, my clinics are
having a sustained increase of 65 percent of people meeting our
criteria, people are waiting much longer than they have ever
waited before between treatments, and we did see a lot of our
local population actually drop out of treatment during the
height of the disaster when we had to see the new folks who had
escaped harm in New Orleans. And so we know that the frequency
by which we need to see them is not where it should be because
we do not have enough physicians or psychiatrists, to see them.
So although I think it is huge that we address the crisis
needs that Dr. Stephens is talking about and the needs of
people that meet the criteria in my clinic, we cannot just
focus on crisis. If we only put our resources in crisis, that
is all we will ever be able to support. And so we need to look
at the other interventions for people who are experiencing
mental health needs who are not seriously mentally ill, have
their interventions in a timely way. We need to meet the needs
of people that are chronic and seriously mentally ill. They
have to be able to have access to doctors, their medicine, and
the other needs for wrap-around service. And I include
homelessness. Housing is so critical. It is just not possible,
it is not feasible to stabilize people when they are half-
living on the street or in a car.
So I would say from my perspective that timely
interventions for people in need who do not meet our criteria,
the interventions for people that do meet our criteria so that
they can be seen in a timely way, attain and be maintained in
stability, and also have housing so that they can get on with
their lives.
Senator Landrieu. Let me ask you this, and if it is in your
testimony, forgive me, but what are the costs associated with
what you could identify as sort of the typical case of a
middle-class family who was not mentally--or person who was not
mentally ill before but who shows fairly severe signs of stress
associated with either the loss of home, community, etc., what
would be the--and assuming that the health insurance that they
still have--which is a big assumption, but assuming they have
it, does not cover mental illness because most do not--and the
Federal Government has yet to mandate that, although we are
very close to doing so, as you know. What would the average
cost be for a person to receive either treatment or medicine,
to move them from this point to a healthier situation? I know
this is a broad question, so all of you could answer generally
what you think the cost might be to an individual.
Ms. Kasofsky. I am going to need to claim incompetence in
that area because the people that come to see us, they are not
typically middle-class people because of their disabilities.
And so we do see really only the people that are seriously and
chronically mentally ill.
Senator Landrieu. Dr. Stephens, would you know what the
cost would be to a family that is not covered by a government
program?
Dr. Stephens. I do not know, but what we can do after this
hearing, we can go back and I can compile that and give you
something other than just off the top of my head, something
that is based on some real numbers, and get it back to you.
Senator Landrieu. That would be very helpful. Dr. Speier.
Mr. Speier. And we have the same situation where we have
the Medicaid dollars; we know what people spend in that arena.
We do not have a private sector number. One of the limitations
is the kinds of services that are available and accessible to
people, especially people who are not in the Medicaid system.
Senator Landrieu. Well, it brings me to a point that has
been a pattern or a common thread through all of these hearings
as I have observed and tried to help with this recovery, is the
point that in a normal situation you have a population that is
either disabled, elderly, very poor, sick, homeless, that are
covered by government programs, and it is, of course, their
income limits that are sometimes very low. In other words, you
can get your services if your income is below $10,000 a year or
$15,000 a year. But if you think about the hundreds of
thousands of people that were affected who were generally
healthy, single earners, or double-earner families, who now
find themselves homeless, without a neighborhood, were healthy
before and working before but are unable because of the
catastrophe. If we do not increase the income limits, this
whole group is basically without an ability to finance their
own mental health and physical health recovery. And it is
something that I think the Federal Government is having a very
difficult time understanding about this population of recovery
population. It is not only your typical poor people who have
limited resources that are struggling desperately under the
circumstances, but it is a whole new population of middle-
income families who are otherwise generally healthy,
financially, emotionally, etc., that without a change in the
Federal programs are basically left without virtually any
assistance or aid. And that is what is happening along the Gulf
Coast.
We are having a hard time explaining to the Federal
Government that while we understand we want to and will
continue to commit our first to the poorest first, and the
sickest--and we will always have to do that just because of the
moral obligation--that there is still this huge population when
you look at the mental health--in particular the mental health
needs, but it is not only limited to mental health.
Dr. Stephens.
Dr. Stephens. Thank you, Senator. I will look at that, and
perhaps even another graph that you could look at is the
mortality rate. It was reported by the AMA in the journal
Disaster Medicine that for the first 6 months in 2006, we had a
47-percent increase in the mortality rate in New Orleans. And,
in fact, if you look at the mortality rate of New Orleans and
compare it to the rest of the country, before Hurricane Katrina
we were elevated. So this is 47 percent on top of that. And
part of it is the mental illness and so forth that we see, and
that is something that I think we definitely need to look at
and address also.
Senator Landrieu. And, Dr. Stephens, this will be the last
question of this panel and we will move to the third, but could
you comment briefly? We have had hearings and it has been the
focus of attention about the criminal justice situation, the
rising murder rate, the challenges to the criminal justice
system. Just today the district attorney of New Orleans stepped
aside and a new district attorney has taken over to try to
stabilize the situation. But is there a nexus potentially
between lack of mental health services and a rising crime rate?
Do you have any studies that would suggest that or any data,
either today you can give that testimony or submit it later, or
any comments about from your perspective if there is any
relationship there?
Dr. Stephens. Well, thank you again very much. No doubt,
like in the past 6 months, we average 500 hours in transporting
patients to institutions. The police in July logged 534 hours
at the emergency room for our EMS. Our EMS director said we
waste basically a million hours in personnel costs and unbilled
revenue over the last 6 months because of waiting.
And so when you go to the prison system, they have the
largest psychiatric hospital, if you will, in our city, which I
think is a shame that the largest psychiatric care that you can
get is a 60-bed unit at the prison. We have 15 female and 45
male. And I talked to Dr. Gore, the prison medical director,
and he said he was having the same challenges. He has one full-
time psychiatrist and one part-time psychiatrist and 60
patients, and these are critically ill. And then what happens
is their patients either are sent back into the community or
they are discharged from home or they are discharged from
prison without places to go, and so they end up either getting
hurt or hurting someone else and contributing to the crime
problem and recidivism and so forth. It is just problematic.
Senator Landrieu. OK. Thank you very much. It has been an
excellent panel. I appreciate it.
They have just called a vote at 3:45, so I am going to
recess for 10 minutes, and we will resume the third panel
probably right at 4 o'clock. Thank you so much.
The Subcommittee will stand in recess.
[Recess.]
Senator Landrieu. Our hearing will resume. Let me begin by
introducing our third panel, if you all will have a seat.
Our first witness on our last panel is Dr. Ronald Kessler,
a Professor of Health Care Policy at Harvard Medical School and
Director of the World Health Organization's World Mental Health
Survey Initiative. He directs the Hurricane Katrina Community
Advisory Group. Thank you, Dr. Kessler, for joining us and for
all the things that Harvard University across the board has
done to help us. We are really grateful for your support, and
the many of universities in the country that have stepped
forward to help.
Dr. Howard Osofsky is Chairman and professor and head of
the Department of Psychiatry at LSU. He has been in the
forefront of this recovery effort and a long-time champion of
people with mental illness and mental challenges, adults as
well as children. He is a Psychiatric Association member,
American Psychiatric Association member and American College of
Psychiatric Fellow. We thank you very much for your help and
support.
And then Mark Townsend is a professor of psychiatry and
Vice Chairman for General Psychiatry at LSU Health Sciences
Center in New Orleans. He has extensive experience in community
psychiatry, having served as medical director of the LSU
Partial Hospitalization Program and is an assertive and active
member in community team treatment.
So I thank you very much, all of you, and we will start
with you, Dr. Kessler.
TESTIMONY OF RONALD C. KESSLER, PH.D.,\1\ PROFESSOR OF
HEALTHCARE POLICY, HARVARD MEDICAL SCHOOL, AND PRINCIPAL
INVESTIGATOR OF THE HURRICANE KATRINA COMMUNITY ADVISORY GROUP
Mr. Kessler. Thank you, Madam Chairman and Members of the
Subcommittee. As you mentioned, I am the Principal Investigator
of the Hurricane Katrina Community Advisory Group, and this is
a group of about 1,000 people that we assembled shortly after
the hurricane. It is representative of all those who were pre-
hurricane residents of the areas affected by the hurricane who
we asked to allow us to follow over time in a series of surveys
to track the mental health and well-being of people in the
population. This is a series of studies funded by the National
Institute of Mental Health, FEMA, and by the Assistant
Secretary for Planning and Evaluation at HHS.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Kessler appears in the Appendix
on page 100.
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In our baseline survey, we found that about 14 percent of
people who were residents of the hurricane-affected area met
criteria for SAMHSA's definition of a serious mental illness;
another 21 percent met criteria for some other mental disorder
according to the standard DSM categories, and this is roughly
twice as high as what we find in typical general population
surveys.
We also found, though, that unlike typical general
population surveys where we find that women have higher rates
than men, poor people higher rates than rich people and old
people higher rates than young people, the changes in the
prevalence associated with the hurricane were largely unrelated
to socio-demographics. This was, for better or worse, an equal
opportunity disaster that affected broad segments of the
population, irrespective of their prior vulnerabilities.
We also found something very encouraging and intriguing,
and that is despite the high rates of anxiety and depression
and PTSD in the population, very small proportions of the
people in this population reported having suicidal ideation,
plans, or suicide attempts in the first months after the
disaster. As a matter of fact, we found that these things were
vanishingly small in the first few months, and what seemed to
be happening was that in questioning more depth about this,
despite the fact that many people were understandably anxious
and worried about the future, they were sad and depressed about
their losses, there was a sense of strength and optimism in the
population that was quite remarkable. Many people, as a matter
of fact, the majority of the population said they felt that
they were stronger because they had lived through this and they
survived. They had a sense of greater meaning and purpose in
their life. They felt more religious. They felt more connected
to their fellow citizens. So that strength was something that
seemed to be buffering people from the worst excesses of this
emotional crisis.
Now, this kind of positive effect has been found in the
past. However, we know that this kind of psychological
adrenaline goes away in about a year. Fortunately, in most
disasters the crisis period also goes away in a year.
Construction efforts are made and so forth. That has not been
the case here. And as a result, when we looked at our follow-up
survey, the first survey that was about a year later, close to
2 years after the hurricane, rather than the typical pattern
one finds where prevalence goes down, we found either
stabilization of the prevalence, no decrease at all in the New
Orleans metro area, and an actual increase in the prevalence of
serious emotional problems in the areas outside the New Orleans
metro area--Alabama, Mississippi, the other parts of
Louisiana--and suicidality, a dramatic increase across the
board in the New Orleans metro area as well as in the rest of
the hurricane area. About half the people who were affected
emotionally in a really clinically significant way have been in
some kind of treatment. Most of that treatment has been
medications, not psychotherapy. Most of it has been delivered
by primary care physicians. Most of the psychiatrists that have
been involved in this effort--as you mentioned already, there
is a smaller number--they have been focused on the people who
had pre-existing mental disorders, that severe, persistent
population. The nuanced cases that we have already talked
about, the people who are doing well--and these are new cases--
they are mostly being seen by primary care doctors and being
given pills without any psychotherapy.
This is a problem, and as many speakers have said already,
in a situation of this sort when you have a lot more need and
lower resources, we are in a tough situation. There is a need
to expand services. But at the same time, I want to emphasize
that it is also important to realize that no matter what the
expansion of services, it is unlikely to be adequate for the
need. And so in addition to just expanding services, we have to
think creatively about how to make those services as cost-
effective and stretch as far as they can. There are some
interesting models that are out there: Commission Corps we just
heard about from Kathryn Power, but also there is
telepsychiatry, collaborative care models where psychiatrists
part-time consult with primary care physicians to expand their
services, patient program matching things. And these are things
that it seems to me we have to encourage work to be done on in
the future.
Thank you.
Senator Landrieu. Thank you, and I am going to be getting
back to that final point in my line of questioning, because I
think that is really key to helping to solve the crisis that we
are in, and I thank you.
Dr. Osofsky.
TESTIMONY OF HOWARD J. OSOFSKY, M.D., PH.D.\1\ CHAIRMAN,
DEPARTMENT OF PSYCHIATRY, LOUISIANA STATE UNIVERSITY HEALTH
SCIENCES CENTER
Dr. Osofsky. Senator Landrieu, Members of the Subcommittee,
thank you very much for asking me to testify today. This
testimony is not about pointing fingers; rather, it is about
the real problems of real children and adolescents in the
greater New Orleans area.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. Osofsky appears in the Appendix
on page 113.
---------------------------------------------------------------------------
I want to focus on the dilemma that these children and
adolescents face in having their mental health service needs
met. The resources and funding provided do not adequately
address the mental health treatment service needs of the tens
of thousands of children traumatized by Hurricane Katrina and
further traumatized by the continuing stresses due to the slow
recovery.
The Stafford Disaster Relief Act Crisis Counseling Program,
including the Specialized Crisis Counseling Program, while
helpful, prohibits mental health diagnosis and treatment.
Children and adolescents, while resilient and pleased to be
back home, are in desperate need of proven outreach clinical
evaluation and treatment services. Collaborative efforts of
LSUHSC trauma trained mental health professionals and returning
school districts have demonstrated the importance of
integrating mental health services in school and preschool
settings to provide support and needed therapeutic help in a
destigmatized manner.
The devastation to children and families resulting from the
displacement and significant losses of all that was familiar as
a result of Hurricane Katrina provides a unique perspective on
the effects of this disaster. Our data gathered since the storm
demonstrates the widespread nature of this disaster which
personally affected the majority of children assessed. In
addition to the data we submitted, during the second year after
Hurricane Katrina, the 2006-2007 school year, well over half of
the 7,000 children assessed in the most heavily devastated
Orleans, Plaquemines, and St. Bernard parishes had still not
returned to their pre-storm homes. Over 40 percent still met
the cut-off for mental health referral indicating the chronic
effect of this disaster on children and adolescents. We
currently are receiving many and increasing numbers of
referrals and requests for mental health evaluation and
services from school personnel and parents. The students
referred are having severe school difficulties--academic,
behavioral, emotional, and risk-taking. The scientific
consensus is that we cannot leave these cries for help
unanswered. Without adequate mental health services, we can
count on these children having increased incidences of post-
traumatic stress disorder and depression and decreased ability
to meet their potential. We strongly believe, and available
evidence has proven, that these negative outcomes can be
prevented if adequate mental health evaluation, diagnosis, and
services can be provided.
Some lessons we have learned:
One, it is perfectly clear that we need a better national
plan for children and families following disasters that can be
funded at the Federal level and implemented and channeled at
the local level.
Two, the Stafford Disaster Relief Act should be revised to
allow for needed mental health evaluation and treatment
services.
Three, mental health services after a major disaster need
to be funded on a long term basis not only to address current
problems, but to prevent serious mental health and behavioral
sequelae.
Four, if volunteers are to be used effectively, they need
to be trained in trauma-focused services for children before
being deployed.
Five, mental health services have been and should be
increasingly provided in child- and family-friendly settings
such as schools and preschools.
In closing, we very much appreciate your efforts to help
these children and families. We beseech you that if there are
resources and discretionary funds available from FEMA and
SAMHSA, these funds should be provided immediately for
evidence-based mental health services for these struggling
children, adolescents, and families who so desperately need
them. It is clear that this funding is needed now to prevent
irreparable damage to children traumatized by Hurricane
Katrina. Your leadership has made and can make all the
difference.
Thank you for your attention to this important matter, and
I will be glad to provide either more data or clinical
vignettes to demonstrate what we are discussing.
Senator Landrieu. Thank you very much. Dr. Townsend.
TESTIMONY OF MARK H. TOWNSEND, M.D., DFAPA,\1\ PROFESSOR AND
VICE CHAIRMAN FOR GENERAL PSYCHIATRY, DIRECTOR OF PSYCHIATRY,
MEDICAL CENTER OF LOUISIANA AT NEW ORLEANS
Dr. Townsend. Thank you, Senator Landrieu and Members of
the Subcommittee, for letting me testify to you about our
achievements and challenges. Since July of this year, I have
been the Director of Psychiatry for the Medical Center of
Louisiana at New Orleans, which is a part of the LSU Hospitals
Health Care Services Division. Our medical center consists of
the newly renovated LSU interim hospital as well as
comprehensive and specialty clinics throughout the region. Our
department is composed of faculty mainly from the psychiatry
departments of LSU, chaired by Dr. Howard Osofsky, and also
from Tulane University. We have been given the mandate to
provide psychiatric treatment to a city that, as you know, has
survived many other traumas, only to be in part irreparably
flooded in August 2005.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. Townsend appears in the Appendix
on page 117.
---------------------------------------------------------------------------
One such flooded place was Charity Hospital, which is where
I worked, which was second oldest continually operating public
hospital in the United States, which is now closed. Charity
Hospital at one time had 2,500 beds. At the time of the storm,
psychiatry staffed 92 of them. Although with relatively fewer
beds, Charity's emergency department experienced an enormous
volume. We handled about 600 psychiatric emergencies a month.
Most of those were treated successfully and returned to the
community within 24 hours, and that was in our crisis
intervention unit.
Of course, because of that I am keenly and personally aware
of what we have lost at Charity, and I am happy to be able to
work with the LSU Hospitals administration to preserve what I
think were the best aspects of treatment at Charity while we
all transition to a new and more flexible system of care. We
have to be flexible because we have lost much of the bricks and
mortar that housed the previous system. And we have to take new
approaches because patients are best treated and stabilized in
the community. They have to not present to emergency
departments and have to not be admitted to hospitals. I also
think we must identify at-risk youth, as has been already said,
to prevent those with psychiatric illness from being identified
and literally treated as criminals. If arrested, we must divert
these people from prison and address their psychiatric medical
illness.
Two years after Hurricane Katrina devastated the city,
Charity Hospital and its 92 psychiatric beds remain closed. The
medical center now directs medical and surgical treatment from
its smaller, sister--University Hospital. Comprehensive
psychiatric services have been planned for LSU's new teaching
hospital, but that will be 5 years down the line. Today, the
region lacks most of its pre-storm inpatient psych beds, even
though its people have not only largely returned, but also have
demonstrated persistently elevated rates of mental illness. And
as you have shown there, New Orleans had more than 300 licensed
beds prior to the storm.
However, progress is being made. In September of this year,
the LSU interim hospital opened new psychiatric inpatient units
uptown New Orleans at DePaul Hospital in a leased building.
DePaul hospital had served the region for about 100 years by
providing a full range of psychiatric services for adults and
children. And LSU Hospitals hopes to open approximately 40 beds
on that site, which is an extremely positive development but,
still, the city has less than a third of its former inpatient
beds.
I also want to say that LSU is also addressing other
important needs. The LSU interim hospital has created an
emergency room. It is called an emergency room extension that
is handling 200 psychiatric patients a month. We have also
opened 20 medical detox beds, and I have to say the LSU
psychiatry outpatient clinics, which were largely staffed by
members of the LSU psychiatry faculty, opened very early, way
back in October 2005. But recent grants, including the much
needed primary care access and stabilization grant, have
allowed LSU to expand its office space and also its culturally
sensitive programs for patients of all ages.
Both LSU and Tulane medical schools have demonstrated
tremendous resiliency to be able to be present in New Orleans
today. And LSU Hospitals' medical centers are more than able to
provide top-quality psychiatric education. But as we discussed
already today, the region itself continues to lack key pieces
of public health infrastructure. I am going to summarize what I
think those would be.
These next steps are very complex. Charity's CIU, which Dr.
Stephens referenced, was able to treat people so efficiently,
600 people a month, because it was well staffed and the
community had sufficient inpatient, respite, step-down, and
group home beds. More mental health professionals, not just
psychiatrists, which we have spoken about today, but others--
psychologists, social workers, rehabilitation counselors,
recreation therapists--all need to be lured back into the area
to resume clinical practice if we are to open these hospitals
and these facilities. And community services must be increased
so that crises can be defused, where they should be, within the
neighborhoods and not within emergency rooms. And, finally,
criminal justice diversion programs have to be developed for
individuals with psychiatric illness whose behavioral symptoms
have led to arrest. They must be diverted from our jails.
Senator Landrieu, I want to express my sincere thanks to
you for allowing me to speak about our progress and our
challenges, and I am grateful for the assistance that you have
already provided, and I look forward to assisting you in the
work yet to come.
Senator Landrieu. Thank you all very much for your
testimony.
Let me begin, Dr. Kessler, with you, where you ended your
opening remarks. Could you give three or four specific
recommendations, which I think are included in your statement,
about new strategies, kind of more effective approaches?
Because you hit the nail on the head when you said that there
is basically not enough money in the bank to cover the needs
that have been expressed and described here.
Assuming, however, that we can identify some additional
resources, it is going to take a combination of some additional
resources and some change of strategy or innovations or new
tools or methods or approaches.
Could you comment from your view, having conducted this
fairly large study, on what some of those effective approaches
might be?
Mr. Kessler. Sure. Well, the study itself does not tell us
anything about effective strategies, but we know from past
experience that emergency psychiatric medicine has been an area
where we have lagged in our development of effective strategies
because emergency situations are emergencies, and we jump in
and do the best we can. As you probably know, for many years
debriefing was this method that was considered to be the first
thing to do where paraprofessionals would go and talk to people
about their experiences and let them work them out and so
forth. We now know on the basis of just recent controlled
studies that not only does debriefing not work, it actually
hurts people.
Now the development of psychological first aid just in the
past few years has been shown to be a much more effective
strategy. The problem is we do not have a lot of things in our
bag of tricks that we know to be effective things that work
specifically in crisis situations. And in this particular
crisis, we do not have anything that we can pull out right now
and say it works.
However, during a crisis of this sort is exactly the time
where some limited amount of incremental resources should be
devoted to trying new things, to think about the next crisis
down the line. It is a hard thing to do when we are in the
middle of this emergency, but as you mentioned at the onset,
disasters are becoming increasingly common in America, $50
billion a year of infrastructure damaged, on average, each year
for the past decade in the United States. The number of people
in the aging population who are moving to coastal areas where
they are subject to these things is increasing. This is not
just a one-time thing. This is an opportunity to learn
something about how we can do better during the next disaster
and the next after that.
So I hope that in the midst of jumping in and trying to
plug our hole in the dike at this particular time, we divert
some resources to thinking creatively about things that we do
not yet know whether they work but there is potential. I
mentioned telepsychiatry, which is something that is a
development in rural areas in America, but is something that
has a potential here. We know that telephonic cognitive
behavioral therapy has now been shown to work almost as well as
face-to-face cognitive behavioral therapy, and there are a lot
of people that could profit from that.
Senator Landrieu. Interpreting that to mean counseling over
telephone?
Mr. Kessler. Yes, counseling over the telephone. And there
is good evidence now that this is quite effective, and one of
the resources that we have in crisis situations is that there
are many people around the country who are willing to help.
They do not have any structure to do that. There are
psychiatrists, social workers, clinical psychologists all
around America who would be willing to donate 2 hours a week if
we had a system that would allow them to do that. We know that
on September 11, 2001 the problem was that there was an
inundation of an army of people who wanted to help, but there
was no mechanism to get the help to the people. If we could
devote some resources to coordination of allowing the resources
that are potentially available to get to people, there is one
good one.
A second one that is of great value is something called
collaborative care models where psychiatrists do not work with
patients but work with primary care doctors, so each doctor--
one psychiatrist is connected to 10 primary care doctors, so
when the primary care doctor finds a patient that has an
emotional problem that is well beyond the skill level of the
primary care doctor, they have one psychiatrist who they talk
to 3 days a week, and it extends those rare resources in ways
that could be useful.
These are just two examples. I do not know if they are the
best, but the idea is----
Senator Landrieu. No, I think they are excellent, and I
would really urge you--and I know your time is very valuable
and limited. But any other ideas like that that you could
present in writing or in conversations with the staff to this
Subcommittee would be appreciated.
Mr. Kessler. Sure.
Senator Landrieu. Because we intend to make some of these
strong recommendations for the future, and I particularly am
interested in your noting that a larger and larger segment of
the population is moving towards the coast, not in every case
but I think the details would suggest that these are retired--
in some instances, retired elderly, and hurricanes and other
disasters have a disproportionate effect on older people, as I
have just observed from our limited background in this. But I
think this is a very important issue for our country, the aging
of the population, the increased incidence of major disasters,
particularly this hurricane-prone region of the Gulf Coast,
Florida, and the East Coast.
The other point I wanted you to just--and I want to be
clear that I heard this correctly. You said that your study so
far has indicated that some of the initial counseling was not
only not helpful but it was potentially harmful. Could you go
over that one more time?
Mr. Kessler. There is something called ``psychological
debriefing,'' which was popular for many years among
paraprofessionals, and Dr. Osofsky can tell you more details
about it. But it was essentially the idea of telling people
about your trauma, reliving it, getting it out of your system,
and sort of catharsis. And that was something that was a
commonly done thing. It was sort of the norm in the field of
disaster medicine. We move in and we have all these essentially
lay people debrief trauma victims.
Senator Landrieu. And let people tell their story so they
will feel better.
Mr. Kessler. And there have now been some studies that have
shown that it does not work. As a matter of fact, not only
doesn't it work, but since they do it in groups, what it really
does is it retraumatizes so everybody hears everybody else's
story and they go away feeling worse.
Because we were in the midst of doing all these--running
around and doing this stuff in crises, nobody took a step back
and said let's systematically see whether that works or not. So
taking a step back and sort of thinking carefully about what
works and what does not has the potential to leverage our
limited resources by getting us to invest more in the things
that do work rather than the things that do not work. And right
now we are in a knowledge deficit situation. We have a lot of
good psychotherapies that we know that work in general, but
what works particularly for particular people in these
situations we do not know. So there is a lot that we need to
discover about what is most cost-effective in these kinds of
populations that could help us leverage those rare resources in
ways that we cannot.
Senator Landrieu. And, finally, has anyone from any Federal
agency approached you with a plan to do exactly as you have
outlined, trying to invest some research dollars and trying to
find out what works?
Mr. Kessler. No, they have not, but there are these
interesting things, and Project Liberty, for example, where, as
you probably know, there was a hotline set up to refer people
who called for help to professionals who volunteered to provide
free help, over 400,000 people were referred to psychotherapy
in New York. Not a single piece of information was collected on
whether any of those people went, whether the psychotherapy
worked, what kind of psychotherapy they got. But there is an
opportunity to set up systems of this sort that with just a
little bit extra data collection we could see what things
worked and what did not, what worked for what kinds of people.
Instead of referring somebody just to the psychotherapist who
is closest to you, maybe we will discover that women profit
more from interpersonal and men from cognitive behavioral
therapy, and there should be more matching of people to places.
A one-percent increment in the investment of resources and
thinking that through could have a dramatic multiplier effect
in the effectiveness of what we can do.
Senator Landrieu. And the cost savings.
Dr. Osofsky, do you currently know of any program that is
reaching specifically out to teachers or to educators as they
come back to the community to stand up their schools, any
particular programs that are helping them to then be able to
help the children or the parents that they come into contact
with? Because that would seem to me to be one effective
strategy. Is there anything that you are aware of currently
that is being funded in either Louisiana, Mississippi, or the
Gulf Coast area?
Dr. Osofsky. If I could just take one moment to comment on
the points Dr. Kessler was making.
Senator Landrieu. Go ahead.
Dr. Osofsky. We have been working with Dr. Speier on the
idea of training even within the Crisis Counseling Program,
within the Specialized Services Program, to train the
counselors in what we call learning collaboratives about mental
health approaches that can be of help, so that not only within
the limits of the program, the effectiveness they can do, but
also they then can go back into their communities and have
other positions, the additional skill sets that they will have.
And we are also working with the States on the telemedicine
program, especially in the child and adolescent area, but in
psychiatry to help expand services to other parts of the State.
But I think these are crucial.
I do want to let you know that we have actually been
screening--at the schools' request--teachers and to try and
provide additional services for them, because we are dealing
with individuals who themselves are very traumatized, who need
to deal with the traumatized children and adolescents, and then
at the end of the day also have to deal with their own issues
that they are going through. And this comes up over and over
again.
What I think would also be effective--and we actually find
there is great acceptance of it, and we do training for
teachers about red flags and how to look for things and how to
respond in classrooms, but also to extend this further, I find
the pediatricians, primary care doctors, nurse practitioners
would be very responsive to this type of approach in a way
where--for example, we have seen so many youngsters come in who
are on large amounts of medication that are inappropriate, or
some who need medication or they need other types of treatment.
But we see this with adults, too, and the issue of trying to
look at the impact of trauma itself and how to differentiate
and how to respond, how to recognize when there will be
problems and how to best intervene. And I really do think this
could be a very positive thing that could come out of all of
the collective experience and not only help in our State but
help in the country as well.
Senator Landrieu. OK. Our time is limited, so I just have
one more question for you, Dr. Townsend. Given the statistics
of the lack of professionals that are back serving--and I
realize the problem is broader of the solutions than just
recruiting, but it has been mentioned by several members of
this panel today. What is LSU either doing or recommending, or
Tulane, for that matter, what could the State be doing, or the
Federal Government, to help you recruit the professionals you
need to help re-staff, if you will, the mental health network?
Dr. Townsend. I think there are two parts to that. Looking
ahead, unfortunately, all of us seem to be talking about the
next disaster where we can collect data, which, of course,
there will be one. If there was a way beforehand to stabilize
the workforce, just basic profession-specific counseling,
psychiatrist to psychiatrist, psychologist to psychologist, to
buy books for people to replace their offices, would have, I
think, kept some people from leaving the area. But now there is
discipline-specific money that needs to be available. I
understand there was nursing money that has now run out. There
was money to attract physicians. In my opinion, that is not
nearly enough. And the group of people that seems to be
preventing us from opening that next wave of hospital beds is
not nurses; it is licensed clinical social workers.
So we have to come up with a way of having meaningful--and
I guess even though it seems like a lot of money, for some
reason it is not meaningful enough to attract people to south
Louisiana--meaningful amounts of money targeted in ways that
get people to come down. I am very appreciative and I like the
idea of this mobilization corps, but those people will have
places where they definitely can be used and definitely where
it is not appropriate because of the lack of continuity of
care. And, of course, we need people who are going to invest in
living in south Louisiana or south Mississippi and other places
for several years to come.
Senator Landrieu. Do we know what the current recruitment
either bonus is--what is it for nurses or medical
professionals? Do we know?
We will get the information, but I think the Federal
Government has initiated a small program for recruiting for
health care professionals, and I will look into it and get it
put into the record. I do not know if any----
Dr. Osofsky. We do have that. The one piece is--we have
actually been very fortunate in retaining professionals and
recruiting. It is not just having the bonuses to perhaps have
people come, but the funding so that we can guarantee their
salaries because I do find people who are very willing to come
here and want to participate and hopefully to live and stay
here.
Senator Landrieu. This would be a good point to end the
panel. Part of it is not only just recruiting the professionals
to either stay or come back, incentives to stay or come back,
but it is also then leveraging, as Dr. Kessler said, the
nonprofit sector, the volunteer sector, to enhance the capacity
to deliver services at a fraction of a cost, as opposed to just
thinking about one-to-one counseling, doctors, social workers,
etc.
So these are some very excellent ideas. I thank you all
very much for being a part of the panel today. We have gone
over time, but it has been, I think, a very interesting and
worthwhile discussion, so we look forward to visiting with you
all and keeping up as we develop better strategies to deal with
the ongoing crisis in the Gulf Coast and prepare better in the
future.
Thank you, and the hearing will come to an end.
[Whereupon, at 4:56 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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