Gulf Coast Hurricanes: Addressing Survivors' Mental Health and Substance Abuse Treatment Needs

Gulf Coast Hurricanes:
Addressing Survivors’ Mental Health and
Substance Abuse Treatment Needs
November 29, 2006
Ramya Sundararaman
Analyst in Public Health
Domestic Social Policy Division
Sarah A. Lister
Specialist in Public Health and Epidemiology
Domestic Social Policy Division
Erin D. Williams
Specialist in Bioethical Policy
Domestic Social Policy Division



Gulf Coast Hurricanes: Addressing Survivors’
Mental Health and Substance Abuse Treatment Needs
Summary
Major disasters such as Hurricanes Katrina, Rita, and Wilma, which struck Gulf
Coast states in 2005, have the potential not only to cause mental health problems for
individuals, but also to weaken or disable the systems designed to address those
individuals’ needs. Striking an appropriate balance of responsiveness, fiscal
responsibility, and accountability in the provision of federal assistance programs
during and following a disaster remains a difficult goal.
Federal leadership for mental health and substance abuse programs resides in
the Substance Abuse and Mental Health Services Administration (SAMHSA), in the
Department of Health and Human Services (HHS). SAMHSA carries out numerous
activities to address mental health and substance abuse problems following disasters,
including the Crisis Counseling Assistance and Training Program (CCP), which is
authorized in the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(the Stafford Act) and implemented jointly by SAMHSA and the Federal Emergency
Management Agency (FEMA).
The response to the 2005 hurricanes has prompted a re-examination of CCP and
other federal assistance programs that address disaster mental health. Concerns
include the timeliness and effectiveness of services provided, the appropriate scope
and duration of these services, and matters of cost and accountability. In particular,
the respective roles and responsibilities of SAMHSA (which provides technical
expertise for CCP programs), FEMA (which funds them), and states and their
contractors (which implement them), are not always clear.
Following a news investigation, some Members of Congress have expressed
concerns about Project H.O.P.E., the CCP program implemented in Florida in
response to Hurricane Wilma. Others have sought to expand CCP to provide
substance abuse services, and to require that SAMHSA, other federal agencies, and
state and local governments conduct resource assessments and develop strategies to
address mental health and substance abuse service needs following disasters. (See
S. 3721, reported in the Senate.)
This report describes federal assistance programs in HHS that address mental
health and substance abuse problems following disasters. In addition, relevant policy
issues are presented in the context of the 2005 hurricanes, and several prior disasters.
Three appendices provide information on CCP awards made to states in response to
Hurricanes Katrina, Rita, and Wilma, and on the scope of services that constitute
mental health treatment. This report will be updated as circumstances warrant.



Contents
In troduction ......................................................1
SAMHSA Disaster Assistance Programs...............................4
Crisis Counseling Assistance and Training Program (CCP).............4
SAMHSA Emergency Response Grants (SERG).....................6
Supplemental Appropriations....................................6
Other Services................................................7
Issues for Congress................................................8
Disaster Mental Health in Federal Planning.........................9
Concerns Regarding CCP......................................10
Programmatic and Fiscal Accountability.......................10
Evaluating the Effectiveness of CCP..........................11
Scope of Mental Health Services under CCP...................13
Duration of Mental Health Services under CCP.................14
Treatment for Co-occurring Disorders under CCP...............16
Fiscal Year Limits on Availability of SERG Funds...................17
Assessment of Resources and Long-term Needs.....................17
Conclusion ......................................................19
Appendix A......................................................20
Appendix B......................................................21
DRF Allocations for CCP......................................21
Appendix C......................................................23
Scope of Mental Health Treatment Services........................23
List of Tables
Table A. State CCP Awards........................................20
Table B. CCP Funding for the 2005 Hurricanesa........................22



Gulf Coast Hurricanes:
Addressing Survivors’ Mental Health and
Substance Abuse Treatment Needs
Introduction
Hurricane Katrina struck the Gulf Coast in late August 2005, causing
catastrophic wind damage and flooding in several states, and a massive dislocation
of victims across the country. According to government sources, the storm, one of
the worst natural disasters in the nation’s history, killed at least 1,464 people in
Louisiana,1 more than 200 in Mississippi, and about 20 more in Alabama, Florida,
and Georgia.2 Hurricane Rita made landfall along the Gulf Coast in late September
2005. While not as deadly, Rita re-flooded New Orleans and impacted other areas
where Katrina evacuees were struggling to recover. (Rita was directly responsible
for seven deaths and 55 “indirect” deaths, some during the pre-storm evacuation.)
Hurricane Wilma made landfall in south Florida in late October 2005, killing five
people and also causing extensive damage.3 These three hurricanes, as well as
hurricanes Dennis and Ophelia and Tropical Storm Cindy, each resulted in federal
disaster declarations for affected areas in 2005.4
Previous research has shown that substance abuse and various manifestations
of mental illness — including anxiety, depression, post-traumatic stress disorder
(PTSD), and suicidality — often occur or worsen following disasters, and that some
effects may persist for years.5 Early studies suggest a similar trend in the aftermath


1 Louisiana Department of Health and Hospitals, Hurricane Katrina Reports of Missing and
Deceased, Aug. 2, 2006, at [http://www.dhh.louisiana.gov/offices/page.asp?ID=192&
FromSearch=1&Detail=5248].
2 National Oceanic and Atmospheric Administration, National Weather Service, National
Hurricane Center, “Tropical Cyclone Report: Hurricane Katrina, 23-30 August 2005,” Dec.

20, 2005, at [http://www.nhc.noaa.gov/pdf/TCR-AL122005_Katrina.pdf].


3 Hurricane damage and casualty reports are available at the National Hurricane Center’s
archive of tropical cyclone reports, at [http://www.nhc.noaa.gov/pastall.shtml].
4 See Federal Emergency Management Agency, “2005 Federal Disaster Declarations,” at
[ ht t p: / / www.f e ma .gov/ news/ di sast er s.f e ma ?year = 2005] .
5 See, for example, C. L. Katz et al., “Research on Psychiatric Outcomes and Interventions
Subsequent to Disasters: a Review of Literature,” Psychiatry Research, vol. 110, no. 3 (July

2002), pp. 201-217; and National Association of State Alcohol and Drug Abuse Directors,


“Policy Brief: Trauma and Substance Use: Implications for the Response to Hurricane
Katrina/Rita,” Sept. 2005, at [http://www.nasadad.org/resource.php?doc_id=450].

of Hurricanes Katrina and Rita.6 These disasters were especially challenging, given
the extensive relocation of victims, the loss of the medical records of victims with
pre-existing conditions, and the loss of infrastructure and healthcare workers to
support the response. It is reported, for example, that New Orleans now has only
about one-third of the 462 psychiatric beds it had before Hurricane Katrina, though
the remaining population is at more than half of the city’s pre-storm level, and, by
some accounts, has an even greater need for the beds.7
In 1974, Congress enacted broad disaster assistance legislation, the Robert T.
Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act). Section
416 of the act provides authority, when there is a presidentially declared disaster, for
federal assistance to state and local governments to address the mental health needs
of victims.8 Called the Crisis Counseling Assistance and Training Program (CCP),
the program met its first major challenge with the bombing of the Murrah federal
building in Oklahoma City in 1995. Funding for the program that was established
by Oklahoma in response, named Project Heartland, was extended several times to
accommodate the immediate needs of victims as well as the stress experienced by
victims in the long term, such as during the trials of the accused bombers.9
Following the terrorist attack of September 11, 2001, New York established a CCP
program, called Project Liberty, to assist victims in the greater New York City area.
Funding for Project Liberty was also extended several times.10 CCP programs were
established in 29 states in response to Hurricane Katrina, reflecting the widespread
dislocation of the storm’s victims. One year later, with many victims still facing
problems with mental illness, 17 states have asked for program extensions. These
include Alabama, Florida, Louisiana, and Mississippi, which were directly affected,
and 13 states that hosted hurricane evacuees.
The objective of CCP is to help disaster victims understand the breadth of
normal behavioral responses to stressful events, recognize which responses may
warrant specific intervention (including professional treatment), and locate follow-up
services when needed. CCP is not designed to provide or pay for medical, including
psychiatric, treatment for those victims who may need it. Rather, victims needing


6 See R.H. Weisler et al., “Mental Health and Recovery in the Gulf Coast After Hurricanes
Katrina and Rita,” JAMA, vol. 296, no. 5 (Aug. 2006); and Kessler et al., “Mental Illness
and Suicidality after Hurricane Katrina,” Bulletin of the World Health Organization, vol.

84, no. 8 (Aug. 2006), at [http://www.who.int/bulletin/volumes/ 84/10/06-033019.pdf].


7 Robin Rudowitz et al., “Health Care in New Orleans before and after Hurricane Katrina,”
Health Affairs, vol. 25, pp. w393-w406 (Aug. 29, 2006), Web exclusive. See also,
Louisiana Healthcare Redesign Collaborative, “Region 1 Health Care Profile,” Aug. 20,

2006, at [http://www.dhh.louisiana.gov/offices/ news.asp?ID=288&Detail=925].


8 42 USC § 5183.
9 U.S. Department of Justice, Office of Justice Programs, “Responding to Terrorism
Victims: Oklahoma City and Beyond,” p. 19, Oct. 2000, at [http://www.ojp.usdoj.gov/
ovc/pdftxt/NCJ 183949.pdf].
10 See New York City Department of Education, Project Liberty home page, at
[http://www.projectliberty.state.ny.us/]; and GAO, “Crisis Counseling Grants Awarded to
the State of New York after the September 11 Terrorist Attacks,” GAO-05-514, May 2005.

treatment are to be referred to existing service systems. Given that many Americans
lack health insurance, and that mental health and substance abuse services may not
be adequately covered for those who are insured,11 Congress and others remain
concerned that, despite CCP and other federal assistance programs, the mental health
and substance abuse treatment needs of many disaster victims may go unmet.
In October 2006, a local newspaper ran a story questioning a number of aspects
of Project H.O.P.E., the CCP program established by the state of Florida in response
to Hurricane Wilma. The story, which raised questions about the effectiveness of the
program in targeting victims and in addressing their mental health needs, prompted
calls by some Members of Congress for investigations.12
This report describes CCP and other programs administered by the Substance
Abuse and Mental Health Services Administration (SAMHSA, an agency within the
Department of Health and Human Services, HHS) to provide federal assistance for
the mental health and substance abuse treatment needs of disaster victims. (When
a disaster is caused by terrorism or other forms of violence, a number of federal
programs to assist victims of violence may be available through the Department of
Justice or other agencies. Those assistance mechanisms are not discussed here.13)
Several issues associated with CCP are discussed, including whether the services
provided are well matched to need, and whether the effectiveness of the program has
been demonstrated. The report also analyzes the implementation, effectiveness and
coordination of other SAMHSA disaster mental health programs, and discusses
relevant policy issues in ensuring the provision of mental health and substance abuse
treatment services following disasters. This report will be updated as circumstances
warrant.


11 See CRS Report RL31657, Mental Health Parity: Federal and State Action and
Economic Impact, by Ramya Sundararaman and C. Stephen Redhead.
12 Sally Kestin, “FEMA-Funded Projects Blasted; Lawmakers Want to Investigate Puppet
Shows, Bingo Intended for Storm Victims,” South Florida Sun-Sentinel, Oct. 13, 2006.
13 For an inventory of selected federal grant programs to address the mental health needs of
children affected by disasters, see GAO, “Mental Health Services: Effectiveness of
Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma
Largely Unknown,” GAO-02-813, Table 16, p. 79 ff., Aug. 22, 2002. Many of the listed
grant programs are not limited to children.

SAMHSA Disaster Assistance Programs
The Substance Abuse and Mental Health Services Administration (SAMHSA)
is the lead federal agency providing assistance to meet the mental health and
substance abuse treatment needs of disaster victims.14 In addition to its regular
authorities to fund and support substance abuse and mental health treatment services,
the agency has authority to provide emergency assistance through three additional
mechanisms, discussed below: the Crisis Counseling Assistance and Training
Program (CCP), SAMHSA Emergency Response Grants (SERG), and supplemental
appropriations. For its response to Hurricanes Katrina, Rita and Wilma, SAMHSA
received funding to administer CCP programs, and provided SERG grants through
its regular appropriations, but did not receive a supplemental appropriation.
Crisis Counseling Assistance and Training Program (CCP)
The Stafford Act authorizes a variety of assistance programs for individuals,
families, state and local governments and others affected by disasters.15 Section 416
of the act authorizes CCP, a program to provide mental health counseling in
presidentially declared disasters,16 as follows:
The President is authorized to provide professional counseling
services, including financial assistance to State or local agencies or
private mental health organizations to provide such services or
training of disaster workers, to victims of major disasters in order to
relieve mental health problems caused or aggravated by such major17


disaster or its aftermath.
14 HHS, Substance Abuse and Mental Health Services Administration (SAMHSA), home
page, at [http://www.samhsa.gov/]. See, also, SAMHSA disaster relief information, at
[http://www.mentalhealth.samhsa.gov/cmhs/katrina/]; and “SAMHSA’s One-Stop Shop for
Katrina and Rita Resources,” at [http://www.samhsa.gov/hurricane/Parents.aspx?link4=
true&].
15 42 USC § 5121, et seq. For more information, see CRS Report RL33053, Federal
Stafford Act Disaster Assistance: Presidential Declarations, Eligible Activities, and
Funding, by Keith Bea.
16 Section 401 of the Stafford Act authorizes the President to declare that a major disaster
has occurred in affected areas, providing certain forms of assistance, including CCP. In
addition to the authority to declare a major disaster, the President also has authority,
pursuant to the Stafford Act, to declare an emergency, which authorizes a lower level of
federal assistance than does a major disaster declaration. CCP authority is restricted to
major disaster declarations.
17 42 USC § 5183. President George W. Bush declared major disasters in Florida,
Louisiana, Mississippi and Alabama following Hurricane Katrina, and in Texas and
Louisiana following Hurricane Rita. Florida also received a presidential disaster declaration
following Hurricane Wilma in October 2005, and established a CCP program subsequently.
FEMA provides information on Stafford major disaster declarations at [http://www.fema.
gov/ news/disasters.fema].

CCP does not provide mental health treatment or substance abuse services. (See the
subsequent section on “Scope of Mental Health Services under CCP.”) Congress has
amended CCP authority only once since it was first enacted in 1974. In 1988,
Congress removed a reference to the National Institute of Mental Health (NIMH), the
institute within the National Institutes of Health (NIH) that was originally responsible
for administering CCP.18
Through executive orders, the President has delegated to the Federal Emergency
Management Agency (FEMA), an agency within the Department of Homeland
Security (DHS), responsibility for administering the major provisions of the Stafford
Act. FEMA has published regulations that specify, among other things, the scope
and duration of services provided under CCP.19 The program is largely administered
by SAMHSA through an interagency agreement with FEMA. SAMHSA has
published program guidance that further describes the scope of services eligible for
funding, and other matters.20 Eligible awardees are state mental health agencies or
other local or private mental health organizations designated by the governor of the
affected state. Eligible services are reimbursed by FEMA through its Disaster Relief
Fund (DRF), a no-year account in which appropriated funds remain available until
expended. The DRF is typically replenished through supplemental appropriations,
especially in the aftermath of catastrophic disasters.
States apply for funds by preparing a formula-based needs assessment within 10
days of the date of the disaster declaration, documenting the inadequacy of their
available resources, and presenting a plan for service delivery. (The needs
assessment takes into account the level of casualties and destruction of property that
result from the disaster.) There is no matching requirement, and requested CCP
funds must supplement, not supplant, existing local or state resources. CCP consists
of two smaller programs: the Immediate Services Program (ISP) and the Regular
Services Program. The ISP provides funds directly from FEMA to states for up to
60 days of services immediately following a disaster declaration. The RSP provides
funds for up to nine months following a disaster declaration. (Regulations permit
extensions in certain cases, as discussed in the subsequent section on “Duration of
Mental Health Services under CCP.”) RSP funds are provided to the states through
SAMHSA, which is reimbursed by FEMA through the DRF.
CCP services may be provided to victims of presidentially declared disasters
even if they have relocated.21 Hence, HHS reported that in response to Hurricane
Katrina, all 50 states as well as Puerto Rico and the District of Columbia would be


18 P.L. 100-707, the Major Disaster Relief and Emergency Assistance Amendments of 1988.
The act also renumbered certain sections of the Stafford Act, including CCP authority.
FEMA’s regulations for CCP, amended most recently in 2003, continue to refer to NIMH
as the HHS liaison for program administration.
19 44 CFR § 206.171.
20 SAMHSA, Center for Mental Health Services, “Crisis Counseling Training and
Assistance Program Guidance,” undated document, hereafter called CCP program guidance,
at [http://www.mentalhealth.samhsa.gov/cmhs/EmergencyServices/progguide.asp].
21 44 CFR § 206.171(h)(1)(i).

eligible to apply for CCP grants, presumably because they all could potentially host
evacuees from presidentially declared disaster areas.22 Not all states applied,
however. As of October 2006, 29 states had been awarded CCP funding for
Hurricane Katrina, totaling $132 million. In addition, $6 million was awarded to
Louisiana and Texas following Hurricane Rita, and $13 million to Florida following
Hurricane Wilma. Awards by state are listed in Appendix A.
SAMHSA Emergency Response Grants (SERG)
In 2000, in its reauthorization of certain SAMHSA programs, Congress gave the
agency new authority to redirect a portion of its fiscal year funds to make non-
competitive grants to address emergency substance abuse or mental health needs in
communities, via SAMHSA Emergency Response Grants (SERG).23 SERG may be
awarded whether or not there has been a Stafford Act declaration, based on a
determination by the HHS Secretary of the existence of a substance abuse or mental24
health emergency. Hence, SERG may be used to provide assistance when there has
not been a major disaster declaration, or, when there has been, to fund substance
abuse and mental health treatment services that are not permitted under CCP. SERG
grants have been awarded following the 2002 Washington, DC -area sniper incidents
and the 2003 Rhode Island nightclub fire. Following Hurricane Katrina, FY2005
SERG grants totaling $600,000 were made to Alabama ($100,000), Louisiana25
($200,000), Mississippi ($150,000) and Texas ($150,000). Mississippi received an
additional $300,000 in FY2006.26
Supplemental Appropriations
If Congress provides SAMHSA with supplemental funds for disaster response,
the funds, unless they are restricted, may be used to augment activities carried out
under SAMHSA’s standing authority to provide assistance to prevent or treat mental
illness and substance abuse, in particular to meet those needs that may not be met
with CCP or SERG funds. For example, substance abuse and mental health
treatment services, psychotropic medication expenses, methadone treatment, suicide
prevention programs, and major administrative expenses for mental health and
substance abuse resulting from the disaster may be addressed through this
mechanism. Congress provided funding for the response to Hurricanes Katrina and
Rita through several supplemental appropriations, but SAMHSA did not receive any


22 HHS, “Summary of Federal Payments Available for Providing Health Care Services to
Hurricane Evacuees and Rebuilding Health Care Infrastructure,” Jan. 25, 2006, at
[http://www.hhs.gov/katrina/fedpayment.html ].
23 42 USC § 290aa(m). SAMHSA may redirect up to 2.5% of its appropriation for a given
fiscal year, excluding amounts provided for a homeless assistance program.
24 SAMHSA published an interim final rule laying out criteria for such a determination in
66 Federal Register 51873, Oct. 11, 2001, and finalized the rule with only technical
corrections in 67 Federal Register 56930, Sept. 6, 2002.
25 HHS, “HHS Awards $600,000 in Emergency Mental Health Grants to Four States
Devastated by Hurricane Katrina,” news release, Sept. 13, 2005.
26 SAMHSA, Office of Policy, Planning and Budget, Sept. 5, 2006.

of this funding. The bulk of the supplemental funds went toward replenishing the
DRF, with smaller amounts provided to other federal departments and agencies,
including other agencies in HHS.27
Other Services
In response to Hurricanes Katrina and Rita, SAMHSA carried out a variety of
activities through its standing authorities and with its existing funding, including
coordination of services, suicide prevention, mental health services, public education,
and substance abuse services. Some of these services were provided in the immediate
aftermath of the hurricanes, while others were provided six to 12 months afterward.
Coordination of Agencies: SAMHSA convened a national summit in New
Orleans in May 2006 to provide a forum for lessons learned from the 2005
hurricanes. While SAMHSA was the primary federal agency that provided mental
health and substance abuse services, key services were also provided by: the Health
Resources and Services Administration (HRSA), which funded Federally Qualified
Health Centers (FQHCs); the National Institute of Mental Health (NIMH), which
funded deployments of mental health providers; and the Centers for Disease Control28
and Prevention (CDC), which conducted surveillance of mental health needs.
Coordination of Services: SAMHSA established the SAMHSA Emergency
Response Center (SERC) to provide on-the-ground coordination of its mental health
services. The SERC, which was in operation until January 2006, was a point of
contact to receive information and have access to resources, regarding staffing and29
resources to be deployed. The SERC coordinated delivery of mental health services
by managing the deployments of mental health providers to the affected area, and by
organizing daily conference calls with representatives from all HHS agencies.
Suicide Prevention: SAMHSA administered a combination of grants and other
programs for suicide prevention. In the immediate aftermath of the hurricanes,
SAMHSA expanded its toll-free suicide prevention crisis hotline, and coordinated30
deployments of counselors to the affected areas. In September 2006, SAMHSA
awarded Louisiana and Mississippi $2.4 million over three years, through the Garrett31


Lee Smith Memorial Act, for youth suicide prevention activities.
27 For more information, see CRS Report RS22239, Emergency Supplemental
Appropriations for Hurricane Katrina Relief, by Keith Bea.
28 HHS, “Activities at HHS Agencies, Disasters and Emergencies: 2005 Hurricane Season,”
Aug. 10, 2006, at [http://www.hhs.gov/katrina/hhsagencies.html].
29 SAMHSA, “From Hurricane Response to Long-Term Recovery,” SAMHSA News,
Nov/Dec 2005, at [http://www.samhsa.gov/SAMHSA_News/archive05.htm].
30 SAMHSA, “SAMHSA’s One-Stop Shop for Katrina and Rita Resources,” at
[ h t t p : / / www.s a mh s a .gov/ hur r i c a n e / he l p.a s px] .
31 SAMHSA,”Louisiana and Mississippi to Receive $2.4 Million for Youth Suicide
Prevention, Early Intervention,” SAMHSA News, Sept. 14, 2006, at [http://www.samhsa.
gov/ news/newsreleases/060914_la.aspx].

Mental Health Services: SAMHSA’s National Child Traumatic Stress
Network (NCTSN) made its resources available to help parents and service providers
assist children, in both immediate crisis responses and long-term recovery settings.
In addition, SAMHSA’s critical incident stress management program addressed the
mental health needs of first responders who were exposed to the aftermath of the
hurri canes. 32
Public Education: In December 2005, SAMHSA launched a public awareness
campaign through Public Service Announcements and brochures. The campaign
sought to enable victims to recognize the need for mental health treatment for
themselves and their children in the aftermath of the hurricanes.33 Coinciding with
the one year anniversary of the hurricanes, SAMHSA launched a series of new
national public service print and billboard ads, encouraging survivors who
experienced continued psychological distress to seek mental health services. Some
of these new ads targeted first responders as well as parents and caregivers who can
assess their children’s emotional well-being.34
Substance Abuse Services: On August 31, 2005, SAMHSA issued a guidance
for State Methadone Authorities and Opioid Treatment Programs in hurricane-
affected states providing short and long-term emergency methadone and
buprenorphine treatment services to heroin-addicted populations affected by the35
disaster. In addition, SAMHSA has compiled baseline data on pre-hurricane
substance use in states affected by Hurricanes Katrina and Rita.
Issues for Congress
This section discusses several policy issues, including federal leadership and
coordination of mental health and substance abuse treatment and other services in the
aftermath of a disaster; issues regarding CCP, including the scope and duration of
CCP services, as well as matters of program administration and effectiveness; the
availability of funds for SERG grants; and, the assessment of resources and needs for
mental health and substances abuse services.


32 SAMHSA, “From Hurricane Response to Long-Term Recovery,” SAMHSA News,
Nov/Dec 2005, at [http://www.samhsa.gov/SAMHSA_News/archive05.htm].
33 SAMHSA, “HHS Secretary Leavitt Unveils National PSA Campaign to Provide Mental
Health Services to Hurricane Survivors,” SAMHSA News, Dec 7, 2005, at
[ ht t p: / / www.samhsa.gov/ news/ newsr e l eases/ 051207_hur r i cane.ht m] .
34 SAMHSA, “SAMHSA and Ad Council Launch New Ads to Offer Mental Health Services
to Hurricane Survivors,” SAMHSA News, Aug 29, 2006, at [http://www.samhsa.gov/
news/newsreleases/060829_psa.htm] .
35 SAMHSA, “From Hurricane Response to Long-Term Recovery,” SAMHSA News,
Nov/Dec 2005, at [http://www.samhsa.gov/SAMHSA_News/archive05.htm].

Disaster Mental Health in Federal Planning
Federal leadership for responding to the mental health consequences of disasters
can be enhanced by clear delegations of authority, or may be compromised by
ambiguous delegations of authority. In 2004, DHS published the National Response
Plan (NRP), as mandated by Congress in P.L. 107-296, the Homeland Security Act
of 2002. The NRP establishes a comprehensive framework for the coordination of36
federal resources in response to disasters. In the current version of the NRP,
leadership for the federal coordination of mental and behavioral health services
following a disaster appears to be split. The NRP includes 15 Emergency Support
Functions, or ESFs, which are specific plans for certain sectors, such as
transportation. Emergency Support Function 6 (ESF-6), Mass Care, under the
leadership of FEMA and the American Red Cross, lays out the coordination of
emergency shelter, feeding, and related activities for affected populations.
Emergency Support Function 8 (ESF-8), under the leadership of the Secretary of
HHS, lays out the coordination of the public health and medical response to
disasters.37 “Crisis counseling” is among the responsibilities delegated in ESF-6,
while federal coordination of “behavioral health care” — including assessing mental
health and substance abuse needs, and providing disaster mental health training for
workers — is delegated in ESF-8. Hence, federal leadership for disaster mental
health in the NRP is delegated to both FEMA and to HHS. (When the disaster
involves terrorism or other forms of violence, the Department of Justice may also
become a key federal partner, as was seen with Project Heartland following the38
Oklahoma City bombing.)
In the aftermath of a disaster, adequate communication and coordination
between federal agencies and affected states can ensure that services are delivered in
a timely and efficient manner. A recent news report questioned whether FEMA
shared information with the state of Florida about the location of Hurricane Katrina
evacuees, in order to help the state target its CCP program for these individuals as
efficiently as possible.39 While the news report said that FEMA “refuses” to provide
this information to state officials, FEMA stated in a recent Federal Register notice
that its regulations pursuant to the Privacy Act have long permitted such disclosures,
and that it has the authority to provide such information “(t)o another Federal agency
or State government agency charged with administering disaster relief programs to


36 6 USC § 312(6). See Department of Homeland Security, National Response Plan, Dec.
2004, at [http://www.dhs.gov/xprepresp/programs]. The NRP superseded the Federal
Response Plan that had been used since 1992. See also CRS Report RL32803, The National
Preparedness System: Issues in the 109th Congress, by Keith Bea.
37 For more information, see CRS Report RL33579, The Public Health and Medical
Response to Disasters: Federal Authority and Funding, by Sarah A. Lister.
38 The Department of Justice shares leadership responsibilities with DHS for ESF-13, Public
Safety and Security. ESF-13 does not explicitly mention mental health.
39 Sally Kestin, “FEMA Spends Millions on Puppet Shows, Bingo and Yoga,” South Florida
Sun-Sentinel, Oct. 8, 2006.

make available any additional Federal and State disaster assistance to individuals and
households.”40
Problems with coordination and cooperation are mentioned repeatedly by mental
health professionals who have found themselves in the position of responding to
major events in their communities.41 Officials from the Louisiana Department of
Health and Hospitals reported that there was no coordination of services provided by
individuals who were not deployed through SAMHSA.42 While the federal
government plays an important role in addressing the mental health needs of
survivors in the aftermath of a disaster, there may be value in engaging in joint
disaster planning efforts with state and local governments and the private sector to
prepare for future disasters.43 Norris et al. conclude that coordination of delivery of
mental health services through a public health or population-based approach, and
continued coordination to provide services as the long term effects of the crisis
unfold, are likely to be beneficial for the survivors’ mental health. Responses are
seen to be most useful, the authors conclude, when they are tailored to subgroups
according to their unique combinations of risk and protective factors.44
Concerns Regarding CCP
Programmatic and Fiscal Accountability. With one party (FEMA)
responsible for CCP funding, another (SAMHSA) responsible for approval and
oversight of proposals and activities, and the third (the state) responsible for
implementation, accountability for problems with the program may not always be
clear. FEMA does not provide scientific, technical or medical expertise to support
the delivery of mental health or substance abuse services. That expertise, at the
federal level, clearly resides with HHS and SAMHSA. Establishing authority for
CCP in the Stafford Act, which is administered by FEMA, is a means to provide
funding for crisis counseling services quickly and as needed through the DRF,
assuring that such services can be provided without regard to constraints that may be
imposed by HHS’s or SAMHSA’s annual appropriations. It has the effect, however,
of placing FEMA in the position of fiscal responsibility for a program for which it
lacks the requisite technical expertise.
Mechanisms for shared federal responsibility for CCP, and for disaster mental
health and substance abuse services in general, may work well if federal agencies
coordinate with each other and with the states. A recent news report has raised


40 71 Federal Register 38408, July 6, 2006.
41 F.H. Norris et al., “60,000 Disaster Victims Speak: Part II Summary and Implications of
the Disaster Mental Health Research,” Psychiatry, vol. 65, no. 3 (Fall 2002), pp. 240-260.
42 I. Cannella, “Mission to the Gulf: Meeting the Crisis of Hurricanes Katrina and Rita,”
American Psychological Association Annual Convention, New Orleans, Aug. 11, 2006.
43 Siegal et al., “Coping with Disasters: Estimation of Additional Capacity of the Mental
Health Sector to Meet Extended Service Demands,” Journal of Mental Health Policy
Economics, vol. 7, no. 1 (Mar 2004), pp. 29-35.
44 F.H. Norris et al., “60,000 Disaster Victims Speak: Part II Summary and Implications of
the Disaster Mental Health Research,” Psychiatry, vol. 65, no. 3 (Fall 2002), pp. 240-260.

questions about how well recent CCP programs have been carried out in Florida in
response to Hurricanes Katrina and Wilma.45 One question raised in the news
account is whether the program activities developed for Project H.O.P.E. — namely,
puppet shows, bingo and yoga — are appropriate to address disaster mental health
needs. Further, of the three responsible parties, FEMA, SAMHSA and the state of
Florida, which is ultimately responsible for assuring that services are appropriate, or
at fault if they are not? (This question depends in turn on an understanding of the
effectiveness of disaster mental health services in general, a matter discussed in a
subsequent section, “Evaluating the Effectiveness of CCP.”)
A function of good leadership by a federal agency is to ensure that taxpayers’
funds are put to effective use. The news report prompted considerable interest
among Members of Congress, many of whom expressed concern both about the
possible irresponsible use of taxpayers’ funds, as well as a possible failure in meeting
the legitimate needs of hurricane victims.46 FEMA Director R. David Paulison
responded to the original story, noting in a press release that FEMA had merely
supported outreach programs that the state had requested.47 The press release did not
mention SAMHSA or its role.
In May 2005, GAO published its review of financial accounting for CCP
services provided under Project Liberty, in response to the attack on the World Trade
Center in 2001.48 GAO reported that FEMA and SAMHSA did not require grantees
to submit revised budgets as the services provided evolved, and that SAMHSA did
not keep track of program expenditures as well as it tracked the program’s delivery
of services. GAO recommended that SAMHSA and FEMA develop mechanisms for
improved budgetary oversight, as well as mechanisms to measure the effectiveness
of the program. In its comments to GAO, SAMHSA disputed some of GAO’s
assertions, and commented on the difficulties associated with federal fiscal
management of awards given to state and local governments, and then to sub-
grantees.
Appendix A lists CCP awards to states for ISP and RSP programs in response
to Hurricanes Katrina, Rita and Wilma, as reported by SAMHSA. Appendix B
compares these amounts with CCP allocations for the three disasters as reported by
FEMA in the agency’s weekly reports to Congress.
Evaluating the Effectiveness of CCP. Congress authorized CCP “in order
to relieve mental health problems caused or aggravated by [a] major disaster or its
aftermath.” Optimally, CCP services would prevent or minimize mental health


45 Sally Kestin, “FEMA Spends Millions on Puppet Shows, Bingo and Yoga,” South Florida
Sun-Sentinel, Oct. 8, 2006.
46 Sally Kestin, “FEMA-Funded Projects Blasted; Lawmakers Want to Investigate Puppet
Shows, Bingo Intended for Storm Victims,” South Florida Sun-Sentinel, Oct. 13, 2006.
47 FEMA, “FEMA Director Paulison Responds to Criticism of Crisis Counseling Program,”
press release, Oct. 13, 2006, at [http://www.fema.gov/news/newsrelease.fema?id=30705].
48 GAO, “Federal Emergency Management Agency: Crisis Counseling Grants Awarded to
the State of New York after the September 11 Terrorist Attacks,” GAO-05-514, May 2005.

problems in affected individuals or populations. But the actual effect of the program
on health outcomes has not been demonstrated. In 2002, the GAO recommended that
FEMA and SAMHSA collaborate in evaluating the effectiveness of CCP, noting that
the FEMA Inspector General had made the same recommendation in 1995.49 Neither
FEMA nor SAMHSA has published results of outcomes evaluations for Project
Heartland, Project Liberty, or any other CCP programs.50 A recent news report has
questioned whether the activities carried out in Project H.O.P.E., the CCP program
established in Florida in response to Hurricane Wilma (See “Crisis Counseling
Assistance and Training Program”), are likely to benefit the mental health of
victims.51
The intrinsic merit of CCP, as currently implemented, is not the key question,
many observers believe. Rather, they question whether the funds provided could be
more effective in preventing or reducing the burdens of post-disaster mental illness
if spent differently. Ongoing debate about the appropriate scope and duration of
services provided under CCP — discussed later in this report (See “Scope of Mental
Health Services under CCP” and “Duration of Mental Health Services under CCP”)
— reflect ongoing uncertainty about the “best” way to craft the program to meet
statutory objectives. Unfortunately, these discussions are hobbled by a weak
knowledge base. Research in this area is challenging for several reasons. First, there
are technical challenges in mental health research in general, including a limited suite
of standardized measurement tools, limited information on the baseline prevalence
of mental illness in populations, and difficulty in comparing studies that use different
measurement tools or follow-up times. Second, disasters are by their nature episodic,
varying in type, severity and location, making comparisons difficult. Finally,
different types of disasters may affect the mental health of victims in different ways.
For example, some experts feel that victims’ responses to war or terrorism are
substantially different from their responses to natural disasters.
SAMHSA reports that it will be conducting an evaluation of CCP services
delivered in the aftermath of Hurricanes Katrina and Rita, in collaboration with the
National Center for Post-Traumatic Stress Disorder (NCPTSD), a center within the
Department of Veterans Affairs (VA).52 The NCPTSD supports a broad national
network for PTSD research, including several federal departments, academic and
private sector collaborators, making it well suited for the kind of complex outcomes
research that is needed for a better understanding of CCP effectiveness. Whether the


49 GAO, “Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown,” GAO-02-813,
Aug. 2002. At the time of publication, the agency was called the General Accounting
Office.
50 FEMA provides funding, and SAMHSA provides guidance, for states to conduct CCP
“process evaluations,” which focus on the effectiveness of program implementation rather
than on health outcomes. Process evaluations have reportedly been conducted for Projects
Heartland and Liberty, but nothing has been made publicly available.
51 Sally Kestin, “FEMA-Funded Projects Blasted; Lawmakers Want to Investigate Puppet
Shows, Bingo Intended for Storm Victims,” South Florida Sun-Sentinel, Oct. 13, 2006.
52 SAMHSA, Office of Legislative Affairs, August 16, 2006. For more information on the
NCPTSD, see [http://www.ncptsd.va.gov/].

evaluation will encompass the full scope of mental health and substance abuse
problems that have affected the hurricanes’ victims, or whether it is more narrowly
targeted to PTSD, remains to be seen.
Scope of Mental Health Services under CCP. Survivors of a disaster
often need a range of mental health services that go beyond those provided for by
CCP, which only provides referral to mental health services.
Neither the Stafford Act nor FEMA’s regulations clearly articulate or restrict the
scope of “professional counseling services” as stated in the act, or “individual and53
group treatment procedures” as stated in the regulations. These terms do not clearly
relate to specific services delivered in the field of mental health. However,
SAMHSA makes matters more clear in its guidance, explaining that CCP is not
intended to provide mental health treatment, which it describes in clinico-legal terms
as involving a diagnosis and other activities that may only be carried out by state-
licensed providers. According to SAMHSA:
In contrast to the crisis counseling services provided through the CCP, mental
health treatment ... implies the provision of assistance to individuals for an
existing pathological condition or disorder. In this context, it involves providing
a variety of interventions following the assignment of a diagnosis .... This
diagnosis is made following an evaluation and/or psychological testing by a
licensed mental health professional. ... During treatment, the provider maintains
a documented treatment plan and record. The mental health professional is
licensed by the State and is protected by, and is subject to, a wide variety of legal
matters including malpractice, informed consent to treatment, confidentiality,54
and patient/therapist privilege.
SAMHSA notes that “the thrust of the (CCP) since its inception has been to
serve people responding normally to an abnormal experience,” and that the services
funded focus on individual and group counseling, education and referral, and training
of counselors.55 CCP’s scope of services do not, therefore, provide disaster victims
with medications, office-based therapy, diagnostic services, psychiatric treatment, or
inpatient and outpatient services for mental health conditions that are caused or
aggravated by the disaster. CCP funds are not intended to support long-term or
traditional mental health or substance abuse services.
As compared with several other federal programs, SAMHSA’s definition of
“individual and group treatment procedures” for CCP is narrow, and the types of
mental health services available under CCP are limited. For example, in the context
of reporting the number of people receiving mental health services, SAMHSA’s
Office of Applied Statistics’ (OAS) definition of mental health treatment/counseling56


includes inpatient and outpatient care, as well as some prescription medication.
53 44 CFR § 260.171(b)(3).
54 CCP program guidance.
55 Ibid.
56 SAMHSA, “Estimated Numbers (in Thousands) of Persons Aged 18 or Older Receiving
(continued...)

Medicare includes, in the mental health services that it covers, outpatient and
in-hospital programs, as well as treatment for mental health problems.57 The U.S.
Courts include inpatient and outpatient counseling and medication in their definition
of mental health treatment, in the context of services provided to individuals on
probation, parole or awaiting sentencing period.58 (For a more comprehensive
description of the services and treatment venues included under the term “mental
health treatment,” see Appendix C.)
In a recent news story, a psychologist in Florida questioned whether CCP
counselors who were not formally trained in diagnosis could accurately screen
disaster victims, and whether their lack of professional expertise could at times
jeopardize the welfare of those receiving services.59 However, assuming that CCP
services are potentially beneficial, limiting services to those provided by licensed
professionals would likely make the program more costly, and be hampered by the
limited numbers of these professionals.
In Project Liberty, CCP services were expanded to provide enhanced screening
methods and a broader array of brief counseling approaches, for individuals who
continued to experience trauma symptoms and functional impairment after initial
crisis counseling.60 In August 2006, the Senate Committee on Homeland Security
and Governmental Affairs reported S. 3721, the Post Katrina Emergency
Management Reform Act of 2006. Section 219 of the bill would amend Section 416
of the Stafford Act, expanding the scope of CCP to include substance abuse services.
There has been no corresponding legislation introduced in the House. The possible
costs of such an expansion are not known.61
Duration of Mental Health Services under CCP. While post-disaster
mental health needs may persist for quite some time, CCP is designed as a “short-


56 (...continued)
Specific Types of Mental Health Treatment/Counseling in the Past Year, by Demographic
Characteristics: 2000 and 2001,” 2003, at [http://www.oas.samhsa.gov/nhsda/2k1nhsda/
vol3/Sect8v1_PDF_W_35-40.pdf].
57 Center for Medicare and Medicaid Services, “Medicare and Your Mental Health
Benefits,” CMS publication no. 10184, Apr. 2002, at [http://www.medicare.gov/
publications/pubs/pdf/mental.pdf].
58 Administrative Office of the U.S. Courts, “Commonly Used Terms,” at [http://www.
uscourts.gov/library/glossary.html ].
59 Comments of Charles Figley in Sally Kestin, “FEMA Spends Millions on Puppet Shows,
Bingo and Yoga,” South Florida Sun-Sentinel, Oct. 8, 2006.
60 Government Accountability Office, “Crisis Counseling Grants Awarded to the State of
New York after the September 11 Terrorist Attacks,” GAO-05-514, May 2005.
61 The U.S. Congressional Budget Office (CBO), in its cost estimate for S. 3721, noted that
it could not estimate the additional costs associated with amendments to the Stafford Act’s
assistance programs because it cannot predict the timing and severity of future disasters.
See CBO, “S. 3721, Post-Katrina Emergency Management Reform Act of 2006,” cost
estimate for the bill as reported by the Senate Committee on Homeland Security and
Governmental Affairs on August 3, 2006, p. 6, Sept. 18, 2006.

term” intervention.62 Disasters may impose substantial long-term adverse mental
health effects. Residents in affected areas are expected to develop high rates of
mental health disorders, including post-traumatic stress disorder (PTSD), depression
and anxiety. As defined by the VA’s National Center for Post Traumatic Stress
Disorder (NCPTSD), diagnosis of and treatment for chronic PTSD typically starts at
three months, while delayed onset PTSD is known to set in more than six months
after the disaster.63 Weisler et al. have commented that due to limitations on CCP,
mental health services in the states affected by Hurricane Katrina are lacking when
they are most needed.64 Some Louisiana mental health providers have commented
that up to one-third of the people affected by the storm may have PTSD, but that
most have not been able to receive treatment.65
CCP is intended to supplement, not replace, permanent state and local (public
and private) mental health resources. The budgetary and related authority for CCP,
and the limitations in the length of services provided, are laid out in FEMA’s
regulations. CCP RSP grants provide crisis counseling services for individuals
affected by a disaster for a time period ranging from 60 days to nine months
following the disaster. FEMA may grant an additional 90-day extension upon
request. SAMHSA and FEMA expect that individuals with needs that extend beyond
the duration of CCP will be referred to other agencies or services that provide the
appropriate treatment.66
In March 2003, following its experiences with Projects Heartland and Liberty,
FEMA amended its regulations to allow extensions of CCP Regular Services
programs beyond the nine-month-plus-90-day limit, in limited circumstances (such
as disasters of a catastrophic nature), upon the request of a state, when FEMA deems
it to be in the public interest.67 Extending the duration of RSP programs has fiscal
implications for FEMA and the DRF.
Even before FEMA amended its regulations, on two previous occasions — for
Project Heartland and Project Liberty — the duration of CCP services was extended
beyond the nine-month-plus-90-day limit. Because Project Heartland was the first
community mental health response to a large-scale terrorist event in the United
States, there was no previous experience to establish and deliver services for
psychological trauma caused by terrorism. Project Heartland found that traditional
crisis counseling techniques were not sufficient, and new approaches were developed
to reach survivors. FEMA extended funding for Project Heartland three times before


62 44 CFR § 260.171(c)(1).
63 Department of Veterans Affairs, NCPTSD, “What is Posttraumatic Stress Disorder?” July

20, 2006, at [http://www.ncptsd.va.gov/facts/general/fs_what_is_ptsd.html].


64 R.H. Weisler et al., “Mental Health and Recovery in the Gulf Coast After Hurricanes
Katrina and Rita,” JAMA, vol. 296, no. 5, August 2006.
65 Kim Dixon, “Post-Katrina Stress Still Weighs on New Orleans,” Reuters Health E-Line,
Feb. 15, 2006.
66 CCP program guidance.
67 44 CFR § 206.171(g)(4)(i).

it ended on February 28, 1998. Until Project Liberty, this was the longest Regular
Services project FEMA had ever funded.68 Project Liberty, which was created in

2001, received numerous extensions and is still in operation.69


The time extensions for Projects Heartland and Liberty, and the extensions now
being considered for CCP programs in many states in response to Hurricane Katrina,
reflect uncertainty about the appropriate duration of CCP services. Such uncertainty
is likely to persist until the knowledge base regarding the long-term mental health
effects of these programs improves.
Treatment for Co-occurring Disorders under CCP. It has been
observed that many individuals who need mental health care are also in need of
treatment for substance abuse. However, CCP funding does not support substance
abuse treatment services, thus separating treatment for mental health and substance
abuse problems. SAMHSA’s guidance recommends referring people with substance
abuse disorders to specialized providers, because the mental health system, of which
crisis counseling is a part, may not be the most appropriate and qualified to provide
these services. In 2000, Congress directed SAMHSA to report on prevention and
treatment services for individuals who have co-occurring mental illness and
substance abuse disorders, and to realign its block grant programs to better meet the70
needs of these individuals. While the effort to coordinate routine services in the
states could lead to better coordination when states set up post-disaster CCP
programs, as of 2005, only 14 states and the District of Columbia had received
SAMHSA grants to address co-occurring disorders.71
Some have recommended that CCP outreach workers be trained to work with
individuals with substance abuse disorders. Training CCP workers in substance
abuse treatment would enable individuals with co-occurring disorders to receive both
services simultaneously and in the same location. However, the substance abuse
treatment services they receive from CCP workers, who are not specialists in the
area, may not be optimal for their condition, and may lead to a delay in individuals
receiving specialist services.
As discussed earlier (See “Scope of Mental Health Services under CCP”), S.
3721, reported in the Senate, would amend the Stafford Act, expanding the scope of
CCP to include substance abuse services.


68 U.S. Department of Justice, “Responding to Terrorism Victims: Oklahoma City and
Beyond,” Oct. 2000, in Chapter 3 of [http://www.ojp.usdoj.gov/ovc/publications/infores/
respterrorism/].
69 New York City Department of Education, Project Liberty home page, at [http://www.
proj ectliberty.state.ny.us/].
70 P.L. 106-310, the Children’s Health Act of 2002. See also, SAMHSA, “Report to
Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and
Mental Disorders,” Nov. 2002, at [http://www.samhsa.gov/reports/congress2002/ index.
html].
71 SAMHSA, Co-occurring State Incentive Grants (COSIG) page, at [http://www.coce.
samhsa.gov/about/index_right.aspx?obj =7].

Fiscal Year Limits on Availability of SERG Funds
In creating authority for emergency mental health and substance abuse (SERG)
grants in 2000, Congress authorized SAMHSA to reallocate up to 2.5% of its
discretionary appropriations for this purpose in a given fiscal year. The agency may
determine, based on its planned obligations for a fiscal year, that the actual amount
it could make available may be less than the 2.5% permitted. Also, as a fiscal year
progresses, the agency would have available to it fewer funds from which a
reallocation could be made. Because Hurricanes Katrina and Rita occurred at the end
of FY2005, SAMHSA had only $600,000 that it could make available for SERG
grants.
As the timing of the emergencies for which the program is designed are often
unpredictable, Congress may consider options to give SAMHSA more fiscal
flexibility in making SERG grants. These include giving the agency the authority to
fund in advance, up to the 2.5% ceiling, based on the total appropriation for the
current fiscal year, and clarifying a mechanism by which SERG awards could be
made when the agency was functioning under a continuing appropriations resolution.
Each approach carries the risk that the awards made could erode the agency’s budget
for the subsequent fiscal year.
SAMHSA could also finance emergency response grants through the Public
Health Emergency Fund, a no-year funding authority provided by Congress to the
HHS Secretary upon his determination of a public health emergency.72 The fund has
not received a recent appropriation, however, and contains no monies. As a
consequence, the fund was not available for any aspect of the responses to the 2005
hurricanes.
Assessment of Resources and Long-term Needs
Some immediate needs assessments and resource assessments were carried out
by states and federal agencies in the aftermath of the hurricanes. However, there have
been no longer-term assessments and none are statutorily required.
An assessment of resources and needs in the initial stages of disaster response
can improve cost-effective disaster response through prioritization, program planning
and management. As individuals return to their homes and start rebuilding their lives
in the months following a disaster, it would be helpful to reassess the mental health
needs of the community and the state’s resources to meet those needs. In other words,
conducting a follow-up needs and resources assessment can provide a better
understanding of the resources needed to meet the longer-term mental health needs
of the community.
The transition from immediate to long-term disaster mental health services can
be a complex and bureaucratic process, often involving multiple providers with
varying levels of expertise and training. Experts believe that the field of disaster


72 For more information, see CRS Report RL33579, The Public Health and Medical
Response to Disasters: Federal Authority and Funding, by Sarah A. Lister.

mental health should match the intensity of help with survivors’ need.73 A higher
intensity of help may reach those at greatest need if initial and follow-up needs
assessments are conducted.
Needs assessments are required by FEMA’s regulations and SAMHSA’s
guidance, not by the Stafford Act. The Stafford Act does not assign responsibility for
conducting an initial or a follow-up needs assessment. FEMA regulations assign the
responsibility to state governors or their designees.74 SAMHSA guidance provides
greater detail about the initial needs assessment, along with the formula that the state
must use. The requirement to conduct an initial assessment of resources is implicit
in the application for CCP funds: states are required, in their ISP and RSP
applications, to document that their capacity is inadequate to meet the needs created
by the disaster. Also, for the RSP, the guidance requires that states incorporate
FEMA damage assessments into their assessments of mental health and crisis
counseling needs.75
Several initial needs assessments were conducted in the aftermath of the
hurricanes. Following Hurricane Katrina, SAMHSA streamlined the needs-
assessment requirement for states applying for CCP funding. As part of this
streamlined process, states used only preliminary data to submit a needs and
resources assessment for counseling services, as part of their CCP application. In
two separate surveys in October 2005, SAMHSA projected the potential overall
mental health needs of those impacted by the hurricanes, and the CDC conducted a
survey of returning New Orleans residents. SAMHSA estimated that 500,000
residents may have needed mental health assistance, and CDC found that 83%
percent of returning New Orleans residents indicated some need for mental health
assi st ance.76
No longer-term needs assessments have been conducted and none are statutorily
required. A follow-up needs assessment could document the chronic mental health
needs of the survivors and inform the development of a strategy to address these
needs, using public and private resources. States are not required to submit any
follow-up needs or resources assessments in the months following the disaster.
However, states are required to submit a report on how CCP funds were used. While
FEMA’s regulations provide for a mechanism for extension of RSP, they do not
explicitly require a follow-up needs assessment to accompany the application for
extension. Rather, the regulations only require states, for “documented extraordinary
circumstances,” to justify their need for extension of RSP.


73 B.H. Young et al., “Disaster Mental Health: Current Status and Future Directions,” New
Directions for Mental Health Services, No. 82, Summer 1999, pp. 53-64.
74 44 CFR § 206.171(d).
75 SAMHSA, Supplemental Instructions for the Regular Services Program, at
[ h t t p : / / d o w n l o a d . n c a d i . s a mh s a .gov/ken/msword/RSP%20Supplemental%20Ins t r u c t i o n s .
doc].
76 CDC, “Assessment of Health-Related Needs After Hurricanes Katrina and Rita — Orleans
and Jefferson Parishes, New Orleans Area,” MMWR, vol. 55, no. 2, Jan. 20, 2006.

In August 2006, the Senate Committee on Homeland Security and
Governmental Affairs reported S. 3721, the Post Katrina Emergency Management
Reform Act of 2006. Section 219 of the bill would require that SAMHSA, other
relevant federal agencies, and state and local governments, conduct resource
assessments and develop strategies to address mental health and substance abuse
service needs following disasters. There has been no corresponding legislation
introduced in the House. (S. 3721 would also expand CCP to cover substance abuse
services. See the prior section, “Scope of Mental Health Services under CCP.”)
Conclusion
Hurricane Katrina was one of the most devastating natural disasters in the
nation’s history. One year later, Congress and others continue to study the adequacy
of the response and approaches for future improvement. The field of disaster mental
health continues to evolve with lessons learned from the 2005 hurricanes and their
aftermath.
The 2005 hurricanes prompted, once again, a familiar set of questions. What
types of mental health and substance abuse problems are victims likely to face after
a disaster? How long might these problems last, and how might they change over
time? Are there interventions that are likely to be of benefit? If so, when should they
be delivered, and by whom? How can victims who would benefit from assistance be
identified, and how should they be monitored? What can the federal government
offer, through assistance to states, individuals, and others, that would be helpful to
victims in enabling them to recover and move on with their lives? The federal
programs set up to address mental health and substance abuse problems in those
affected by the 2005 hurricanes offer opportunities for scrutiny. Careful study of
these programs, and those established after the Oklahoma City bombing and the 2001
terrorist attacks, could lend clarity to, and improve the effectiveness of future federal
responses.



Appendix A.
Table A. State CCP Awards
(dollars in thousands)
Hurricane KatrinaHurricane RitaHurricane Wilma
St a t e
ISP R SP ISP R SP ISP R SP
Alabamaa, b 3,136 2,189 NA NA NA NA
Ar ka nsa s b 3 4 9 5 3 2 NA NA NA NA
Arizona 236 0 NANANANA
California 1,04 0 NANANANA
Co lo r a d o b 348 1,167 NA NA NA NA
District of Columbia470NANANANA
Flo r id a a, b 2,712 6,900 NA NA 3,312 9,740
Geo r gia b 1,080 3,059 NA NA NA NA
Iowab 2 4 4 2 0 7 NA NA NA NA
I llino isb 3 6 8 6 4 3 NA NA NA NA
Indianab 1 9 3 6 9 0 NA NA NA NA
K e nt uc ky 2 8 5 0 N A N A N A N A
Lo ui s i a n a a, b 21,248 36,797 0 2 ,308 NA NA
Maryland b 3 8 6 6 6 0 NA NA NA NA
M i sso ur i b 5 4 2 5 4 5 NA NA NA NA
M i ssissip p i a, b 4,403 19,975 NA NA NA NA
Neb r aska b 8 3 2 5 7 NA NA NA NA
New Jersey200245NANANANA
Nevad 10 0 NANANANA
Ohio 58 0 NANANANA
Oklahoma 36 0 NANANANA
P e nnsyl va ni a b 312 1,103 NA NA NA NA
Rhode Island400NANANANA
Tenese 128 0 NANANANA
Texasb 5,596 12,128 651 3,094 NA NA
Utah 1 0 4 2 4 5 NA NA NA NA
Washington 129 0 NANANANA
Wisconsin 203 433 NA NA NA NA
West Virgnia460NANANANA
TOTAL 43,856 87,776 651 5,402 3,312 9,740
DISASTER TOTAL131,6326,05313,052
Source: SAMHSA Office of Legislative Affairs, as of Oct. 18, 2006.
Notes: Numbers may not add due to rounding; ISP = Immediate Services Program; RSP = Regular
Services Program; NA = Not Applicable.
a. Denotes states that received Stafford disaster declarations for Hurricane Katrina, and which may
have received CCP awards both for declared” counties as well as for services for evacuees who
relocated to “undeclared” counties. States that are not marked did not receive major disaster
declarations for Hurricane Katrina, but hosted evacuees from areas that did, and were therefore
eligible for CCP awards.
b. Denotes states that have requested RSP program extensions.



Appendix B.
DRF Allocations for CCP
Since the fall of 2005, FEMA has provided weekly reports to Congress on its
allocations from the Disaster Relief Fund (DRF) for CCP activities in response to
Hurricanes Katrina, Rita and Wilma. The weekly reports provide budget lines for
“Crisis Counseling - NIMH” and “Crisis Counseling - SCC” for each disaster. SCC
is not defined. NIMH is the National Institute of Mental Health, an Institute in the
National Institutes of Health (NIH) which administered CCP in the past. NIMH staff
have told CRS that the institute does not administer CCP at this time, and has not
received the reported funds from FEMA.77
FEMA has advised that its reported SCC amounts correspond with SAMHSA’s
Immediate Services Program (ISP) awards — amounts that FEMA provides directly
to states — and that its reported NIMH amounts correspond with SAMHSA’s
Regular Services Program (RSP) awards — amounts that FEMA provides to
SAMHSA.78 FEMA accounts for the discrepancy between its reported NIMH
allocations and SAMHSA’s reported RSP awards by noting that the RSP awards
reflect amounts that have been approved, while the FEMA allocations reflect current
information about states’ use of the funds. The latter is subject to a lag in reporting,
and is further complicated by requests for program extensions that have been made
by many states.
The table below shows amounts for CCP spending for the three disasters, as
reported to CRS by SAMHSA, and as published by FEMA in its weekly reports to
Congress.


77 NIMH Office of the Director, August 29, 2006. NIMH has not administered the CCP
since the early 1980s, but is still cited in FEMA regulations as the HHS liaison agency for
the program.
78 FEMA Office of Legislative Affairs, November 10, 2006.

Table B. CCP Funding for the 2005 Hurricanesa
(dollars in thousands)
Awards Reported by SAMHSAAllocations Reported by FEMA
I S P RSP TO TAL S CC NI M H TO TAL
Hurricane Katrina
43,856 87,776 131,632 40,210 43,036 83,246
Hurricane Rita
651 5,402 6,053 1,557 4,355 5,912
Hurricane Wilma
3,312 9,740 13,052 2,424 8,247 10,671
TOTAL for three disasters
47,819 102,918 150,737 44,191 55,638 99,829
Source: Amounts reported by SAMHSA were provided by the SAMHSA Office of Legislative
Affairs, as of October 18, 2006, as shown in Appendix A. Amounts reported by FEMA are from
the Department of Homeland Security, Federal Emergency Management Agency, “Weekly
Disaster Relief Fund (DRF) Report,” weekly report to Congress, October 4, 2006, stating
amounts as of October 4, 2006.
Note: Numbers may not add due to rounding.
a. Beyond the explanation provided in earlier text in this Appendix, CRS is unable, at this time, to
explain discrepancies in the amounts provided by FEMA and SAMHSA.



Appendix C.
Scope of Mental Health Treatment Services
Mental health treatment is a term that has been used in the fields of psychology
as well as psychiatry. While psychiatric services typically include a greater emphasis
on pharmacotherapy, mental health services in the aftermath of Hurricane Katrina
were primarily psychological. In this context, mental health treatment can include any
or all of the following services:
Education and prevention services. Information on predictors and symptoms
of mental disorders, where mental health services are available, how to access them.
Emergency services. Immediate response service available 24-hours a day for
persons having a mental health crisis, or emergency. This includes the National
Suicide Prevention Lifeline, 1-800-273-TALK (8255).
Case management services. Functional assessment, individual community
support plan, referral and assistance in getting mental health and other services,
coordination of services and monitoring of the delivery of services.
Rehabilitative and community support services. Services which enable
individuals with serious and persistent mental illness to develop and enhance
psychiatric stability, social competencies, adjustment, and independent living and
community skills.
Assertive Community Treatment (ACT). Intensive, non-residential
rehabilitative evidence-based mental health service provided by multidisciplinary
staff.
Treatment venues may include the following:
Outpatient treatment. Individual, group and family therapy; individual
treatment planning; diagnostic assessments; medication management; and
psychological testing.
Day treatment. Short-term structured program consisting of therapeutic
services to stabilize a recipient’s mental health status while developing and
improving his/her independent living and socialization skills.
Residential treatment. 24-hours-a-day program provided under the clinical
supervision of a mental health professional, in a community residential setting other
than an acute care hospital or regional treatment center inpatient unit.
Partial hospitalization. Time limited, structured program of therapeutic
services provided in an outpatient hospital facility or Community Mental Health
Center to resolve or stabilize an acute episode of mental illness.
Acute care hospital inpatient. Short-term medical, nursing and psychosocial
services provided in an acute care hospital.
Regional treatment center inpatient. Twenty-four-hours-a-day comprehensive
medical, nursing, or psychosocial services provided in a regional treatment center.
Specialty mental health services. Services provided by mental health
providers that focus on mental health issues related to specific cultures or languages,
including the deaf and hearing impaired.