Catastrophic Disasters: Federal Efforts Help States Prepare for  
and Respond to Psychological Consequences, but FEMA's Crisis	 
Counseling Program Needs Improvements (29-FEB-08, GAO-08-22).	 
                                                                 
Catastrophic disasters, such as Hurricane Katrina, may result in 
trauma and other psychological consequences for the people who	 
experience them. The federal government provides states with	 
funding and other support to help them prepare for and respond to
disasters. Because of congressional interest in these issues, GAO
examined (1) federal agencies' actions to help states prepare for
the psychological consequences of catastrophic disasters and (2) 
states' experiences obtaining and using grants from the Crisis	 
Counseling Assistance and Training Program (CCP) to respond to	 
the psychological consequences of catastrophic disasters. CCP is 
a program of the Department of Homeland Security's (DHS) Federal 
Emergency Management Agency (FEMA). GAO reviewed documents and	 
interviewed program officials from federal agencies and conducted
additional work in six states with experience responding to	 
catastrophic disasters: Florida, Louisiana, Mississippi, New	 
York, Texas, and Washington.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-22						        
    ACCNO:   A81171						        
  TITLE:     Catastrophic Disasters: Federal Efforts Help States      
Prepare for and Respond to Psychological Consequences, but FEMA's
Crisis Counseling Program Needs Improvements			 
     DATE:   02/29/2008 
  SUBJECT:   Data collection					 
	     Disaster planning					 
	     Disaster relief aid				 
	     Emergency management				 
	     Emergency medical services 			 
	     Emergency preparedness				 
	     Federal aid to states				 
	     Federal funds					 
	     Federal/state relations				 
	     Hurricane Katrina					 
	     Mental health					 
	     Mental health care services			 
	     Natural disasters					 
	     Program management 				 
	     Strategic planning 				 
	     Substance abuse					 
	     Program implementation				 
	     Crisis Counseling Assistance and			 
	     Training Program					 
                                                                 

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******************************************************************
GAO-08-22

   

     * [1]Results in Brief
     * [2]Background

          * [3]Psychological Consequences of Catastrophic Disasters
          * [4]Federal Role in Public Health Preparedness and Response
          * [5]Primary Federal Response Program for Crisis Counseling Servi

     * [6]Federal Agencies Have Awarded Grants to States to Support Pr

          * [7]Federal Grants Have Supported States' Mental Health and Subs
          * [8]SAMHSA Has Assessed State Mental Health and Substance Abuse
          * [9]HHS Is Taking Steps to Be Better Prepared to Send Federal Re

     * [10]States Experienced Several Difficulties in Applying for and

          * [11]States Encountered Difficulties in Preparing CCP Application
          * [12]States Experienced Lengthy Application Reviews following Cat
          * [13]States Faced Difficulties in Implementing Their CCPs after C

               * [14]Obtaining Reimbursement for Indirect Costs
               * [15]Providing Expanded Crisis Counseling Services
               * [16]Additional CCP Implementation Difficulties

     * [17]Conclusions
     * [18]Recommendations for Executive Action
     * [19]Agency Comments and Our Evaluation
     * [20]Appendix I: Scope and Methodology
     * [21]Appendix II: Additional Federal Programs Used to Respond to
     * [22]Appendix III: Comments from the Department of Homeland Secur
     * [23]Appendix IV: Comments from the Department of Health and Huma
     * [24]Appendix V: GAO Contact and Staff Acknowledgments

          * [25]GAO Contact
          * [26]Acknowledgments

     * [27]Related GAO Products

          * [28]Order by Mail or Phone

Report to Congressional Requesters

United States Government Accountability Office

GAO

February 2008

CATASTROPHIC DISASTERS

Federal Efforts Help States Prepare for and Respond to Psychological
Consequences, but FEMA's Crisis Counseling Program Needs Improvements

GAO-08-22

Contents

Letter 1

Results in Brief 4
Background 6
Federal Agencies Have Awarded Grants to States to Support Preparation for
Psychological Consequences of Catastrophic Disasters, and SAMHSA Has
Assessed States' Disaster Plans 13
States Experienced Several Difficulties in Applying for and Implementing
Their CCPs Following Catastrophic Disasters 20
Conclusions 32
Recommendations for Executive Action 33
Agency Comments and Our Evaluation 33
Appendix I Scope and Methodology 39
Appendix II Additional Federal Programs Used to Respond to Psychological
Consequences of Catastrophic Disasters 43
Appendix III Comments from the Department of Homeland Security 47
Appendix IV Comments from the Department of Health and Human Services 50
Appendix V GAO Contact and Staff Acknowledgments 55
Related GAO Products 56

Tables

Table 1: Number of Days for States' ISP and RSP Application Submission and
Federal Review for Selected Catastrophic Disasters 23
Table 2: Amount of Claims for Deficit Reduction Act Funds Submitted by
Selected States to Serve People Affected by Hurricane Katrina, as of June
27, 2007 45

Abbreviations

ASPR: Assistant Secretary for Preparedness and Response: 
CCP: Crisis Counseling Assistance and Training Program: 
CDC: Centers for Disease Control and Prevention: 
CMS: Centers for Medicare & Medicaid Services: 
DHS: Department of Homeland Security: 
FDNY: New York City Fire Department: 
FEMA: Federal Emergency Management Agency: 
HHS: Department of Health and Human Services: 
HRSA: Health Resources and Services Administration: 
ISP: Immediate Services Program: 
MBES: Medicaid Budget and Expenditure System: 
NCPTSD: National Center for PTSD: 
Project SERV: Project School Emergency Response to Violence: 
PTSD: posttraumatic stress disorder: 
RSP: Regular Services Program: 
SAMHSA: Substance Abuse and Mental Health Services Administration: 
SCHIP: State Children's Health Insurance Program: 
SERG: SAMHSA Emergency Response Grant: 
VA: Department of Veterans Affairs: 
WTC: World Trade Center: 

This is a work of the U.S. government and is not subject to copyright
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separately.

United States Government Accountability Office
Washington, DC 20548

February 29, 2008

Congressional Requesters

Hundreds of thousands of people nationwide have been exposed to
psychological trauma resulting from catastrophic disasters, such as the
terrorist attacks of September 11, 2001, and Hurricane Katrina in August
2005.^1 Traumatic experiences such as losing a loved one, losing one's
home, or witnessing disturbing scenes can affect the residents,
responders, and others involved in a catastrophic disaster and its
aftermath. These experiences have led to a variety of psychological
consequences, including depression, posttraumatic stress disorder
(PTSD),^2 and increased use or abuse of tobacco or alcohol. In addition,
catastrophic disasters can affect a community's ability to deliver mental
health and substance abuse services. For example, hospitals had problems
meeting the demand for inpatient psychiatric care after Hurricane Katrina
because of disruption to the health care infrastructure.^3123Hundreds of
thousands of people nationwide have been exposed to psychological trauma
resulting from catastrophic disasters, such as the terrorist attacks of
September 11, 2001, and Hurricane Katrina in August 2005. Traumatic
experiences such as losing a loved one, losing one's home, or witnessing
disturbing scenes can affect the residents, responders, and others
involved in a catastrophic disaster and its aftermath. These experiences
have led to a variety of psychological consequences, including depression,
posttraumatic stress disorder (PTSD), and increased use or abuse of
tobacco or alcohol. In addition, catastrophic disasters can affect a
community's ability to deliver mental health and substance abuse services.
For example, hospitals had problems meeting the demand for inpatient
psychiatric care after Hurricane Katrina because of disruption to the
health care infrastructure.

Effectively delivering mental health and substance abuse services to
address psychological consequences related to catastrophic and other
disasters requires that both predisaster preparedness efforts and
postdisaster response^4 efforts be well planned and coordinated among the
multiple jurisdictions, agencies, and nongovernmental organizations
involved. In the aftermath of the September 11 attacks, the Institute of
Medicine reported that there were gaps in the preparedness of the nation's
mental health, public health, medical, and emergency response systems to
Effectively delivering mental health and substance abuse services to
address psychological consequences related to catastrophic and other
disasters requires that both predisaster preparedness efforts and
postdisaster response^45 efforts be well planned and coordinated among the
multiple jurisdictions, agencies, and nongovernmental organizations
involved. In the aftermath of the September 11 attacks, the Institute of
Medicine reported that there were gaps in the preparedness of the nation's
mental health, public health, medical, and emergency response systems to
meet the psychological needs that result from terrorism. It noted, for
example, that government agencies and service providers were not well
coordinated and mental health providers often did not have disaster
training.

^1In this report, we consider disasters that are unusually devastating and
require extensive federal support to be catastrophic.

^2PTSD is an often debilitating and potentially chronic disorder that can
develop after experiencing or witnessing a traumatic event and includes
such symptoms as distressing dreams and intrusive memories.

^3GAO, Hurricane Katrina: Status of Hospital Inpatient and Emergency
Departments in the Greater New Orleans Area, [29]GAO-06-1003 (Washington,
D.C.: Sept. 29, 2006), 13. A list of additional GAO products related to
mental health and catastrophic disasters is included at the end of this
report.

^4For the purposes of this report, we are defining response to include
both short-term response after a disaster occurs and long-term recovery.

For predisaster preparedness, the Department of Homeland Security (DHS) is
responsible for coordinating with federal, state,^6 and local agencies to
develop plans, procedures, training, and other activities. In coordination
with DHS, the Department of Health and Human Services (HHS) is responsible
for helping the nation develop public health--including mental health and
substance abuse--systems that are prepared to meet the surge in medical
needs that may occur following disasters. Within HHS the Substance Abuse
and Mental Health Services Administration (SAMHSA) helps integrate mental
health and substance abuse services into these federal efforts. Federal
agencies may carry out these responsibilities through a variety of
efforts, including the following activities: the provision of grants to
states for preparedness efforts,^7 development of training and guidance
related to preparedness, assessment of state activities, and development
of plans for utilizing federal staff and medical supplies to assist
states.

For postdisaster response, DHS and HHS efforts may include providing
states with funding to assist their response to the psychological
consequences of the disaster. The primary long-standing federal
postdisaster grant program for helping states respond to short-term crisis
counseling needs following disasters is the Crisis Counseling Assistance
and Training Program (CCP),^8 which is administered by DHS's Federal
Emergency Management Agency (FEMA) and its federal partner, SAMHSA.^9 A
state's application for CCP funds must demonstrate that the need for
crisis counseling in the affected area is beyond the capacity of state and
local resources. If awarded funds, states typically contract with
community organizations to provide the crisis counseling services,
including outreach and public education, individual and group counseling,
and referral for other services. We and others have reported on
difficulties with CCP. In 2005, for example, we reported that following
the September 2001 attack on the World Trade Center (WTC), limited
financial oversight of New York's CCP by FEMA and SAMHSA made it difficult
to determine whether program funds were being used efficiently and
effectively to help alleviate psychological distress.^10 In addition,
other federal agencies have reported on difficulties that states have
experienced implementing their CCPs.^11

^5 Institute of Medicine, Preparing for the Psychological Consequences of
Terrorism: A Public Health Strategy (Washington, D.C., 2003), 1.

^6 For the purposes of this report, "state" includes states, territories,
Puerto Rico, and the District of Columbia.

^7 For the purposes of this report, "grant" includes grants and cooperative
agreements. Cooperative agreements are used when substantial interaction
is expected between the federal agency and the funding recipient.

^8 In this report, the program administered by the federal government is
referred to as "CCP," and individual programs administered by states
through CCP grants are referred to as "state CCPs."

^9 FEMA administers CCP through an annual interagency agreement with
SAMHSA.

Because of your interest in ensuring that our nation is prepared to
respond effectively to the psychological consequences of catastrophic
disasters, we examined the following questions: (1) What actions have
federal agencies taken to help states prepare for the psychological
consequences of catastrophic disasters? (2) What have been the states'
experiences in obtaining and using CCP grants to respond to the
psychological consequences of catastrophic disasters?

In general, to address our objectives, we obtained program documents from
federal agencies involved in disaster preparedness and response
activities--including DHS and HHS. We also interviewed officials from
these agencies, academic institutions, and national organizations that
focus on mental health, substance abuse, and emergency management. We
conducted additional work in six judgmentally selected states. We included
New York, Florida, Louisiana, and Mississippi because they were directly
affected by one of three catastrophic disasters that we included in our
scope: the WTC attack in 2001, Hurricane Charley in 2004, and Hurricane
Katrina in 2005. We included Texas because it hosted a large number of
people displaced by Hurricane Katrina, and we included Washington because
it both hosted people displaced by Hurricane Katrina and has features that
make it vulnerable to natural and man-made disasters, such as large ports.
Results from this nongeneralizable sample of states cannot be used to make
inferences about other states.

^10 GAO, Federal Emergency Management Agency: Crisis Counseling Grants
Awarded to the State of New York after the September 11 Terrorist Attacks,
[30]GAO-05-514 (Washington, D.C.: May 31, 2005), 29.

^11 See National Center for PTSD, "Retrospective 5-Year Evaluation of the
Crisis Counseling Assistance and Training Program," unpublished report
requested by SAMHSA (White River Junction, Vt., June 2005); and
Congressional Research Service, Gulf Coast Hurricanes: Addressing
Survivors' Mental Health and Substance Abuse Treatment Needs, RL33738
(Washington, D.C., Nov. 29, 2006).

To examine actions by federal agencies to help states prepare for the
psychological consequences of catastrophic disasters, we identified
federal grants awarded and other activities that occurred during fiscal
year 2002 through fiscal year 2006 to help states prepare for the
psychological consequences of disasters. We also reviewed mental health
and substance abuse disaster plans from the six states in our review and
interviewed officials from these agencies. To examine states' experiences
in obtaining and using CCP grants to respond to the psychological
consequences of catastrophic disasters, we interviewed mental health
officials from the six states in our review concerning their experiences
in applying for CCP funding and implementing their programs. We also
reviewed CCP grant applications or other relevant documentation submitted
by the six states in our review. In addition, we interviewed officials
from FEMA and SAMHSA to obtain their perspectives on the states'
applications and the states' experiences implementing programs using CCP
funds. We also reviewed reports by GAO and other entities and pertinent
legislation. (For additional information on our methodology, see app. I.)
We conducted our work from March 2006 through February 2008 in accordance
with generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.

Results in Brief

Federal agencies have awarded grants to help states prepare for the
psychological consequences of catastrophic and other disasters, and SAMHSA
has conducted an assessment of state mental health and substance abuse
disaster plans. In fiscal years 2003 and 2004, SAMHSA provided
preparedness grants to mental health and substance abuse agencies in 35
states for disaster planning. In addition, HHS's Centers for Disease
Control and Prevention (CDC), HHS's Health Resources and Services
Administration (HRSA), and DHS have also provided preparedness funding
that states may use for mental health or substance abuse preparedness, but
the agencies' data-reporting requirements do not produce information on
the extent to which states used funds for this purpose. We found that,
according to state officials, five of the six states in our review used
CDC or HRSA preparedness funds to support mental health and substance
abuse agencies at least once during fiscal years 2002 through 2006. In
2007, SAMHSA completed an assessment of mental health and substance abuse
disaster plans developed by states that received a SAMHSA preparedness
grant. The agency found that, for the 34 states with plans available for
review, these plans generally showed improvement over those that had been
submitted by states as part of their application for SAMHSA's preparedness
grant. The agency also identified several ways in which the plans could be
improved. For example, about half the plans did not indicate specific
planning and response actions that substance abuse agencies should take.
Similarly, our review of plans available from the six states in our review
found varying attention among the plans to covering substance abuse
issues. SAMHSA officials told us that the agency was exploring methods of
determining states' individual technical assistance needs. HHS is also
taking steps to be better prepared to send federal resources to help
states address the psychological consequences of a catastrophic disaster.
For example, HHS is increasing its capacity to deploy teams of trained
providers who can provide mental health services following a catastrophic
disaster.

Officials from the six states in our review told us they experienced
difficulties in applying for CCP funding and implementing their programs,
particularly in response to catastrophic disasters. They reported
difficulty collecting information needed for their applications, in part
because the application guidance did not provide sufficient detail. In
addition, states sometimes experienced lengthy application reviews by FEMA
and SAMHSA after catastrophic disasters, which contributed to delays in
executing contracts with service providers. FEMA and SAMHSA officials told
us they had taken steps to improve the application submission and review
process. State officials also identified problems in implementing CCPs
after catastrophic disasters. For example, they said that FEMA's policy of
not reimbursing states and service providers for indirect program costs,
such as certain administrative expenses, made it difficult for state CCPs
to recruit and retain providers. Other FEMA postdisaster response grant
programs allow reimbursement for indirect costs. A FEMA official told us
that the agency had been considering whether to allow reimbursement for
indirect costs under CCP since June 2006 but did not know when a decision
would be made. Including indirect costs in CCP and not requiring service
providers to absorb these costs could expand the pool of providers willing
to participate in this program, which could strengthen states' ability to
assist disaster victims in coping with the psychological consequences of
catastrophic disasters. State officials also cited difficulties assisting
people who could benefit from expanded services, such as more intensive
crisis counseling services than those traditionally provided through state
CCPs. FEMA and SAMHSA officials told us they planned to examine whether
certain expanded services should be incorporated into CCP. These officials
did not know when they would complete their review. Promptly determining
what types of expanded crisis counseling services should become a
permanent part of CCP would enable states to more effectively develop
their CCP proposals and more effectively provide their populations with
needed crisis counseling services.

To improve the federal government's ability to help states respond to the
psychological consequences of catastrophic disasters, we are recommending
that the Secretary of Homeland Security direct the Administrator of FEMA,
in consultation with the Administrator of SAMHSA, to expeditiously take
the following two actions: (1) revise CCP policy to allow states and
service providers that receive CCP funds to use them for indirect costs
and (2) determine what types of expanded crisis counseling services should
be formally incorporated into CCP and make any necessary revisions to
program policy. We provided a draft of this report to DHS and HHS for
comment. Both DHS and HHS generally concurred with both of our
recommendations and stated that they had taken or will take steps toward
implementing them. However, they did not provide specific timelines for
completing these actions.

Background

A catastrophic disaster exposes residents and responders to a variety of
traumatic experiences that put them at risk for adverse psychological
consequences. Preparedness at the federal, state, and local levels is
critical to the nation's ability to provide the services needed to address
these problems during response. In light of the emergence of threats posed
by terrorism and the complex issues involved in responding to those
threats, GAO has identified disaster preparedness and response as a major
challenge for the 21st century.^12

Psychological Consequences of Catastrophic Disasters

Research has shown that people who have experienced or witnessed certain
incidents during or after a catastrophic disaster--such as serious
physical injury, destruction of a home, or long-term displacement from the
community--can experience an array of psychological consequences. For
example, studies found that 1 to 2 months after the WTC attack, the rate
of probable PTSD was 11.2 percent among a sample of adults in the New York
City metropolitan area, compared with about 4 percent elsewhere in the
United States,^13 and Manhattan residents reported increases in smoking,
alcohol consumption, and marijuana use.^14 Research has also shown that
psychological effects can persist or emerge months or years after the
event has occurred. For example, a 2006 study on the use of counseling
services by people affected by the WTC attack found that some people first
sought counseling services more than 2 years after the event.^15

^12 GAO, 21st Century Challenges: Reexamining the Base of the Federal
Government, [31]GAO-05-325SP (Washington, D.C.: February 2005), 39-43.

Certain populations may be especially vulnerable to psychological
consequences following a disaster. These include children and survivors of
past traumatic events. Others who may be especially vulnerable include
people who had a preexisting mental illness at the time of a disaster.
Research has also shown that disaster responders may be especially
vulnerable because of the direct and protracted nature of their exposure
to traumatic experiences, extended working hours, and sleep deprivation. A
CDC survey of New Orleans firefighters and police officers about 2 to 3
months following Hurricane Katrina found that about one-third of
respondents reported symptoms of depression or PTSD, or both.^16

Psychological responses can also be affected by the characteristics of the
particular disaster and its aftermath. Terrorism differs from natural
disasters in that it can create a general sense of fear in the population
outside the affected area. The Institute of Medicine noted that although
terrorism and other disasters may share important characteristics, "the
malicious intent and unpredictable nature of terrorism may carry a
particularly devastating impact for those directly and indirectly
affected."^17 During the recovery phase of a catastrophic natural
disaster, ongoing stress due to the perceived loss of support associated
with large-scale dislocation of the population can also affect mental
health. In an assessment of health-related needs for residents returning
to the New Orleans area 7 weeks after Hurricane Katrina, researchers found
that many respondents had emotional concerns--such as feeling isolated or
crowded--and about half had levels of distress that indicated a possible
need for mental health services.^18

^13 W.E. Schlenger et al., "Psychological Reactions to Terrorist Attacks:
Findings from the National Study of Americans' Reactions to September 11,"
Journal of the American Medical Association, vol. 288, no. 5 (2002),
581-588.

^14 D. Vlahov et al., "Increased Use of Cigarettes, Alcohol, and Marijuana
among Manhattan, New York, Residents after the September 11th Terrorist
Attacks," American Journal of Epidemiology, vol. 155, no. 11 (2002),
988-996.

^15 N.H. Covell et al., "Use of Project Liberty Counseling Services over
Time by Individuals in Various Risk Categories," Psychiatric Services,
vol. 57, no. 9 (2006), 1268-1270.

^16 CDC, "Health Hazard Evaluation of Police Officers and Firefighters
after Hurricane Katrina--New Orleans, Louisiana, October 17-28 and
November 30-December 5, 2005," Morbidity and Mortality Weekly Report, vol.
55, no. 16 (2006), 456-458.

^17 Institute of Medicine, Psychological Consequences of Terrorism, 4.

Federal Role in Public Health Preparedness and Response

The Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act)^19 is the principal federal statute governing federal
disaster assistance and relief. State and local governments have the
primary responsibility for disaster response, and the Stafford Act
established the process for states to request a presidential disaster
declaration for affected counties in order to obtain supplemental
assistance--such as physical assets, personnel, and funding--from the
federal government when a disaster exceeds state and local capabilities
and resources. The President may make a disaster declaration for both
catastrophic disasters and smaller-scale disasters that exceed a state's
ability to respond.

The Stafford Act and FEMA's regulations contain provisions related to
disaster preparedness. The act encourages each state to have a plan that
stipulates the state's overall responses in the event of an emergency.
FEMA regulations require that, as a condition of receiving CCP funds to
respond to a disaster, states agree to include mental health disaster
planning in their overall plans.^20 The regulations do not require that
state mental health and substance abuse agencies develop their own
disaster plans, but such plans are recommended by SAMHSA as important
components of disaster preparedness. In 2003, SAMHSA issued mental health
disaster planning guidance to help state and local mental health agencies
create or revise disaster plans.^21 The agency recommends, for example,
that plans describe the specific responsibilities of state mental health
agencies and other organizations in responding to a disaster and
responsibilities for maintaining and revising a disaster plan. In 2004,
SAMHSA issued guidance recommending that state substance abuse agencies
develop all-hazard substance abuse disaster plans.^22 The guidance
recommends, among other things, that these plans include information on
working with other agencies and providers and on providing medications,
such as methadone.^23

^18 CDC, "Assessment of Health-Related Needs after Hurricanes Katrina and
Rita--Orleans and Jefferson Parishes, New Orleans Area, Louisiana, October
17-22, 2005," Morbidity and Mortality Weekly Report, vol. 55, no. 2
(2006), 38-41.

^19 Pub. L. No. 93-288, 88 Stat.143 (1974) (codified as amended at 42
U.S.C. S5121 et seq.).

^20 44 C.F.R. S206.171(f)(1) and (g)(1)(iv).

DHS created the National Response Plan in December 2004 to provide an
all-discipline, all-hazards approach for the management across
jurisdictions of domestic incidents such as catastrophic natural disasters
and terrorist attacks when federal involvement is necessary. The National
Response Plan details the missions, policies, structures, and
responsibilities of federal agencies for coordinating resource and
programmatic support to states, tribes, and other federal agencies.^24

DHS has responsibility for coordinating the federal government's response
to disasters, including administering the provisions of the Stafford Act.
FEMA administers funding for disaster relief by reimbursing federal,
state, and local government agencies and certain nongovernmental
organizations for eligible disaster-related expenditures.^25 The National
Response Plan also gives FEMA responsibility to coordinate mass care,
housing, and human services, including coordinating the provision of
immediate, short-term assistance for people dealing with the anxieties,
stress, and trauma associated with a disaster. In addition, HHS is
designated as the primary agency for coordinating public health and
hospital emergency preparedness activities and coordinating the federal
government's public health and medical response.^26 Depending on the
circumstances of a disaster, HHS's responsibilities may include assessing
mental health and substance abuse needs, providing disaster mental health
training materials, and providing expertise in long-term mental health
services. Other agencies--including the Departments of Defense, Justice,
Labor, and Veterans Affairs (VA)--support HHS's preparedness and response
efforts.^27

^21 See SAMHSA, Mental Health All-Hazards Disaster Planning Guidance
(Rockville, Md., 2003). SAMHSA's mental health disaster planning guidance
is intended to be a companion to the emergency operations planning
guidance published by FEMA in 1996, which recommends that state and local
emergency management organizations have emergency operations plans that
include a health and medical annex with provisions for responding to the
mental health needs of people affected by disasters.

^22 An all-hazards approach recognizes that some aspects of response to
terrorism, such as providing emergency medical services and managing mass
casualties, can be the same as for response to other emergencies, such as
natural disasters and epidemics.

^23 See SAMHSA, All Hazards Response Planning for State Substance Abuse
Service Systems, July 2004,
http://www.samhsa.gov/csatdisasterrecovery/toc.htm (accessed Nov. 6,
2007).

^24 In January 2008, DHS issued a National Response Framework to supersede
the National Response Plan. The framework is effective as of March 22,
2008.

^25 The Congress appropriates funds for disaster relief on a no-year basis;
that is, they remain available without fiscal year limitation.

Primary Federal Response Program for Crisis Counseling Services

For over 30 years, the federal government has used CCP to support
short-term crisis counseling and public education services to help
alleviate the psychological distress caused or aggravated by disasters for
which a presidential disaster declaration has been made.^28 FEMA
administers CCP in conjunction with SAMHSA, which provides technical
assistance, develops program guidance, and conducts oversight on behalf of
FEMA.

States seeking CCP funding following a presidentially declared disaster
can apply to FEMA for an immediate grant and, if necessary, a longer-term
grant.^29 The Immediate Services Program (ISP) grant funds CCP services
for up to 60 days following a disaster declaration, and states applying
for the grant must do so within 14 days of the declaration. The Regular
Services Program (RSP) grant is designed to help states meet a continuing
need for crisis counseling services for up to an additional 9 months.^30
States applying for an RSP grant must do so within 60 days of a disaster
declaration. If a state decides to apply for an RSP grant, the ISP grant
can be extended until the RSP application is reviewed and a funding
decision has been made. A state's CCP application must demonstrate that
the need for crisis counseling in the affected area is beyond the capacity
of state and local resources. A state must develop its needs assessment by
using a prescribed formula that, among other things, includes the
estimated numbers of deaths, persons injured, and damaged or destroyed
homes attributable to the disaster. This needs assessment is critical for
developing a state's program plan and budget request, which must also be
included in its application. FEMA reviews all ISP and RSP applications and
receives input from SAMHSA, which also reviews the applications. FEMA has
final authority for all funding decisions. Both ISP and RSP grants are
generally managed by state mental health agencies, which typically
contract with community organizations to provide CCP services.

^26 Within HHS, the Office of the Assistant Secretary for Preparedness and
Response (ASPR) coordinates and directs the department's emergency
preparedness and response program.

^27 In the National Response Framework, FEMA continues to have
responsibility to coordinate mass care, housing, and human services and
HHS continues to be designated as the primary agency for coordinating
public health and hospital emergency preparedness activities.

^28 See app. II for information on other federal programs that have been
used to help states and localities respond to mental health and substance
abuse needs following catastrophic disasters.

^29 Generally, only states that have received a presidential major disaster
declaration are eligible to request CCP funding. However, following
Hurricane Katrina, FEMA allowed states that did not receive a presidential
major disaster declaration to apply for CCP funding to assist people who
had evacuated from the affected areas to their jurisdictions.

The CCP model was designed to meet the short-term mental health needs of
people affected by disasters through outreach that involves education,
individual and group counseling, and referral for other services. The main
focus of the model is to help people regain their predisaster level of
functioning by, among other things, providing emotional support,
mitigating additional stress, and providing referrals to additional
resources that may help them recover. CCP services, which are to be
provided anonymously and free of charge, are primarily delivered through
direct contact with disaster survivors in familiar settings--such as
homes, schools, community centers, and places of religious worship.
Services are designed to be delivered by teams of mental health
professionals and paraprofessionals from the community affected by the
disaster. The mental health professionals, who have prior specialized
mental health or counseling training and are usually licensed by the
state, typically coordinate and supervise paraprofessionals who may not
have had previous training as mental health professionals.
Paraprofessionals working as CCP crisis counselors provide outreach,
crisis counseling, and referrals. All members of the teams are to be
trained in the basics of crisis counseling and CCP. States cannot use CCP
funds to provide longer-term services such as treatment for psychiatric
disorders or substance abuse, office-based therapy, or medications. The
state programs are expected to refer survivors who may need such services
to an appropriate agency or licensed mental health professional.

^30 In some cases, FEMA may extend a state's RSP for an additional 90 days
in response to a documented need. In limited circumstances, such as
disasters of a catastrophic nature, FEMA can extend a state's RSP beyond
the additional 90 days.

From fiscal year 2001 through fiscal year 2006, the majority of CCP grant
funding has been used to meet needs following catastrophic disasters.
According to FEMA, during this period, the agency obligated a total of
about $424 million in CCP funds, with about $289 million (about 68
percent) obligated for states that responded to the three catastrophic
disasters in our review--the WTC attack, Hurricane Charley, and Hurricane
Katrina. According to FEMA, the agency obligated about $167 million for
New York and other states that responded to the WTC attack;^31 about $7
million for Florida to respond to Hurricane Charley; and about $51 and $23
million in CCP funds for Louisiana and Mississippi, respectively, to
respond to Hurricane Katrina.^32 In addition, FEMA allowed 26 additional
states, commonly called "host states," to apply for CCP funding to assist
people displaced as a result of Hurricane Katrina. According to FEMA, the
agency obligated for these host states a total of about $37 million,
ranging from about $13,000 to about $13 million each.^33 For example, the
agency obligated about $13 million and $129,000 for Texas and Washington,
respectively.^34

At SAMHSA's request, VA's National Center for PTSD (NCPTSD) conducted an
evaluation of CCP and provided its report in June 2005.^35 NCPTSD
researchers examined state CCPs that were for disasters occurring from
October 1996 through September 2001 and that concluded by December 2003,
which resulted in an examination of programs implemented by 27 states to
respond to 28 disasters. The evaluation also included case studies of four
specific disasters--the bombing of the Murrah Federal Building in Oklahoma
City, Oklahoma, in 1995; Hurricane Floyd in 1999; the WTC attack in 2001;
and the Rhode Island nightclub fire in 2003. Although NCPTSD's evaluation
found that CCP performed well in certain respects, it identified a number
of ways in which states had difficulties implementing their CCPs, and it
indicated that drawing conclusions about some aspects of the program was
difficult because data were of poor quality and incomplete.

^31 According to a FEMA official, RSP obligations could not be provided
separately for each state that received CCP funding related to the WTC
attack. The $167 million includes funds that FEMA obligated to New York as
well as Connecticut, Massachusetts, New Jersey, and Pennsylvania.

^32 As of October 2007, Louisiana was still providing CCP services and FEMA
had obligated about $47.6 million for the state to serve persons in
counties directly affected by Hurricane Katrina, which were covered by the
disaster declaration, and an additional $3.3 million to serve people in
counties not covered by the disaster declaration. FEMA also obligated
about $4 million in CCP funding for Alabama to respond to Hurricane
Katrina.

^33 Fifteen of the host states received both ISP and RSP funding.

^34 According to FEMA, CCP obligation data are as of October 8, 2007.

^35 NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program.

Federal Agencies Have Awarded Grants to States to Support Preparation for
Psychological Consequences of Catastrophic Disasters, and SAMHSA Has Assessed
States' Disaster Plans

Federal grants have helped states prepare for the psychological
consequences of catastrophic and other disasters, and SAMHSA has conducted
an assessment of disaster plans from many state mental health and
substance abuse agencies. In fiscal years 2003 and 2004, SAMHSA awarded
grants to mental health and substance abuse agencies in 35 states
specifically for disaster planning. CDC, HRSA, and DHS have also provided
preparedness funding that states may use for mental health or substance
abuse preparedness, but the agencies' data-reporting requirements do not
produce information on the extent to which states used funds for this
purpose. In 2007, SAMHSA completed an assessment of mental health and
substance abuse disaster plans developed by states that received its
preparedness grant. SAMHSA found that these plans showed improvements over
those that had been submitted by states as part of their application for
the preparedness grant. The agency also identified several ways in which
the plans could be improved. In addition to assisting states with their
preparedness, HHS is taking steps to be better prepared to send federal
resources to help states respond to the psychological consequences of
disasters.

Federal Grants Have Supported States' Mental Health and Substance Abuse
Preparedness for Catastrophic and Other Disasters

SAMHSA awarded $6.8 million over fiscal years 2003 and 2004 specifically
to help state mental health and substance abuse agencies prepare for the
psychological consequences of catastrophic and other disasters. The agency
awarded 35 states;^36 the total amount awarded to each individual state
ranged from about $105,000 to about $200,000.^37 Two of the six states in
our review, New York and Texas, received a SAMHSA grant. New York, which
already had a mental health disaster plan, used the funds to develop a
plan for its state substance abuse agency. Texas, which was already
developing a mental health disaster plan, used the grant to help fund a
consortium of state agencies with postdisaster mental health
responsibilities--including mental health, public safety, and victims'
services--and to increase the role of substance abuse providers in
preparedness activities. Mental health officials from one of the four
states in our review that did not apply for a SAMHSA grant told us their
agency did not apply because it was already engaged in planning with the
state public health agency, and officials from the other three states said
they did not apply due to competing demands on their time.

CDC, HRSA, and DHS public health and homeland security preparedness grant
funds can also be used by states to prepare for the psychological
consequences of disasters, and we found examples of states using CDC and
HRSA funds for this purpose. During fiscal years 2002 through 2006, CDC
and HRSA awarded about $6.1 billion in grants to states and selected urban
areas to improve public health and hospital preparedness,^38 and DHS
provided about $12.1 billion in grants to states and localities for broad
preparedness efforts.^39 CDC and HRSA require that states document how
they plan to engage in certain mental health and substance abuse
preparedness activities,^40 and although there is no requirement that
states spend their DHS grant funds to prepare for the psychological
consequences of disasters, a state may choose to do so. These grant
programs fund broader preparedness efforts, and their data-reporting
requirements do not produce information on the full extent to which states
used funds for mental health and substance abuse preparedness activities.
We found that, according to state officials, public health agencies in
five of the six states in our review--all but Mississippi--used either CDC
or HRSA preparedness funds to support mental health and substance abuse
agencies' activities at least once during fiscal years 2002 through
2006.^41 For example, in Florida, Texas, and Washington, public health
agencies allocated funds to mental health and substance abuse agencies for
the development of a disaster plan or to pay the salaries of disaster
planners. In Louisiana, the mental health agency received funds to, among
other things, develop criteria for a registry of volunteer mental health
professionals and help mental health and substance abuse treatment
facilities develop disaster plans. Mental health or substance abuse
officials in the six states we reviewed told us their agencies were not
allocated funds from their state's DHS grant during fiscal years 2002
through 2006.

^36 SAMHSA awarded grants for disaster planning to the following states:
Alabama, Alaska, California, Colorado, Connecticut, the District of
Columbia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maine, Maryland,
Massachusetts, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New
Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon,
Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee,
Texas, Virginia, West Virginia, and Wisconsin.

^37 State activities funded by these grants were completed by the end of
2006. SAMHSA has not allocated funds to make any additional preparedness
grants to states.

^38 The grant programs are CDC's Public Health Emergency Preparedness
Program and HRSA's National Bioterrorism Hospital Preparedness Program.
These funds were awarded annually to public health agencies in states and
three urban areas--Chicago, Los Angeles, and New York City. In March 2007,
the National Bioterrorism Hospital Preparedness Program was transferred
from HRSA to ASPR and was renamed the Hospital Preparedness Program.

^39 In fiscal year 2006, DHS integrated five preparedness grant programs
into the Homeland Security Grant Program.

In addition to awarding grants to states, federal agencies have funded
training and developed guidance to enhance states' preparedness for the
psychological consequences of disasters. For example, SAMHSA established
its Disaster Technical Assistance Center^42 in fiscal year 2003 to provide
training and technical assistance to state mental health and substance
abuse agencies. SAMHSA also distributes various guidance documents, such
as guidance to help prevent and manage stress in disaster response workers
before, during, and after a disaster.^43 In addition, CDC, HRSA, and DHS
fund the development of training activities that can benefit the
preparedness of states' mental health providers. For example, HRSA
officials told us that the agency's Bioterrorism Training and Curriculum
Development Program awarded a contract in 2006 to an accrediting body for
counseling programs to incorporate mental health disaster preparedness
into its educational standards,^44 and CDC's Centers for Public Health
Preparedness Program awarded grants to academic institutions to develop
and assess training on mental health preparedness and response.

^40 For example, CDC's program required in fiscal years 2005 and 2006 that
states document how they planned to increase the availability of crisis
counseling, mental health, and substance abuse support for public health
responders. In addition, HRSA's program encouraged states to allocate a
portion of their funds to develop registries of volunteer mental health
care providers who could provide services following a disaster. In middle
to late 2006, CDC and HRSA began developing formal data analysis programs
that could be used to generate standardized reports. GAO, Public Health
and Hospital Emergency Preparedness Programs: Evolution of Performance
Measurement Systems to Measure Progress, [32]GAO-07-485R (Washington,
D.C.: Mar. 23, 2007), 15.

^41 According to state officials, from fiscal year 2002 through fiscal year
2006, state public health agencies allocated CDC and HRSA grant funds to
state mental health agencies as follows: Florida ($140,000), Louisiana
($500,000), New York ($400,000), Texas ($172,000), and Washington
($70,000).

^42 The Disaster Technical Assistance Center is operated by Educational
Services, Inc., under contract with SAMHSA.

SAMHSA Has Assessed State Mental Health and Substance Abuse Disaster Plans

SAMHSA reviewed state mental health and substance abuse plans as part of
its disaster preparedness grant program. In 2007, the agency completed a
review of the disaster plans of 34 of the 35 states that received a SAMHSA
preparedness grant to, among other things, give SAMHSA aggregated
information about states' disaster planning and technical assistance
needs.^45 According to SAMHSA, the mental health and substance abuse
disaster plans of these 34 states showed improvement over the plans the
states had submitted in 2002 as part of their grant applications. Areas
SAMHSA identified as showing improvement included

           o stronger partnership for planning and response among state
           mental health and substance abuse services agencies;

           o an increased number of unified plans that encompass both mental
           health and substance abuse services issues;

           o stronger partnerships with key stakeholders such as emergency
           management, public health agencies, and voluntary organizations
           that are active in disasters; and

           o clearer identification and articulation of the disaster response
           role of state mental health and substance abuse agencies.
			  
^43 SAMHSA, A Guide to Managing Stress in Crisis Response Professions
(Rockville, Md., 2005).

^44 The Bioterrorism Training and Curriculum Development Program was
transferred from HRSA to ASPR in March 2007.

^45 SAMHSA did not review one state's disaster plan because it was not
available at the time of SAMHSA's review. SAMHSA, "State Behavioral Health
All-Hazards Disaster Plan Review Report," unpublished report (Rockville,
Md., June 2007).			  

           SAMHSA also identified several ways in which the plans could be
           improved. For example, it reported that while most plans indicated
           that the state deploys disaster responders to provide mental
           health and substance abuse services, about one-third of the plans
           needed to provide more detailed information on the training,
           qualifications, and safe deployment of these responders. SAMHSA
           also reported that although states were more likely to incorporate
           substance abuse services into their disaster planning, about half
           the plans still did not indicate specific planning and response
           actions that substance abuse agencies should take.

           In reviewing mental health and substance abuse disaster plans from
           five of the six states in our study, we made observations that are
           consistent with SAMHSA's findings.^46 For example, we found that
           the five states' disaster plans varied in their attention to
           substance abuse topics. Two states in our review issued separate
           mental health and substance abuse plans. Each of the other three
           states issued a unified disaster plan to cover both mental health
           and substance abuse, but only one of the three plans specifically
           discussed both types of services. The other two plans primarily
           discussed mental health services and had few specific references
           to providing substance abuse services following a disaster. For
           example, these plans did not include specific information about
           providing methadone treatment for people with a drug abuse
           disorder following a disaster--information that was provided in
           the separate substance abuse plans. In addition, we found that
           disaster plans of the states in our review did not always identify
           specific actions or responsibilities related to serving the mental
           health and substance abuse needs of certain special
           populations.^47 Three state disaster plans did not identify
           specific actions for preparing to work with children, and two
           plans did not include provisions for specific cultural minorities.

^46 Of the six states we included in our review of disaster plans, New York
and Texas were also included in SAMHSA's review. We did not review a
disaster plan from Washington. An official from Washington told us that
the state began developing a unified mental health and substance abuse
disaster plan in 2005 and was scheduled to complete that plan by January
1, 2008.

^47 Experts have observed that some people--including children, those with
preexisting mental illness, disaster response workers, frail elderly, and
cultural minorities--may warrant specialized approaches when states plan
for the psychological consequences of disasters.

           Mental health and substance abuse officials from the states in our
           review told us that they recognized various gaps in their disaster
           preparedness. For example, state officials discussed the need to
           provide additional training to disaster responders and said they
           would like to collaborate more extensively with state health,
           emergency management, and education agencies. One observation that
           state mental health officials made was that schools could be an
           important local resource for providing postdisaster services to
           children but that relationships between state mental health
           agencies and schools are sometimes not in place prior to a
           disaster. Officials from several states described benefits from
           meeting other states' officials at SAMHSA's regional training
           conferences, but told us that resource limitations or the need to
           first plan within their own state made it difficult to continue
           these relationships.

           SAMHSA's report recommended that the agency conduct state-specific
           needs assessments to identify individual states' technical
           assistance needs for mental health and substance abuse disaster
           planning. SAMHSA officials told us that the agency is exploring
           methods to conduct such assessments and that the agency would need
           to determine the availability of resources for the assessments.
			  
			  HHS Is Taking Steps to Be Better Prepared to Send Federal Resources
			  to Help States Address the Psychological Consequences of Disasters

           To help states address the psychological consequences of
           disasters, HHS, as the lead federal department for public health
           and medical preparedness, is implementing several efforts to be
           better prepared to send federal resources to help states. For
           example, HHS is increasing the capacity of federal disaster
           response teams to provide mental health services to disaster
           victims and responders. Based on lessons learned following
           Hurricane Katrina, the White House Homeland Security Council
           recommended that HHS organize, train, and equip medical and public
           health professionals in preconfigured and deployable teams.^48 In
           response, HHS organized U.S. Public Health Service Commissioned
           Corps officers^49 into several teams--including five Rapid
           Deployment Force teams that each include 4 mental health providers
           and five Mental Health Teams that each include about 20 mental
           health providers.^50 HHS created team rosters and sponsored a
           large-scale training exercise from July 15, 2007, through August
           24, 2007, that allowed the team members, including the mental
           health providers, to train together.
			  
^48 White House Homeland Security Council, The Federal Response to
Hurricane Katrina: Lessons Learned (Washington, D.C., Feb. 23, 2006), 105.

^49 The U.S. Public Health Service Commissioned Corps is one of the seven
Uniformed Services of the United States. The Commissioned Corps provides a
variety of services to help promote the health of the nation, such as
delivering health care services to medically underserved populations and
providing health expertise during national emergencies. At the time of
Hurricane Katrina, U.S. Public Health Service Commissioned Corps officers
were not assigned to preexisting teams; rather, teams were formed as they
were needed.

           HHS also plans to recruit additional mental health providers into
           the Commissioned Corps. HHS officials told us that there has been
           a shortage of mental health providers in the Commissioned Corps
           and that requirements for deployment on short notice made it
           difficult for agencies to ensure that team members' regular
           responsibilities are fulfilled while the team member is deployed.
           For fiscal year 2008, HHS proposed to recruit providers to staff
           full-time, dedicated Health and Medical Response Teams.^51 Two
           teams--each with 105 members, including at least 4 mental health
           providers--would serve as the primary responders for the
           Commissioned Corps and reduce the deployment burden placed on
           other officers.

           HHS has also taken steps to increase the supply of drugs indicated
           for psychological disorders that should be available in the event
           of a disaster. Prior to Hurricane Katrina, HHS began developing
           Federal Medical Stations to provide mass casualty capability
           (i.e., equipment, material, and pharmaceuticals) to augment local
           health care infrastructures overwhelmed by a terrorist attack or
           natural disaster. These stations included a cache of drugs focused
           on urgent and emergency care. Given the large number of evacuees
           with special medical needs who required care following the
           hurricane, HHS revised the cache in 2006 to increase the types of
           drugs specifically indicated for mental health conditions from 20
           to 33. For example, HHS increased the types of antidepressants and
           antipsychotics and added five new classes of drugs, including
           drugs to treat sleep disorders.
			  
^50 HHS officials told us that the teams were configured primarily to
provide mental health support, although elements of the training related
to substance abuse. For example, training materials list alcohol abuse as
a symptom of psychological problems and note that people in recovery for
substance abuse may relapse following a disaster.

^51 When not deployed in response to an emergency, the Health and Medical
Response Team members would obtain training, provide training to other
Commissioned Corps and Medical Reserve Corps members, and provide clinical
and public health services to underserved communities.

           States Experienced Several Difficulties in Applying for and
			  Implementing Their CCPs Following Catastrophic Disasters

           State officials told us they experienced difficulties in applying
           for CCP funding and implementing their programs, particularly in
           the wake of catastrophic disasters. States had problems collecting
           information needed to prepare their ISP applications within FEMA's
           application deadline and preparing parts of their ISP and RSP
           applications, including estimating the number of people who might
           need crisis counseling services. FEMA and SAMHSA officials told us
           they had taken steps to revise the applications and supporting
           guidance to help address these difficulties. States also
           experienced lengthy application reviews, and FEMA and SAMHSA
           officials said they had taken steps to improve the submission and
           review process. In addition, state officials told us they
           experienced problems implementing their CCPs, such as difficulties
           resulting from FEMA's policy of not reimbursing state CCPs for
           indirect program costs. Additional problems that state officials
           cited were related to assisting people in need of more intensive
           counseling services and making referrals for mental health and
           substance abuse treatment. FEMA and SAMHSA are considering options
           to address some of these concerns, but they do not know when they
           will make these decisions.
			  
			  States Encountered Difficulties in Preparing CCP Applications, and
			  FEMA and SAMHSA Officials Cited Efforts to Clarify the Applications
			  and Provide Training

           Officials in the six states in our review told us they encountered
           difficulties as they prepared their CCP applications following the
           catastrophic disasters included in our review, including
           difficulties in collecting the information required for their ISP
           applications within established deadlines.^52 Officials said that
           the amount of information required for their applications was
           difficult to collect because of the scope of the disasters and the
           necessity for responding on other fronts, such as ensuring the
           safety of patients and personnel at state-run mental health
           facilities. For example, Texas officials estimated that the state
           hosted more than 400,000 Hurricane Katrina evacuees and that they
           had to collect information for over 250 counties to estimate how
           many people might need crisis counseling services. Furthermore,
           several state officials said that some of the information required
           for the ISP application, such as that on preliminary damages and
           the location of people who might need services, was not always
           available or reliable immediately following a catastrophic
           disaster. According to SAMHSA, because information from
           traditional sources was lacking following Hurricane Katrina,
           states were allowed to use other sources--such as newspaper
           reports and anecdotal evidence--to complete their applications.
           However, Louisiana and Mississippi officials told us that
           obtaining the information required by SAMHSA to complete the
           application was difficult and was sometimes unavailable in the
           immediate aftermath of the hurricane. Officials in three states we
           contacted said that the difficulty of completing their
           applications on time was exacerbated because multiple disasters
           affected the same jurisdictions in close succession and they were
           required to submit a separate application for each one. Louisiana,
           for example, had to submit separate ISP applications following
           Hurricanes Katrina and Rita, even though the hurricanes affected
           overlapping areas and occurred less than 1 month apart.^53
			  
^52 According to an agency official, following Hurricane Katrina the agency
did not require host states to abide by the 14-day application deadline.
Once FEMA determined that 100 or more disaster survivors had registered
with FEMA for federal disaster assistance in a state, the state was
notified that it was eligible to submit an abbreviated version of the
application for ISP funding and that it had 10 days from the date of
notification to apply.

^53 In addition, Louisiana had to administer each CCP separately, which
included, for example, submitting separate quarterly reports for each
program.

           State officials also told us that the CCP application's needs
           assessment formula, which they are to use to estimate the number
           of people who might need crisis counseling services, created
           problems in estimating needs following catastrophic disasters in
           their states. The needs assessment formula includes several
           categories of loss, including deaths, hospitalizations, homes
           damaged or destroyed, and disaster-related unemployment.^54 State
           officials told us that the formula's loss categories did not
           capture data that they considered critical to assessing mental
           health needs following a catastrophic disaster, such as estimates
           of populations at increased risk for psychological distress,
           including children and the elderly, or information on destroyed or
           damaged community mental health centers. While states can include
           such information in a narrative portion of their application,
           several state officials told us it was not clear to them how this
           narrative information is factored into funding decisions. NCPTSD's
           evaluation of CCP for SAMHSA described concerns similar to those
           noted by states in our review about the accuracy of the results
           produced by using the formula. Moreover, NCPTSD concluded that the
           formula could be a contributing factor in discrepancies it found
           between states' estimates of people in need and the numbers of
           people actually served.^55
			  
^54 The CCP needs assessment formula did not include a specific category
for estimating crisis counseling needs in situations, such as Hurricane
Katrina, in which a state was hosting disaster evacuees and did not itself
experience casualties or property destruction. Therefore, according to a
FEMA official, the agency made an ad hoc decision after Hurricane Katrina
to allow states hosting evacuees to develop their ISP needs assessments
based solely on the number of evacuees in their state who had registered
for federal disaster assistance.

^55 The researchers found both overestimation and underestimation of people
needing crisis mental health services, with some state CCPs reporting that
they served 3 to 10 times more people than had been estimated to need CCP
services and others reporting that they served one-half to one-fourteenth
the number of people that had been estimated. See NCPTSD, Retrospective
5-Year Evaluation of the Crisis Counseling Program, B27-B28, E12.

           Preparing the sections of the application on plans for providing
           CCP services and on program budgets also was difficult, according
           to state officials. For example, state officials said the
           application guidance did not provide sufficient detail to indicate
           what federal officials would consider reasonable numbers of
           supervisors, outreach workers, and crisis counselors to hire.
           Several officials also said it was difficult to use the fiscal
           guidance to determine what agency officials would consider a
           reasonable budget for various CCP activities, such as use of paid
           television and radio advertisements for outreach. State officials
           said that having more detailed guidance would help them develop
           better proposals and minimize the need to revise their
           applications during the review process.

           Federal program officials told us they have taken steps to address
           various difficulties that states experienced in collecting
           information and preparing their CCP applications. Agency officials
           told us that they recently made changes intended to reduce the
           amount of information required in the ISP and RSP applications,
           modified the needs assessment formula, and clarified the
           applications and supporting guidance. For example, in the revised
           needs assessment formula the weights assigned to most of the loss
           categories have been adjusted for estimating the number of people
           who could benefit from CCP services. According to SAMHSA, the
           revised ISP and RSP applications were approved in September 2007;
           the agency made these available to states in November 2007. In
           2006, in response to feedback from states regarding difficulties
           with the application process, FEMA and SAMHSA revised their 4-day
           CCP basic training course for states to increase its focus on
           preparing CCP applications. According to a FEMA program official,
           the course was also revised in 2007 to reflect recent changes to
           the applications and supporting guidance, and FEMA program
           officials have requested that FEMA's Emergency Management
           Institute offer the course annually instead of every other year.
           This program official also told us that a Web-based CCP
           orientation course was developed and that it is required for all
           those who attend the basic training course.
			  
			  States Experienced Lengthy Application Reviews following Catastrophic
			  Disasters, and FEMA and SAMHSA Have Taken Steps Intended to Shorten
			  the Review Process

           State officials told us that FEMA and SAMHSA's CCP application
           review process was lengthy after catastrophic disasters,
           especially for RSP applications submitted following Hurricane
           Katrina. A FEMA official estimated that for CCP applications
           submitted in 2002 through 2006 it had generally taken the agencies
           about 14 days to review and make funding decisions for ISP
           applications and about 28 to 70 days to review and make funding
           decisions for RSP applications. Our analysis of CCP applications
           for the catastrophic disasters in our review showed that it took
           FEMA and SAMHSA from 5 to 39 days to review and make funding
           decisions for ISP applications and 58 to 286 days to review and
           make funding decisions for RSP applications. (See table 1.)

Table 1: Number of Days for States' ISP and RSP Application Submission and
Federal Review for Selected Catastrophic Disasters

ISP Application: Days from disaster declaration to state submission of 
application; 
WTC attack, New York: 8; 
Hurricane Charley, Florida: 14; 
Hurricane Katrina: Louisiana: 14; 
Hurricane Katrina: Mississippi: 14; 
Hurricane Katrina: Texas: 10[A]; 
Hurricane Katrina: Washington: 26[A]. 

ISP Application: Days from state submission of application to 
completion of federal review; 
WTC attack, New York: 5; 
Hurricane Charley, Florida: 5; 
Hurricane Katrina: Louisiana: 24; 
Hurricane Katrina: Mississippi: 22; 
Hurricane Katrina: Texas: 39; 
Hurricane Katrina: Washington: 14. 

RSP Application: Days from disaster declaration to state submission of 
application; 
WTC attack, New York: 63[B]; 
Hurricane Charley, Florida: 59; 
Hurricane Katrina: Louisiana: 59; 
Hurricane Katrina: Mississippi: 60; 
Hurricane Katrina: Texas: 55; 
Hurricane Katrina: Washington: [C]. 

RSP Application: Days from state submission of application to 
completion of federal review; 
WTC attack, New York: 213; 
Hurricane Charley, Florida: 58; 
Hurricane Katrina: Louisiana: 286; 
Hurricane Katrina: Mississippi: 110; 
Hurricane Katrina: Texas: 125; 
Hurricane Katrina: Washington: [C]. 

Source: GAO analysis based on information provided by FEMA, SAMHSA, and
states.

^a Texas and Washington applied for CCP funding as host states to serve
persons displaced from states directly affected by Hurricane Katrina. Host
states were not required to abide by the standard 14-day application
deadline. Once FEMA determined that 100 or more disaster survivors had
registered with FEMA for federal disaster assistance in a state, the state
was notified that it was eligible to submit an application for ISP funding
and that if the state wanted to apply it had 10 days from the date of
notification to do so.

^b According to a FEMA official, the agency allowed New York to submit its
RSP application after the 60-day application deadline.

^c Washington did not apply for RSP funding.

State officials told us that the lengthy reviews and the resulting delays
in obtaining RSP funding created difficulties for their CCPs. According to
state officials, delays in application approval contributed to delays in
executing contracts with service providers, delays in hiring staff, and
problems retaining staff. They told us they needed to obtain a decision on
their RSP application as quickly as possible so they could better plan and
implement their programs.

Federal program officials told us that several factors contributed to the
time it took to review applications following these catastrophic
disasters. These factors included an unanticipated high volume of CCP
applications following Hurricane Katrina. CCP applications submitted by
states that were directly affected by Hurricane Katrina, as well as by 26
states hosting people who had evacuated after Hurricane Katrina, created
unanticipated demands that were well beyond the normal capacity of their
CCP staff to handle.^56 FEMA officials told us that the two agencies
typically reviewed an average of 17 new ISP applications and 13 new RSP
applications each year from fiscal year 2002 through 2006, but that they
reviewed 31 ISP applications and 20 RSP applications in response to
Hurricane Katrina alone. According to SAMHSA officials, the agency had not
planned for the surge of applications created by FEMA's decision to allow
host states to apply for CCP funding and had no policies in place at the
time to enable SAMHSA's CCP and grants management staff to adapt quickly
to the submission of so many CCP applications within a few weeks. To
respond, some SAMHSA staff had to handle double the number of applications
they usually process, and the agency supplemented its six CCP reviewers by
using six staff from other parts of the agency to help review CCP grant
applications. FEMA hired three temporary staff to assist with the
application review process after Hurricane Katrina. However, a report
prepared for SAMHSA on its response to Hurricane Katrina noted that some
agency staff who assisted with the review of applications did not have
sufficient knowledge of CCP and the grant review process and therefore
required training.^57

SAMHSA and FEMA have taken actions to be prepared for such a surge in
applications in the future. A SAMHSA official told us that the agency sent
five staff from various parts of the agency to the August 2007 4-day CCP
basic training course to help them gain a better understanding of the CCP
application process. In December 2007, the agency hired a staff person,
whose position was funded by FEMA, in its grants management office to,
among other things, assist in the review of CCP applications and the
fiscal monitoring of CCP grants. They expect the addition of this employee
to help to shorten application review times for RSP grants.

^56 Louisiana, for example, submitted ISP and RSP applications to provide
services in parishes that received a presidential disaster declaration for
Hurricane Katrina. The state also submitted an abbreviated ISP application
and RSP application to provide CCP services in parishes that did not
receive a presidential disaster declaration but that hosted evacuees.
According to SAMHSA officials, the state also submitted an RSP application
to provide services to people affected by Hurricane Rita.

^57 Educational Services, Inc., "Beyond Katrina: An After-Action Report on
Improving Substance Abuse and Mental Health Response to Future Disasters,"
unpublished report, prepared at the request of SAMHSA (Bethesda, Md., May
8, 2006), 39.

SAMHSA officials told us that the need to obtain further information from
the states also contributed to the length of the reviews following
Hurricane Katrina. In examining various CCP applications submitted by the
states in our study after Hurricane Katrina and related correspondence, we
noted instances in which SAMHSA sent letters to states informing them that
their applications contained errors, were incomplete, or required
clarification for the agency to proceed with its review. In some
instances, the agency made multiple requests to a state to clarify a
specific part of its application. For example, SAMHSA found that Louisiana
did not provide complete information in its RSP application related to the
process the state planned to use to identify the local service providers
with which it would contract--a process that was different from the one
traditionally used to contract for CCP services. According to federal
officials, issues related to this process resulted in Louisiana not
submitting a complete application until 6 months after its initial
application, which in turn created enormous delays in the application
review process.

SAMHSA officials told us that another reason for the need to obtain
additional clarification was that the agency had established a more
stringent CCP application review process in July 2005.^58 According to
SAMHSA officials, the revised CCP applications and guidance should help
reduce the need for states to revise their applications during the review
process. In addition, agency officials told us that the 2007 CCP basic
training course for applicants included information on the application
process and on the new review standards.

^58 SAMHSA officials told us they made changes in the application review
process based in part on our 2005 report on New York's CCP, known as
Project Liberty, which was established after the 2001 WTC attack. We
reported, among other things, that FEMA and SAMHSA had not obtained
realistic budget information during the CCP application process that they
could use to effectively assess how New York was planning to spend Project
Liberty grant funds. See [33]GAO-05-514 .

States Faced Difficulties in Implementing Their CCPs after Catastrophic
Disasters, including Problems Related to Lack of Indirect-Cost Reimbursement and
Need for Expanded Services

State officials said they faced difficulties in implementing their CCPs
following catastrophic disasters. For example, they told us that FEMA's
policy of not reimbursing states and counseling service providers for
indirect costs^59 caused difficulties for state CCPs. They also described
the need for expanded crisis counseling services and cited additional
concerns.

  Obtaining Reimbursement for Indirect Costs

States told us that FEMA's policy of precluding states and their CCP
service providers from obtaining reimbursement for indirect costs has
created difficulties in implementing their programs. Under CCP guidelines,
states and their CCP service providers cannot be reimbursed for indirect
costs related to managing and monitoring their programs that are not
directly itemized in their program budgets. However, state officials told
us that it can be difficult for their agencies and service providers to
determine what proportion of their overall administrative costs is
attributable to CCP activities. In addition, several state officials also
told us that CCP service providers often have limited capacity in their
overall agency budgets to redirect funds from other services to cover the
indirect costs associated with their CCP work.

State officials told us that the inability to obtain reimbursement for
indirect costs contributed to difficulties in recruiting and retaining
service providers. According to Louisiana officials, for example, that
inability contributed to the decision of one of its largest Hurricane
Katrina CCP contractors providing services in New Orleans to withdraw from
the state's program in 2007. While CCP guidance precluded reimbursement
for indirect costs, the provider decided to request reimbursement. In a
June 2006 letter to the state mental health office, the provider stated
that participating in the state's CCP had created a financial burden that
included moving funds from other services to its CCP contract. In July
2006, FEMA declined the provider's request to include indirect costs in
its budget, stating that under CCP guidelines all budget charges must be
direct and that the provider should work with the state to see whether any
of these costs could be reclassified as direct costs in the provider's
budget.

^59 Indirect costs are those incurred by an organization that are not
readily identified with a particular project but are necessary to the
operation of the organization and the performance of the project. Typical
examples of indirect costs include the cost of operating and maintaining
facilities, accounting and personnel services, and depreciation.

Officials in FEMA's grants management office told us that although CCP
policy prohibits reimbursement for indirect costs, they were unaware of
statutory or regulatory prohibitions on the reimbursement of such
costs.^60 Furthermore, they told us that other FEMA disaster response
grant programs do allow indirect cost reimbursement. For example, grantees
can be reimbursed for indirect costs under FEMA's Public Assistance
Program^61 and Hazard Mitigation Grant Program.^62 Other federal
postdisaster response grant programs also allow grantees to be reimbursed
for indirect costs, including the SAMHSA Emergency Response Grant (SERG)
program and the Department of Education's Project School Emergency
Response to Violence (Project SERV) program.

Concern about the exclusion of indirect costs from CCP reimbursement has
been a long-standing issue. In 1995, FEMA's Inspector General issued a
report on CCP that said that the reimbursement of indirect costs appeared
allowable under applicable federal law and regulations.^63 The Inspector
General recommended that FEMA review its policy on reimbursement for
indirect costs.^64 FEMA and SAMHSA officials told us that reimbursement
for indirect costs was a recurring concern for states and service
providers and that states have advocated for a change in this policy.
SAMHSA officials said that allowing indirect cost reimbursement would
promote participation of a broader array of local service providers.

A FEMA official told us that the agency had been considering whether to
develop a new CCP policy to allow reimbursement for such costs. According
to this official, FEMA had been examining this issue since June 2006, when
it received the letter from the Louisiana CCP service provider. This
official also told us that SAMHSA provided recommendations in March 2007
on potential modifications to CCP guidance and application materials to
allow reimbursement for indirect costs. According to this official,
however, FEMA still needed to examine various implementation issues,
including which types of indirect costs might be reimbursed and what
changes to the application review process might be needed. As of October
2007, this official did not know when the agency would make a decision
about whether to allow reimbursement for indirect costs.

^60 A FEMA official responsible for CCP told us that it was unclear why CCP
policy does not allow for the reimbursement of indirect costs.

^61 The Public Assistance Program can provide financial assistance to state
governments, local governments, Indian tribes or authorized tribal
organizations, Alaskan Native villages, and certain nonprofit
organizations to help them recover from disasters.

^62 The Hazard Mitigation Grant Program provides assistance to states,
local governments, Indian tribes, and private nonprofit organizations for
long-term hazard mitigation projects following a major disaster
declaration to reduce the loss of life and property after a natural
disaster.

^63 FEMA Office of Inspector General, Inspection of FEMA's Crisis
Counseling Assistance and Training Program, I-01-95 (Washington, D.C.,
June 1995), 25.

^64 FEMA Office of Inspector General, Inspection of FEMA's Crisis
Counseling Assistance and Training Program, 25.

  Providing Expanded Crisis Counseling Services

State officials told us that after catastrophic disasters they faced the
challenge of how to assist people who were experiencing more serious
postdisaster distress than traditional CCP services could resolve.
According to New York, Louisiana, and Mississippi officials, some CCP
clients who did not display symptoms suggesting they needed a referral for
mental health or substance abuse treatment nevertheless could have
benefited from more intensive crisis counseling than was provided in the
CCP model. Furthermore, in the case of Hurricane Katrina, Mississippi
officials told us that they wanted to able to serve as many people as
possible within their CCPs because the devastation resulted in fewer
mental health and substance abuse providers being available to accept
referrals for treatment.

To assist these people, officials in New York, Louisiana, and Mississippi
asked FEMA and SAMHSA to allow their state CCPs to offer expanded types of
services after catastrophic disasters in their states. In response to the
states' requests, FEMA and SAMHSA officials allowed the existing state
CCPs to develop pilot programs offering expanded crisis counseling
services consistent with the nonclinical, short-term focus of the CCP
model.^65 New York's expanded services, known as "enhanced services," were
offered through the New York City Fire Department (FDNY) and through
community-based providers for both adults and children. FDNY's services
started in September 2002, about 12 months after the WTC attack. The
community-based services started in spring 2003. Provided by mental health
professionals, these expanded services were based on cognitive behavioral
approaches. These services included helping clients recognize symptoms of
postdisaster distress and develop skills to cope with anxiety, depression,
or other symptoms. Individuals referred for expanded services were offered
a series of up to 12 counseling sessions. New York's community-based
expanded services for adults ended in December 2003; its community-based
services for children ended in December 2004, as did the FDNY's services.

^65 In the past, SAMHSA had provided Florida with supplemental financial
assistance to fund services outside the state's CCP. Following Hurricane
Charley and the three other hurricanes that affected Florida in 2004,
state officials found that some people required services that went beyond
the scope of the state's CCP, and so officials requested federal funds to
provide additional services. In response, SAMHSA awarded an $11 million
grant to help the state provide services not included in the state's CCP,
such as mental health treatment, case management, substance abuse
treatment, and other services.

In November 2006, FEMA and SAMHSA allowed Louisiana and Mississippi to
plan for providing expanded crisis counseling services, known as
"specialized crisis counseling services," to supplement CCP services
offered to people affected by Hurricane Katrina. Each state developed and
implemented expanded services based on operating principles developed by
SAMHSA^66 and tailored to the needs of its population. Louisiana and
Mississippi began offering their expanded services in January 2007, about
17 months after the hurricane. In contrast to New York's series of up to
12 sessions, the expanded services offered by Louisiana and Mississippi
were designed to be delivered in a single stand-alone session by mental
health professionals, although clients could obtain additional sessions.
The states' CCPs used a standardized assessment and referral process to
determine whether to refer people for expanded services, such as stress
management. Louisiana and Mississippi used providers with prior mental
health training to refer expanded services clients for mental health and
substance abuse treatment services. In addition, the states used
paraprofessionals to link clients with other disaster-related services and
resources, such as financial services, housing, transportation, and child
care. According to a SAMHSA official, Louisiana's CCP is scheduled to stop
providing expanded services to adults and children in February

^66 SAMHSA's six operating principles are (1) disaster-trained clinical
professionals are a key component of specialized crisis counseling teams;
(2) an active outreach must be maintained; (3) appropriate assessment and
referral techniques will be utilized; (4) specialized techniques must be
appropriate to the short-term, temporary nature of CCP and phases of
disaster recovery; (5) specialized techniques must focus on immediate
practical needs and priorities of survivors; and (6) training,
supervision, and oversight are critical to successful implementation and
operation.

2008.^67 Mississippi, which focused on providing expanded services to
adults,^68 stopped providing services in April 2007.

Several state officials said that it would be beneficial if the CCP model
could be expanded to include more intensive crisis counseling services and
if states could make these types of services available sooner. For
example, several officials told us that if expanded services were a
permanent part of CCP it would enable states responding to catastrophic
disasters to incorporate expanded services at an earlier stage in their
CCP service plans, training programs, and budgets. A New York official
told us that after the state received approval for the general concept of
expanded services, it took the state a few additional months to prepare a
proposal, obtain federal approval, and contract with and train the
providers. Because the state did not begin offering expanded services
until it started phasing down its delivery of traditional CCP services,
fewer crisis counselors were available to refer clients from traditional
services to expanded services. NCPTSD's 2005 evaluation of CCP for SAMHSA
recommended that, at least on a trial basis, expanded services should
become a well-integrated part of state CCPs that is implemented relatively
early in state programs.^69 NCPTSD also recommended evaluating the
efficacy of such services. FEMA and SAMHSA officials told us that after
completion of Louisiana's program they planned to examine which elements
of Louisiana's, Mississippi's, and New York's expanded services programs
might be beneficial to incorporate into CCP. FEMA and SAMHSA officials
also said that NCPTSD has begun to develop an additional approach to
providing postdisaster counseling services that they would also like to
examine after it has been developed. FEMA and SAMHSA officials said they
also planned to try to determine the most opportune time to start offering
expanded services to disaster survivors. These officials did not know when
the review would be completed.

  Additional CCP Implementation Difficulties

Officials we interviewed in three of the states in our review expressed
concerns about the ability of state CCPs to appropriately refer people
needing mental health or substance abuse treatment services. Several state
officials said that the paraprofessional crisis counselors who generally
identify people for referral are not always able to properly identify
people who have more serious psychological problems. Officials said there
was a constant need to provide staff with training on CCP assessment and
referral techniques to ensure that they could identify people who needed a
referral. In its evaluation of CCP for SAMHSA, NCPTSD also reported
concerns by states related to the ability of paraprofessionals to identify
people needing a referral.^70 According to SAMHSA, a CCP trainer's toolkit
that was completed in August 2007 includes information on proper
techniques for conducting CCP assessments and referrals. The agency is
planning to distribute the toolkit to states in spring 2008 when it holds
a planned training.

^67 According to SAMHSA, Louisiana's entire Hurricane Katrina CCP was
scheduled to end February 28, 2008. However, as of November 2007, SAMHSA
and FEMA were reviewing a request from Louisiana to extend the state's CCP
through December 31, 2008.

^68 Mississippi did not include children in its expanded program because it
was already involved in two other initiatives related to the mental health
needs of children affected by the hurricane.

^69 NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, D148.

Officials we spoke to in all six states in our review told us that their
CCPs were constrained by FEMA's policy of not allowing CCP funds to be
used to provide some case management services. According to CCP guidance,
case management is not typically an allowable program service.^71 Several
state officials told us that it would be beneficial if state CCPs could
provide some form of case management after catastrophic disasters, when
many survivors are likely to have numerous needs and may require
additional support to obtain services necessary for their recovery. State
officials said that Hurricane Katrina highlighted the difficulties that
disaster survivors can have negotiating complex service and support
systems. Louisiana officials said, for example, that many people who
experienced extraordinary levels of stress because of the hurricane had
low literacy skills and clearly needed support to make connections to
additional services and resources. One state official also told us that
because the practical difficulties of meeting needs involving housing can
often be a cause of the emotional distress that CCPs are trying to
alleviate, they would like CCP crisis counselors to be able to more
directly help people connect with disaster-related services to meet these
needs.

^70 NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, E19.

^71 Case management involves a range of services to help people recover
from a disaster, such as helping them obtain health, social, and financial
services. According to CCP guidance, providers may give survivors
information about other FEMA disaster assistance programs and information
on other resources. However, the guidance states that it is beyond the
scope of CCP for crisis counselors to serve as advocates for disaster
survivors in obtaining services or resolving disputes or function in a way
that might create dependence on CCP staff and programs that will not exist
following the end of CCP.

State officials also told us that it was difficult to identify people in
need of crisis counseling services because FEMA does not give state CCPs
access to specific information on the location of people registered for
federal disaster assistance. NCPTSD's evaluation of CCP also noted that
the unavailability of this information made it difficult for state CCPs to
locate people who might need services.^72 Several state officials told us
that FEMA had provided them with some counts of disaster registrants at
the state, county, or Zip Code levels but that they also needed
information on the specific locations of disaster survivors to conduct
effective outreach. FEMA officials told us that the agency stopped
providing information on the specific location of registrants in the
1990s. They also told us that it was their understanding that FEMA stopped
providing this information due to concerns about the privacy of
registrants.

Conclusions

The scope and magnitude of catastrophic disasters can result in acute and
sustained psychological trauma that can be debilitating for extended
periods of time. While CCP is a key component of the federal government's
response to the psychological consequences of disasters, we have
identified two important limitations that can affect states' ability to
use CCP to respond to the special circumstances of catastrophic disasters.
First, state officials responding to the WTC attack and Hurricane Katrina
identified the need to provide expanded crisis counseling services through
CCP. FEMA and SAMHSA recognized such a need when they permitted three
state CCPs to expand their programs to provide more intensive short-term
crisis counseling than the CCP model generally allows. FEMA and SAMHSA
officials told us they intended to consider incorporating certain types of
expanded services into CCP. Promptly determining what types of expanded
services should become a permanent part of CCP would enable states to more
effectively develop their CCP proposals and provide their populations with
needed counseling services in the event of future catastrophic disasters.

Second, FEMA's policy of precluding states and their CCP service providers
from obtaining reimbursement for indirect costs associated with managing
and monitoring their CCPs has made it difficult for states to effectively
administer their CCPs. State officials reported that the lack of
reimbursement for indirect costs made it more difficult to recruit and
retain service providers and contributed to a major contractor's
withdrawal from Louisiana's Hurricane Katrina CCP. Other FEMA disaster
response grant programs allow reimbursement for such costs. Although FEMA
had been examining this issue for over a year, an agency official did not
know when the agency would reach a decision on whether to revise CCP
policy to allow coverage of indirect costs. Including indirect costs in
CCP and not requiring service providers to absorb these costs could expand
the pool of providers willing to participate in this program. This could
strengthen states' ability to assist disaster victims in coping with the
psychological consequences of catastrophic disasters.

^72 NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, C60.

Recommendations for Executive Action

To address gaps identified by federal and state officials in the federal
government's ability to help states respond to the psychological
consequences of catastrophic disasters, we recommend that the Secretary of
Homeland Security direct the Administrator of FEMA, in consultation with
the Administrator of SAMHSA, to expeditiously take the following two
actions:

           o determine what types of expanded crisis counseling services
           should be formally incorporated into CCP and make any necessary
           revisions to program policy, and

           o revise CCP policy to allow states and service providers that
           receive CCP funds to use them for indirect costs.
			  
			  Agency Comments and Our Evaluation

           We provided a draft of this report to DHS and HHS for comment.
           Both DHS and HHS generally concurred with both of our
           recommendations and stated that they had taken or will take steps
           toward implementing them. However, they did not provide specific
           timelines for completing these actions. (DHS's comments are
           reprinted in app. III; HHS's comments are reprinted in app. IV).

           In response to our recommendation to expeditiously allow
           reimbursement for indirect costs within CCP, both departments
           commented that allowing reimbursement for such costs will promote
           broader participation of local service providers. In its comments,
           DHS also said that the inclusion of indirect costs will help
           expedite the application review process and that FEMA has been
           working with SAMHSA to revise CCP policy to allow reimbursement
           for indirect costs. HHS stated that the draft report accurately
           reflected concerns regarding the exclusion of indirect costs and
           that SAMHSA had previously given FEMA a recommendation supporting
           a change in this policy. Although DHS and HHS indicated that they
           are working on a revision of the policy to allow reimbursement of
           such costs, they did not provide a timeline for completing this
           activity. As our report notes, FEMA has been examining this issue
           since 2006, and it is important to complete this work
           expeditiously so that in the event of a future disaster, state
           CCPs could be in a better position to attract the participation of
           a broad array of service providers.

           In response to our recommendation to expeditiously determine what
           types of expanded crisis counseling services should be formally
           incorporated into CCP, HHS and DHS commented that, as our draft
           report indicated, they plan to wait until Louisiana has completed
           its pilot expanded services program before making this
           determination. They said that because Louisiana had applied for an
           extension of its CCP, they cannot provide a timeline for
           completion of their reviews of expanded services pilots. We
           believe, however, that federal program officials already have a
           considerable amount of information about these pilots--New York
           and Mississippi have completed their programs and Louisiana has
           been providing information on an ongoing basis. We believe that it
           is important for FEMA and SAMHSA to expeditiously review the
           experience of the pilot programs and other relevant information so
           they can expeditiously determine which expanded services should be
           formally incorporated into CCP. This will help ensure that states
           responding to a disaster will be able to provide the appropriate
           range of CCP services to assist people who are in need of crisis
           counseling services. In addition, HHS commented that SAMHSA has
           initiated a workgroup to ensure that the CCP model reflects
           current best practices. However, we have learned that, as of
           January 2008, the workgroup had not yet begun to conduct its work.

           HHS and DHS commented on our discussion of states' reports on
           difficulties they had experienced in preparing their CCP
           applications. DHS stated that FEMA, in consultation with SAMHSA,
           took action to expedite the submission, review, and approval of
           ISP applications submitted after Hurricane Katrina, including
           allowing the use of shorter applications by states hosting
           Hurricane Katrina evacuees. We clarified our discussion of host
           states' ability to apply for CCP funds to note that FEMA allowed
           them to submit an abbreviated ISP application. DHS also commented
           that it is not feasible to have one grant application or one grant
           for two separate disasters because FEMA must separately account
           for and report on funds for specific disasters. We attempted to
           obtain further clarification from DHS about why FEMA separately
           accounts for funds for each disaster, but DHS did not provide this
           information.

           In addition, HHS and DHS commented that the draft report's
           description of the needs assessment process failed to capture the
           degree to which they had provided states flexibility in
           quantifying survivor needs after Hurricane Katrina. DHS said that
           FEMA and SAMHSA did not rely primarily on damage assessments, as
           few had been completed. Rather, FEMA registration numbers,
           newspaper reports, and anecdotal data were relied on to estimate
           need. Our draft report described action taken by FEMA to help
           states collect information needed to prepare their ISP
           applications after Hurricane Katrina, and we have revised the
           final report to make it clear that states were allowed to use
           other sources of information.

           In commenting on the CCP application review process, HHS and DHS
           said that the data in our report showing that it took up to 286
           days to review applications were misleading because only
           Louisiana's application took that long to review and the state's
           proposed use of a different procedure for identifying the local
           service providers with which it would contract caused enormous
           delays in the review process. However, the review of New York's
           RSP after the WTC disaster also took over 200 days, and the
           reviews for four of the five states in our study took longer than
           FEMA's estimated average review period. The draft report contained
           information on several factors that contributed to longer review
           times, and we added to the final report information on Louisiana's
           proposal to use an alternative procedure and its effect on the
           length of the review of Louisiana's RSP application.

           HHS also commented on our discussion of states' concerns that
           lengthy reviews and resulting delays in obtaining funding created
           difficulties for CCPs in executing contracts with service
           providers and implementing their programs. HHS said that the
           report should note that these challenges were the result of state
           fiscal and contracting practices that do not relate to the
           availability of federal funds. Although state practices may
           contribute to delays, extended federal reviews also may contribute
           to delays in states' ability to implement their CCPs.

           DHS commented on our description of states' discussion of the
           importance of case management services for CCP clients and
           mentioned the Post-Katrina Emergency Management Reform Act of
           2006,^73 which amended the Stafford Act to allow for the provision
           of case management services to meet the needs of survivors of
           major disasters. These services could include financial assistance
           to help state or local government agencies or qualified private
           organizations to provide case management services. In its
           comments, DHS also stated that FEMA has entered into an
           interagency agreement with HHS to collaborate closely on the
           development and implementation of a case management program; this
           agreement is for the development of a pilot program to determine
           the best methods of providing case management services. FEMA
           provided additional information indicating that its case
           management program will coordinate with CCP.
			  
^73 Pub. L. No. 109-295, Title VI, S689f, 120 Stat. 1355, 1452 October 4,
2006.

           In its comments, HHS made observations about the importance of
           recognizing culture and language issues as barriers to effective
           responses to catastrophic disasters, incorporating behavioral
           health into all grantee planning and response activities, and
           requiring grant recipients to report on how funds were used to
           address the psychological consequences of a disaster. These are
           important points, and we would encourage HHS agencies to consider
           them in their disaster preparedness and response programs. HHS
           noted that HRSA's National Bioterrorism Hospital Preparedness
           Program, Emergency System for Advance Registration of Volunteer
           Healthcare Professionals, and Bioterrorism Training and Curriculum
           Development Program have been transferred to ASPR; we added this
           information to the final report where appropriate. HHS also
           identified actions it had taken in response to GAO's May 2005
           report on the CCP, including improving the fiscal monitoring of
           grants.^74 In addition, HHS noted that the grants management
           position funded by FEMA that we discussed in our draft report was
           filled in December 2007. Our final report reflects this
           development.

           In its comments, HHS said that instead of referring to 35 states
           that received disaster preparedness grants, our report should
           refer to 34 states and the District of Columbia; the draft report
           noted that our use of the word "state" included states,
           territories, Puerto Rico, and the District of Columbia. In
           addition, HHS suggested that we revise the title of the report by
           removing the reference to CCP needing improvements. In light of
           our findings and recommendations, we believe the need for
           expeditious action supports the original title. HHS also provided
           technical comments, which we incorporated where appropriate.

^74 GAO, Federal Emergency Management Agency: Crisis Counseling Grants
Awarded to the State of New York after the September 11 Terrorist Attacks,
[34]GAO-05-514 (Washington, D.C.: May 31, 2005).

           We are sending a copy of this report to the Secretaries of Health
           and Human Services and Homeland Security. We will make copies
           available to others on request. In addition, the report will be
           available at no charge on the GAO Web site at http://www.gao.gov.

           If you have any questions about this report, please contact me at
           (202) 512-7114 or [email protected]. Contacts for our Offices of
           Congressional Relations and Public Affairs may be found on the
           last page of this report. GAO staff who made major contributions
           to this report are listed in appendix V.

           Cynthia A. Bascetta
			  Director, Health Care

           List of Requesters

The Honorable Joseph I. Lieberman: 
Chairman: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The Honorable Bennie G. Thompson: 
Chairman: 
Committee on Homeland Security: 
House of Representatives: 

The Honorable Mike Michaud: 
Chairman: 
Subcommittee on Health: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable Carolyn B. Maloney: 
House of Representatives: 

           Appendix I: Scope and Methodology

           To do our work, we obtained program documents and interviewed
           officials from the Department of Health and Human Services (HHS),
           including the Administration for Children and Families, Centers
           for Disease Control and Prevention (CDC), Centers for Medicare &
           Medicaid Services (CMS), Health Resources and Services
           Administration (HRSA), National Institutes of Health, Office of
           the Assistant Secretary for Preparedness and Response,^1 and
           Substance Abuse and Mental Health Services Administration
           (SAMHSA); the Department of Education; the Department of Homeland
           Security (DHS), including the Federal Emergency Management Agency
           (FEMA); the Department of Justice; and the Department of Veterans
           Affairs (VA), including the National Center for Posttraumatic
           Stress Disorder (NCPTSD). We spoke with researchers from the
           National Center for Child Traumatic Stress at the University of
           California, Los Angeles, and the National Center for Disaster
           Preparedness at Columbia University. We also interviewed officials
           from national organizations, including the American Red Cross,
           National Alliance on Mental Illness, National Association of State
           Mental Health Program Directors, National Association of State
           Alcohol and Drug Abuse Directors, and National Emergency
           Management Association. In addition, we reviewed relevant
           literature.

           We conducted additional work in six judgmentally selected states
           that had experience responding to the psychological consequences
           of three catastrophic disasters during fiscal years 2002 through
           2006 that we included in our scope: the World Trade Center (WTC)
           attack in 2001, Hurricane Charley in 2004, and Hurricane Katrina
           in 2005. We included New York because it responded to the WTC
           attack;^2 Florida because it responded to Hurricane Charley; and
           Louisiana and Mississippi because they responded to Hurricane
           Katrina. We included Texas in our review because it hosted a large
           number of people displaced by Hurricane Katrina, and we included
           Washington because it hosted people displaced by Hurricane Katrina
           and has features, such as large ports, that make it vulnerable to
           natural and man-made disasters. Results from this nongeneralizable
           sample of six states cannot be used to make inferences about other
           states.

^1 The Office of the Assistant Secretary for Preparedness and Response
coordinates and directs HHS's emergency preparedness and response program.
In December 2006 the Office of Public Health Emergency Preparedness became
the Office of the Assistant Secretary for Preparedness and Response.

^2 Although the September 11, 2001, WTC attack occurred in fiscal year
2001, we included this event in our review because the response primarily
occurred during the time period we examined.

           To examine actions by federal agencies to help states prepare for
           the psychological consequences of catastrophic disasters, we
           reviewed key federal preparedness and response documents--such as
           the National Response Plan, the Interim National Preparedness
           Goal, and FEMA's Guide for All-Hazard Emergency Operations
           Planning--and recent reports on the federal government's response
           to Hurricane Katrina.^3 We identified federal grant programs and
           other activities that were related to disaster preparedness and
           were funded during fiscal year 2002 through fiscal year 2006 by
           reviewing relevant documents and through discussions with federal
           and state officials. For key HHS and DHS preparedness grant
           programs, we reviewed relevant documentation, such as application
           guidance, and interviewed federal program officials. We obtained
           disaster plans for the mental health and substance abuse agencies
           in the six states included in our review and examined the plans we
           received. We also interviewed mental health and substance abuse
           officials from these six states about their preparedness
           activities. In addition, we examined SAMHSA's 2007 report on
           mental health and substance abuse disaster plans developed by
           states that received its preparedness grant.^4

           To examine states' experiences in obtaining and using federal
           Crisis Counseling Assistance and Training Program (CCP) grants to
           respond to the psychological consequences of catastrophic
           disasters, we reviewed program documentation, including the
           applicable statute, regulations, guidance, and grantee reports. We
           also reviewed CCP applications or other relevant documentation
           that the six states submitted to FEMA for declared counties^5 in
           response to one of the three catastrophic disasters in our review.
           We reviewed documentation to obtain information on states'
           experiences in applying for CCP funding and on FEMA's and SAMHSA's
           processes for reviewing applications, including examining the
           length of time it took the agencies to review applications and
           make funding decisions for the selected catastrophic disasters. In
           addition, we interviewed state mental health officials from the
           six states to obtain additional information on their experiences
           applying for CCP funding and implementing their CCPs following
           these three disasters. We interviewed FEMA and SAMHSA officials to
           obtain their perspectives on states' applications and states'
           experiences implementing their CCPs to respond to catastrophic
           disasters and to obtain information pertaining to FEMA's and
           SAMHSA's administration of the program. Furthermore, we examined
           the 2005 report on CCP prepared for SAMHSA by NCPTSD.^6
			  
^3 These reports included U.S. House of Representatives, Select Bipartisan
Committee to Investigate the Preparation for and Response to Hurricane
Katrina, A Failure of Initiative: Final Report of the Select Bipartisan
Committee to Investigate the Preparation for and Response to Hurricane
Katrina (Washington, D.C., Feb. 15, 2006); White House Homeland Security
Council, The Federal Response to Hurricane Katrina: Lessons Learned
(Washington, D.C., Feb. 23, 2006); U.S. Senate Committee on Homeland
Security and Governmental Affairs, Hurricane Katrina: A Nation Still
Unprepared (Washington, D.C., May 2006); and Educational Services, Inc.,
"Beyond Katrina: An After-Action Report on Improving Substance Abuse and
Mental Health Response to Future Disasters," unpublished report, prepared
at the request of SAMHSA (Bethesda, Md., May 8, 2006).

^4 SAMHSA, "State Behavioral Health All-Hazards Disaster Plan Review
Report," unpublished report (Rockville, Md., June 2007).

^5 Generally, only states that have received a presidential disaster
declaration are eligible to request CCP funding. These presidential
declarations are county-specific.

^6 NCPTSD, "Retrospective 5-Year Evaluation of the Crisis Counseling
Assistance and Training Program," unpublished report requested by SAMHSA
(White River Junction, Vt., June 2005).

           To identify other federal programs that have supported mental
           health and substance abuse services in response to catastrophic
           disasters, we reviewed GAO reports,^7 Congressional Research
           Service reports,^8 the Catalog of Federal Domestic Assistance, and
           pertinent legislation and program regulations. We interviewed
           federal program officials about these programs and obtained
           available information, including grantee applications, award data,
           and reports, to determine how the programs were used to respond to
           mental health or substance abuse needs following the three
           catastrophic disasters included in our review. We present
           information on the use of various federal programs to respond to
           needs following the catastrophic disasters in our review; the list
           we present is not exhaustive. To determine the amount of Deficit
           Reduction Act of 2005 funds used by the 32 states that had been
           approved by CMS for demonstration projects following Hurricane
           Katrina, we analyzed data in CMS's Medicaid Budget and Expenditure
           System (MBES), which includes claims data for health care
           services, including inpatient mental health care services. We
           analyzed MBES claims data available as of June 27, 2007, for
           services provided August 24, 2005, or later to eligible people
           affected by Hurricane Katrina. To assess the reliability of the
           MBES data, we discussed the database with an agency official and
           conducted electronic testing of the data for obvious errors in
           completeness. States submit all claims data to the system
           electronically and must attest to the completeness and accuracy of
           the data. These data are preliminary in nature, in that they are
           subject to further review by CMS and are likely to be updated as
           states continue to submit claims for Deficit Reduction Act
           funding. We determined that these data were sufficiently reliable
           for the purpose of our report.
			  
^7 See, for example, GAO, Mental Health Services: Effectiveness of
Insurance Coverage and Federal Programs for Children Who Have Experienced
Trauma Largely Unknown, [35]GAO-02-813 (Washington, D.C.: Aug. 22, 2002).

^8 See, for example, Congressional Research Service, Federal Stafford Act
Disaster Assistance: Presidential Declarations, Eligible Activities, and
Funding, RL33053 (Washington, D.C., Mar. 6, 2007); and Congressional
Research Service, Gulf Coast Hurricanes: Addressing Survivors' Mental
Health and Substance Abuse Treatment Needs, RL33738 (Washington, D.C.,
Nov. 29, 2006).			  

           We conducted our work from March 2006 through February 2008 in
           accordance with generally accepted government auditing standards.
           Those standards require that we plan and perform the audit to
           obtain sufficient, appropriate evidence to provide a reasonable
           basis for our findings and conclusions based on our audit
           objectives. We believe that the evidence obtained provides a
           reasonable basis for our findings and conclusions based on our
           audit objectives.
			  
			  Appendix II: Additional Federal Programs Used to Respond to
			  Psychological Consequences of Catastrophic Disasters

           In addition to CCP, federal agencies have used other programs
           following catastrophic disasters to help states and localities
           provide mental health and substance abuse services to disaster
           survivors. The following list presents information on the use of
           various federal programs to respond to needs following the
           catastrophic disasters in our review; it is not an exhaustive
           list.

           Federal agencies have used established grant programs to help
           states respond to the psychological consequences of catastrophic
           disasters, some of which are generally intended to be used
           following smaller-scale emergencies.

           o SAMHSA awarded funds through its Emergency Response Grant (SERG)
           program following Hurricane Katrina.^1 The agency provided a total
           of $900,000 to Alabama, Louisiana, Mississippi, and Texas to help
           meet the overwhelming need for assistance. For example, Texas was
           awarded $150,000 and helped evacuees in the Houston Astrodome and
           other shelters who needed methadone medication because of opiate
           addiction.

           o The Department of Education awarded funds through its Project
           School Emergency Response to Violence (Project SERV) program
           following the 2001 terrorist attacks and Hurricanes Katrina and
           Rita. The agency provided about $14 million and $7 million
           following these respective disasters to help local education
           agencies respond by providing services that could include crisis
           counseling, mental health assessments, and referrals.^2 For
           example, following the 2001 terrorist attacks, New York used
           Project SERV funds to provide counseling and after-school mental
           health services.

           o The Department of Justice provided funds through its
           Antiterrorism and Emergency Assistance Program to help states and
           localities respond to victims' mental health needs following mass
           violence and acts of terrorism. Following the WTC attack, for
           example, New York used $5 million of its grant award from the
           Department of Justice to provide additional funding to 15 service
           providers providing crisis counseling services through the state
           CCP.
			  
^1 SERG can be used to support mental health and substance abuse services
after smaller-scale emergencies that have not received a presidential
disaster declaration. SERG typically does not fund long-term mental health
or substance abuse treatment, medications, hospitalization, or services
that may be provided through CCP.

^2 Project SERV is generally used following smaller-scale emergencies, such
as school shootings and suicides, that have not received a presidential
disaster declaration. Grant funds may not be used for medical services,
drug treatment, or rehabilitation, except for pupil services or referral
to treatment for students who are victims of, or witnesses to, a crime, or
who illegally use drugs. See 20 U.S.C. S7164 (2).			  

           HHS has also temporarily modified or expanded ongoing federal
           health care and social service programs to help states provide
           mental health and substance abuse services after specific
           catastrophic disasters.

           o CMS allowed states to temporarily cover certain health care
           costs associated with catastrophic disasters through Medicaid and
           the State Children's Health Insurance Program (SCHIP). For
           example, following Hurricane Katrina, the Congress appropriated $2
           billion to cover certain health care costs related to Hurricane
           Katrina through Medicaid and SCHIP.^3 CMS allowed 32 states that
           either were directly affected by the hurricane or had hosted
           evacuees to temporarily expand the availability of coverage for
           certain people affected by the hurricane.^4 CMS allowed states to
           submit claims for reimbursement for health care services that were
           provided August 24, 2005, or later. As of June 27, 2007, these
           states had submitted claims to CMS for health care services
           totaling about $1.7 billion, of which about $15.7 million was for
           mental health services provided in inpatient facilities--such as
           hospitals, nursing homes, and psychiatric facilities.^5 (See table
           2 for information on the amount of claims submitted by states,
           including four states that were in our review.)^6

^3 The Deficit Reduction Act of 2005, Pub. L. No. 109-171, S6201, 120 Stat.
4, 132 (2006).

^4 GAO, Hurricane Katrina: Allocation and Use of $2 Billion for Medicaid
and Other Health Care Needs, [36]GAO-07-67 (Washington, D.C.: Feb. 28,
2007).

^5 This total does not include mental health claims that states may have
reported to CMS within other reportable categories--such as physician
services or outpatient services--for which claims specific to mental
health services could not be identified.

^6 New York and Washington did not participate in this temporarily expanded
program.

           Table 2: Amount of Claims for Deficit Reduction Act Funds
           Submitted by Selected States to Serve People Affected by Hurricane
           Katrina, as of June 27, 2007
			  
State: Florida; 
Total claims: $1,232,069; 
Claims for mental health services provided in inpatient facilities[A]: 
0. 

State: Louisiana; 
Total claims: $961,645,567; 
Claims for mental health services provided in inpatient facilities[A]: 
$2,344,421. 

State: Mississippi; 
Total claims: $491,425,133; 
Claims for mental health services provided in inpatient facilities[A]: 
$8,812,012. 

State: Texas; 
Total claims: $12,380,827; 
Claims for mental health services provided in inpatient facilities[A]: 
$566. 

State: Other states; 
Total claims: $243,103,398; 
Claims for mental health services provided in inpatient facilities[A]: 
$4,571,568. 

Dollars: State: Total; 
Total claims: $1,709,786,994; 
Claims for mental health services provided in inpatient facilities[A]: 
$15,728,567. 

           Source: GAO analysis of CMS data.

           a These amounts do not include claims for mental health services
           that states may have reported to CMS within other categories--such
           as physician services and outpatient services--for which claims
           specific to mental health services could not be identified.

           o HHS's Administration for Children and Families awarded $550
           million in supplemental Social Services Block Grant funds
           following the 2005 Gulf Coast hurricanes to temporarily expand the
           program to help 50 states and the District of Columbia meet social
           and health care service needs.^7 The funds could be used for
           providing case management and counseling, mental health, and
           substance abuse services, including medications. States could also
           use the funds for the repair, renovation, or construction of
           community mental health centers and other health care facilities
           damaged by the hurricanes. For example, Mississippi was awarded
           about $128 million in supplemental funding and used about $10
           million of the funding in part to restore services to mental
           health treatment facilities for adults and children and provide
           transportation to mental health services.

           Federal agencies also awarded funding outside of these established
           programs to help states provide disaster-related mental health and
           substance abuse services after specific catastrophic disasters in
           our review. Some of these programs focused on specific at-risk
           groups, such as disaster responders, while others were established
           to meet the mental health needs of broader populations.

^7 The Department of Defense Appropriations Act, 2006, Pub. L. 109-148,
Division B, 119 Stat. 2680, 2745, 2768 (2005).

           o HHS is coordinating federally funded programs for responders to
           the WTC disaster--including firefighters, police, other workers or
           volunteers, and federal responders--that provide free screening,
           monitoring, or treatment services for physical illnesses and
           psychological problems related to the disaster.^8 We have
           previously reported on the progress of these programs.^9

           o SAMHSA provided $28 million to nine states most directly
           affected by the September 11 attacks to provide various substance
           abuse and mental health services for people directly affected by
           the attacks.^10 These services included assessments, individual
           counseling, group therapy, specialized substance abuse treatment,
           and case management.

^8 The WTC health programs are (1) the New York City Fire Department WTC
Medical Monitoring and Treatment Program; (2) the New York/New Jersey WTC
Consortium; (3) the WTC Federal Responder Screening Program; (4) the WTC
Health Registry; (5) the Police Organization Providing Peer Assistance
program; and (6) Project COPE. The WTC Health Registry also includes
people living or attending school in the area of the WTC, or working or
present in the vicinity on September 11, 2001. In addition to these six
programs, a New York State responder screening program received federal
funding for screening New York State employees and National Guard
personnel who responded to the WTC attack in an official capacity. This
program ended its screening examinations in November 2003.

^9 For information on the progress of these programs and difficulties they
have experienced, see, for example, GAO, September 11: HHS Needs to Ensure
the Availability of Health Screening and Monitoring for All Responders,
[37]GAO-07-892 (Washington, D.C.: July 23, 2007); GAO, September 11: HHS
Has Screened Additional Federal Responders for World Trade Center Health
Effects, but Plans for Awarding Funds for Treatment Are Incomplete,
[38]GAO-06-1092T (Washington, D.C.: Sept. 8, 2006); and GAO, September 11:
Monitoring of World Trade Center Health Effects Has Progressed, but
Program for Federal Responders Lags Behind, [39]GAO-06-481T (Washington,
D.C.: Feb. 28, 2006).

^10 Grantees were Connecticut, Maryland, Massachusetts, New Jersey, New
York, Pennsylvania, Rhode Island, Virginia, and the District of Columbia.
States received funds through one or more of SAMHSA's three centers: the
Center for Mental Health Services, the Center for Substance Abuse
Prevention, and the Center for Substance Abuse Treatment.

Appendix III: Comments from the Department of Homeland Security

U.S. Department of Homeland Security: 
Washington, DC 20528: 
[hyperlink, http://www.dhs.gov]: 

January 24, 2008: 

Ms. Cynthia Bascetta: 
Director: 
Health Care: 
U.S. Government Accountability Office: 
441 G St, NW: 
Washington, DC 20548: 

Dear Cynthia Bascetta: 

The Department of Homeland Security (DHS) appreciates the opportunity 
to review and comment on the Government Accountability Office's (GAO) 
draft report GAO-08-22 entitled Catastrophic Disasters: Federal Efforts 
Help States Prepare for and Respond to Psychological Consequences, but 
FEMA's Crisis Counseling Program Needs Improvements (GAO Job Code 
290506). 

DHS generally concurs with both recommendations that state "GAO 
recommends that FEMA, with the Substance Abuse and Mental Health 
Services Administration (SAMSHA), expeditiously (1) revise CCP policy 
to allow reimbursement for indirect costs and (2) determine what types 
of expanded crisis counseling services should be incorporated into the 
CCP." 

Inclusion of indirect cost recovery within the Crisis Counseling 
Assistance and Training program (CCP) will facilitate an expedited 
application review process, as well as, promote participation of a 
broader array of local service providers resulting in a more accessible 
and effective program. Federal Emergency Management Agency (FEMA) is 
working with SAMHSA and internal agency partners to implement this 
change to current policy. 

In regards to expanding crisis counseling services, an expansion of CCP 
services has been piloted in three states affected by catastrophic 
disasters: New York, Louisiana and Mississippi. As the draft report 
correctly states, a full review of each expanded program is planned in 
order to determine which elements of each program should be utilized in 
the development of an appropriate, effective and responsible 
augmentation to the CCP. The Louisiana pilot program remains open and 
has recently requested a program extension to continue the provision of 
services. It is not possible for program staff to provide a timeline 
for completion of the reviews until program services are completed in 
Louisiana. 

In an effort to ensure that the CCP model reflects the most up-to-date 
and best practices available, FEMA will continue to work with our 
partners at SAMHSA, as well as, state, academic, non-profit and 
government experts in disaster mental health throughout the country. 

Even prior to the GAO report, FEMA staff was working closely with 
SAMHSA staff on the revision of CCP policy to allow reimbursement for 
indirect costs, as well as reviewing the types of expanded crisis 
counseling services to be incorporated within the CCP model. FEMA and 
SAMHSA are collaborating through workgroups charged with developing 
guidelines to implement these changes. 

CCP Implementation Difficulties Encountered By States: 

Information Collection: 

According to the draft report, state officials indicated that the 
"States had problems collecting information needed to prepare their 
Immediate Services Crisis Counseling Program (ISP) applications within 
FEMA' s application deadline and preparing parts of their ISP and 
Regular Services Crisis Counseling Program (RSP) applications." FEMA 
recognized that Hurricane Katrina was a catastrophic incident that 
called for extraordinary measures and solutions. Victims were 
evacuated, or traveled on their own, to at least forty-four states. In 
order to address the crisis counseling needs of the people displaced as 
a result of Hurricane Katrina, FEMA made the decision to allow "host" 
states the opportunity to apply for CCP funds. To expedite the 
submission, review and approval of ISP applications for undeclared 
counties and states receiving evacuees affected by Hurricane Katrina, 
FEMA, in consultation with SAMHSA, developed a simplified ISP 
application that states were encouraged to use. In lieu of the 
traditional application, the revised format asked for brief, but 
informative, information with the recommendation that the application 
be no longer than five pages. Application submission expectations were 
clearly identified in a guidance document provided as part of the 
simplified application. 

The description of the needs assessment process fails to capture the 
degree to which flexibility was given the states in quantifying 
survivor needs. FEMA and SAMHSA reviewers did not rely primarily on 
damage assessments, as few had been completed. Rather, FEMA 
registration numbers, newspaper reports and anecdotal data were relied 
upon to estimate need and to scale initial programs. 

According to the draft report, state officials indicated that "problems 
were exacerbated because multiple disasters affected the same 
jurisdiction in close succession and they were required to submit a 
separate application for each one." One program application, or one 
grant for two separate disasters, is not feasible as FEMA must account 
for and report on disaster specific funds separately. However, when 
situations like this occur, staff from FEMA and SAMHSA work closely 
with the state to ensure that program implementation for both disasters 
is seamless to the disaster victim, planned program efforts are adhered 
to and separate program reports are submitted timely and accurately. 

Application Review: 

The draft report indicates that a state's RSP application is primarily 
reviewed by SAMHSA. This statement is incorrect and should be changed. 
All ISPs and RSPs are reviewed, in detail, by both FEMA and SAMHSA 
program staff. 

The report suggests that the application review process, post 
catastrophic disaster, can be lengthy; taking up to 286 days prior to a 
funding decision. The report indicates that these funding delays 
created difficulties for states in "executing contracts with service 
providers, delays in hiring staff and problems retaining staff." The 
report should clarify that the only application that required 286 days 
prior to a funding decision was the application submitted by the State 
of Louisiana. Louisiana chose to utilize a Request for Proposal (RFP) 
process to determine which providers they would contract with for the 
provision of CCP services. Using a RFP process is atypical for the CCP. 
The initial grant application submitted by the State was incomplete as 
the document simply outlined their plan for the RFP. The completed 
grant application was submitted six months later. This caused the 
enormous delays in the review and funding of this State's grant 
application. 

Case Management: 

State officials advised the GAO that it "would be beneficial if state 
CCPs could provide some form of case management after catastrophic 
disasters." It is important to note that as a result of the recognized 
need for comprehensive case management services following Hurricane 
Katrina, Congress passed the Post Katrina Emergency Management Reform 
Act of 2006 allowing for the provision of "case management services, 
including financial assistance, to state and local government agencies 
or qualified private organizations to provide such services to victims 
of major disasters to identify and address unmet needs." FEMA has 
entered into an interagency agreement with the U.S. Department of 
Health and Human Services to collaborate closely on the development and 
implementation of a Case Management Program. 

We thank you again for the opportunity to offer comments on this draft 
report and look forward to working with you on future homeland security 
issues. 

Sincerely, 

Signed by: 

Steven J. Pecinovsky: 
Director: 
DHS Departmental GAO/OIG Liaison Office: 

Appendix IV: Comments from the Department of Health and Human Services
Department Of Health & Human Services:	
Office of the Assistant Secretary for Legislation
Washington, D.C. 20201: 

January 15, 2008: 

Ms. Cynthia A. Bascetta: 
Director, Health Care: 
U.S. Government Accountability Office 441 G Street, NW
Washington, DC 20548 

Dear Ms. Bascetta: 

Enclosed are the Department's comments on the Government Accountability 
Office (GAO) draft report on Catastrophic Disasters: Federal Efforts 
Help States Prepare for and Respond to Psychological Consequences, but 
FEMA's Crisis Counseling Program Needs Improvements (GAO-08-22). 

The Department appreciates the opportunity to review and comment on 
this draft before its publication. 

Sincerely, 

Signed by: 

Vincent J. Ventimiglia: 
Assistant Secretary for Legislation: 

General Comments Of The U.S. Department Of Health And Human Services 
(HHS) On The U.S. Government Accountability Office's (GAO) Draft 
Report: Catastrophic Disasters: Federal Efforts Help States Prepare For 
And Respond To Psychological Consequences, But FEMA's Crisis Counseling 
Program Needs Improvements (GAO 08-22): 

The GAO report contains several references to what was formerly HRSA's 
National Bioterrorism Hospital Preparedness Program (NBHPP), the 
Emergency System for Advance Registration of Volunteer Healthcare 
Professionals, and the Bioterrorism Training and Curriculum Development 
Program. However, with the passage of the Pandemic and All-Hazards 
Preparedness Act (Public Law 109-417), these programs were transferred 
to the Office of the Assistant Secretary for Preparedness and Response 
(ASPR). Our specific comments include suggestions for acknowledging 
these realignments in the draft report. 

With respect to disaster response, health literacy is an important 
factor in effective disaster response. However, health literacy was 
only mentioned once in the draft report (Page 34) [Now on p. 31] with 
respect to a comment made by Louisiana health officials that many 
people experienced extraordinary levels of stress due to limited 
literacy skills, and these people needed support to make connections to 
additional services. GAO's report should also more fully address the 
issue of culture and language as barriers to effective responses to 
catastrophic disasters. Additionally, implementing post-disaster 
response readiness, with practice drills and mock sessions would be 
helpful for eliminating future errors in disaster responses. 

HHS Response to the Recommendations in the Draft Report: 

The draft report recommends that FEMA, with SAMHSA expeditiously: 

1. Revise CCP policy to allow reimbursement for indirect costs; and
2. Determine what types of expanded crisis counseling services should 
be incorporated into the CCP. 

HHS has no objections to these recommendations. The draft report 
accurately reflects concerns regarding the exclusion of indirect costs 
from allowable CCP expenses, recognizing that allowing indirect cost 
reimbursement for such costs will promote broader participation of 
local service providers. As mentioned in the report, SAMHSA has 
provided a recommendation supporting a change in this policy to FEMA 
and FEMA is working toward implementation. 

Regarding expansion of crisis counseling services, an expansion of CCP 
services has been pilot tested in three States, New York, Louisiana, 
and Mississippi. As the report indicates, FEMA and SAMHSA have 
indicated that a full review of the three pilots will need to be 
conducted to make clinically responsible recommendations for increasing 
the types of services provided by the CCP as well as clear guidance on 
how to do so. Since one of the pilots has not concluded at this time 
and an extension request from this State is under review, it is not 
possible for officials to give a timeline for final review and 
conclusion. 

Moreover, routine inclusion of additional crisis counseling services 
should be appropriately considered to ensure optimal, ethical treatment 
of disaster survivors and to further ensure that these services can be 
provided in a way that does not incur harm. In addition, it should be 
noted that SAMHSA has initiated a workgroup whose goal is to ensure 
that the CCP model reflects the most up to date and best practices 
available. The workgroup is charged with developing a set of strategies 
to achieve this goal and will monitor progress through a tracking 
chart. 

Response to GAO Concerns Regarding FEMA Funded Grants Management 
Position: 

The FEMA funded Grants Management position referenced in the draft 
report was filled in December 2007. In addition to grants management, 
this individual will assist Project Officers with fiscal monitoring of 
CCP grants. The addition of this employee should contribute to shorter 
award times for RSP grants. 

HHS Responses to Improvements Made Since May 2005 GAO Report: 

It is important to note that several actions were taken in response to 
the May 2005 GAO Report. Major improvements have been made in fiscal 
monitoring of grants by SAMHSA and FEMA, including the use of 
standardized budget tables across all programs, development and 
implementation of a budget adjustment request form with close 
monitoring procedures, and encouraging States/providers to hire 
financial professionals to monitor fiscal activities for large grants. 

ISP and RSP applications and supplemental instructions have been 
revised, providing much clearer guidance. Revised instructions were 
made available to States in November 2007 and can be found on the 
SAMHSA website. 

Data Collection and evaluation continue to improve. A data collection 
toolkit has been developed with the assistance of the National Center 
for Post Traumatic Stress Disorder (NCPTSD). The Toolkit includes 
standardized data collection forms, surveys, and instructions. 

Efforts have been made to elicit feedback from our stakeholders through 
a cross site evaluation conducted by NCPTSD. In addition, a lessons-
learned meeting about Katrina, Wilma, and Rita was held in New Orleans 
in May 2007 during which grantees provided information and 
recommendations about their crisis counseling programs. Throughout the 
report, reference is made to 35 States receiving disaster preparedness 
grants. To be accurate, the report should refer to 34 States and the 
District of Columbia. 

Difficulties States Have Encountered Implementing Their CCPs: 

On page 24 [Now on p. 23], reference is made to RSP applications taking 
up to 286 days to review. This statement is misleading and should be 
revised to reflect that the only application that took this long to 
complete was the application from the State of Louisiana. 

The report should also note that Louisiana made the decision to utilize 
a Request for Proposal (RFP) process to determine which providers they 
would contract with to provide CCP services and that utilizing this 
process is atypical for the CCP and took many months, causing enormous 
delays in the review process. 

In the discussion of delays in "executing contracts with service 
providers" on page 6 [Now n p. 5] it should be noted that the 
challenges described are the result of State fiscal and contracting 
practices that do not relate to the availability of Federal funds nor 
does the Federal government have any influence over these kinds of 
State practices. 

Page 12 [Now on p. 11] of the draft report gives the impression that a 
State's RSP application is primarily reviewed by SAMHSA. This is 
incorrect. All ISP's and RSP's are reviewed by both FEMA and SAMHSA, 
with FEMA having the final funding approval authority. Also, SAMHSA 
plays a more direct role in monitoring the activities of an RSP, once 
it is awarded, than it does monitoring an ISP. RSP grants are awarded 
through SAMHSA and are assigned a SAMHSA project officer and grants 
management specialist. ISP grants are awarded through FEMA and are 
monitored by FEMA staff with consultation from SAMHSA staff. 

The description of the needs assessment process following Katrina does 
not capture the degree to which flexibility was given the States in 
quantifying survivor needs. Reviewers did not rely primarily on damage 
assessments, as few had been completed. Rather, FEMA registration 
numbers, newspaper reports and anecdotal evidence were relied upon to 
estimate need and scale initial programs. As more data became 
available, it was incorporated into revised ISP and RSP applications. 

With regard to CCP budgets, as stated in the draft report, Federal 
officials have addressed concerns by extensively revising program 
guidance materials. 

Overall Comments: 

GAO may want to address the limited access State mental health and 
substance abuse authorities have to other types of disaster 
preparedness and response funding. Many State mental health and 
substance abuse officials have commented that most of these kinds of 
funds are provided to public health departments which often do not 
include behavioral health agencies in their planning and activities to 
any significant degree. Clear language and expectations should be 
attached to all disaster related funding mandating that recipients 
partner with and incorporate behavioral health into all planning and 
response activities. Furthermore, funding agencies should require all 
recipients of funding to quantify and report on how funds were used to 
address the psychological consequences of disaster. 

GAO Language (Report Title): 

Since many of the items discussed as concerns have been addressed or 
are in the process of being addressed, we recommend a revision in the 
title to read, "Catastrophic Disasters: Federal Efforts Help States 
Prepare for and Respond to The Psychological Consequences of 
Disasters." 

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Cynthia A. Bascetta, (202) 512-7114 or [email protected]

Acknowledgments

In addition to the contact named above, Helene F. Toiv, Assistant
Director; William Hadley; Alice L. London; and Roseanne Price made major
contributions to this report.

Related GAO Products

September 11: Problems Remain in Planning for and Providing Health
Screening and Monitoring Services for Responders. [40]GAO-07-1253T .
Washington, D.C.: September 20, 2007.

Homeland Security: Observations on DHS and FEMA Efforts to Prepare for and
Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. [41]GAO-07-1142T . Washington, D.C.: July
31, 2007.

September 11: HHS Needs to Ensure the Availability of Health Screening and
Monitoring for All Responders. [42]GAO-07-892 . Washington, D.C.: July 23,
2007.

Emergency Management: Most School Districts Have Developed Emergency
Management Plans, but Would Benefit from Additional Federal Guidance.
[43]GAO-07-609 . Washington, D.C.: June 12, 2007.

Disaster Preparedness: Better Planning Would Improve OSHA's Efforts to
Protect Workers' Safety and Health in Disasters. [44]GAO-07-193 .
Washington, D.C.: March 28, 2007.

Public Health and Hospital Emergency Preparedness Programs: Evolution of
Performance Measurement Systems to Measure Progress. [45]GAO-07-485R .
Washington, D.C.: March 23, 2007.

Catastrophic Disasters: Enhanced Leadership, Capabilities, and
Accountability Controls Will Improve the Effectiveness of the Nation's
Preparedness, Response, and Recovery System. [46]GAO-06-618 . Washington,
D.C.: September 6, 2006.

Federal Emergency Management Agency: Crisis Counseling Grants Awarded to
the State of New York after the September 11 Terrorist Attacks.
[47]GAO-05-514 . Washington, D.C.: May 31, 2005.

Hurricane Katrina: Status of Hospital Inpatient and Emergency Departments
in the Greater New Orleans Area. [48]GAO-06-1003 . Washington, D.C.:
September 29, 2006.

Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown.
[49]GAO-02-813 . Washington, D.C.: August 22, 2002.

(290506)

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Highlights of [57]GAO-08-22 , a report to congressional requesters

February 2008

CATASTROPHIC DISASTERS

Federal Efforts Help States Prepare for and Respond to Psychological
Consequences, but FEMA's Crisis Counseling Program Needs Improvements

Catastrophic disasters, such as Hurricane Katrina, may result in trauma
and other psychological consequences for the people who experience them.
The federal government provides states with funding and other support to
help them prepare for and respond to disasters. Because of congressional
interest in these issues, GAO examined (1) federal agencies' actions to
help states prepare for the psychological consequences of catastrophic
disasters and (2) states' experiences obtaining and using grants from the
Crisis Counseling Assistance and Training Program (CCP) to respond to the
psychological consequences of catastrophic disasters. CCP is a program of
the Department of Homeland Security's (DHS) Federal Emergency Management
Agency (FEMA). GAO reviewed documents and interviewed program officials
from federal agencies and conducted additional work in six states with
experience responding to catastrophic disasters: Florida, Louisiana,
Mississippi, New York, Texas, and Washington.

[58]What GAO Recommends

GAO recommends that DHS, in consultation with HHS, expeditiously (1)
revise CCP policy to allow reimbursement for indirect costs and (2)
determine what types of expanded crisis counseling services should be
incorporated into CCP. DHS and HHS generally concurred with these
recommendations, but did not indicate when they would complete these
activities.

Federal agencies have awarded grants and conducted other activities to
help states prepare for the psychological consequences of catastrophic and
other disasters. For example, in fiscal years 2003 and 2004, the
Department of Health and Human Services' (HHS) Substance Abuse and Mental
Health Services Administration (SAMHSA) provided grants to mental health
and substance abuse agencies in 35 states for disaster planning. In 2007,
SAMHSA completed an assessment of mental health and substance abuse
disaster plans developed by states that received a preparedness grant.
SAMHSA found that, for the 34 states with plans available for review,
these plans generally showed improvement over those that had been
submitted by states as part of their application for its preparedness
grant. The agency also identified several ways in which the plans could be
improved. For example, about half the plans did not indicate specific
planning and response actions that substance abuse agencies should take.
Similarly, GAO's review of the plans available from six states found
varying attention among the plans to covering substance abuse issues.
SAMHSA officials said the agency is exploring methods of determining
states' individual technical assistance needs. Other federal agencies--the
Centers for Disease Control and Prevention, the Health Resources and
Services Administration, and DHS--have provided broader preparedness
funding that states may use for mental health or substance abuse
preparedness, but these agencies' data-reporting requirements do not
produce information on the extent to which states used funds for this
purpose.

States in GAO's review experienced difficulties in applying for CCP
funding and implementing their programs following catastrophic disasters.
CCP, a key federal postdisaster response grant program to help states
deliver crisis counseling services, is administered by FEMA in
collaboration with SAMHSA. State officials said they had difficulty
collecting information needed for their CCP applications and experienced
lengthy application reviews. FEMA and SAMHSA officials said they have
taken steps to improve the application submission and review process.
State officials also said they experienced problems implementing their
CCPs. For example, they said that FEMA's policy of not reimbursing states
and their CCP service providers for indirect costs, such as certain
administrative expenses, led to problems recruiting and retaining service
providers. Other FEMA postdisaster response grant programs allow
reimbursement for indirect costs. A FEMA official said the agency had been
considering since 2006 whether to allow indirect cost reimbursement under
CCP but did not know when a decision would be made. States also cited
difficulties assisting people who needed more intensive crisis counseling
services than those traditionally provided through state CCPs. FEMA and
SAMHSA officials said they plan to consider options for adding other types
of crisis counseling services to CCP, based in part on states' experiences
with CCP pilot programs offering expanded crisis counseling services. The
officials did not know when they would complete their review and reach a
decision.

References

Visible links
  29. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1003
  30. http://www.gao.gov/cgi-bin/getrpt?GAO-05-514
  31. http://www.gao.gov/cgi-bin/getrpt?GAO-05-325SP
  32. http://www.gao.gov/cgi-bin/getrpt?GAO-07-485R
  33. http://www.gao.gov/cgi-bin/getrpt?GAO-05-514
  34. http://www.gao.gov/cgi-bin/getrpt?GAO-05-514
  35. http://www.gao.gov/cgi-bin/getrpt?GAO-02-813
  36. http://www.gao.gov/cgi-bin/getrpt?GAO-07-67
  37. http://www.gao.gov/cgi-bin/getrpt?GAO-07-892
  38. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1092T
  39. http://www.gao.gov/cgi-bin/getrpt?GAO-06-481T
  40. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1253T
  41. http://www.gao.gov/cgi-bin/getrpt?GAO-07-1142T
  42. http://www.gao.gov/cgi-bin/getrpt?GAO-07-892
  43. http://www.gao.gov/cgi-bin/getrpt?GAO-07-609
  44. http://www.gao.gov/cgi-bin/getrpt?GAO-07-193
  45. http://www.gao.gov/cgi-bin/getrpt?GAO-07-485R
  46. http://www.gao.gov/cgi-bin/getrpt?GAO-06-618
  47. http://www.gao.gov/cgi-bin/getrpt?GAO-05-514
  48. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1003
  49. http://www.gao.gov/cgi-bin/getrpt?GAO-02-813
  50. http://www.gao.gov/
  51. http://www.gao.gov/
  52. http://www.gao.gov/fraudnet/fraudnet.htm
  53. mailto:[email protected]
  54. mailto:[email protected]
  55. mailto:[email protected]
  56. http://www.gao.gov/cgi-bin/getrpt?GAO-08-22
  57. http://www.gao.gov/cgi-bin/getrpt?GAO-08-22
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