The attack on the World Trade Center the morning of September 11, 2001, was
the deadliest terrorist act ever committed on U.S. soil. Arriving at a final
tally of the dead— about 2,800—stretched out agonizingly for
months, and confirming victims' identities seemed like a never-ending puzzle.
But if it is possible that something good can come out of something almost too
horrible to imagine, it is this: officials of the New york State Office of
Mental Health (OMH) knew that many people would be severely traumatized by the
attack and realized the importance of providing mental health assistance
quickly. They also realized they had an unprecedented opportunity to learn
lessons that could inform future disaster-response plans.
"Disasters present terrible opportunities to learn about how to get
people needed mental health services," said Susan Essock, Ph.D., a
professor of psychiatry and director of the Division of Health Services
Research at Mount Sinai School of Medicine in New york City.
Essock collaborated with OMH staff on the development and implementation of
Project Liberty, New York state's crisis counseling program.
Project Liberty, funded by grants totaling $155 million from the Federal
Emergency Management Agency (FEMA), quickly became the largest federal
government-funded disaster mental health program in history. New York's OMH
took the lead in implementing the program in collaboration with approximately
200 local agencies.
The Project Liberty program was implemented to "provide free and
anonymous community-based mental health services to help individuals recover
from their psychological distress and regain their predisaster level of
functioning," according to project literature. The services offered were
based on the assumption that most people's stress reactions, although
significantly disturbing to them personally, constituted normal responses to a
traumatic event, and that the reactions would dissipate over the short
As such, the range of interventions offered under Project Liberty was aimed
at helping people identify their trauma responses, understand that those
responses were normal, and reconnect with previously existing social support
"One of the fundamental things we learned," said Chip Felton,
M.S.W., an OMH senior deputy commissioner and chief information officer for
OMH's Center for Information Technology and Evaluation Research, "was
that it proved possible to set up and run a very large crisis counseling and
emergency mental health program and that, in fact, it seemed to be something
that really resonated with a large number of people."
The September issue of the APA journal Psychiatric Services
presents a special section containing a series of 15 reports detailing data on
numerous aspects of the project, from demographic characteristics of those who
used Project Liberty services to data on outcomes of interventions and quality
assurance/quality improvement metrics.
According to those reports, between the time of Project Liberty's launch in
the weeks following September 11 and the point when its services ceased on
December 31, 2003, Project Liberty provided face-to-face counseling and
educational and outreach sesrvices to an estimated 1.2 million individuals in
the New York City metropolitan area. About 465,000 individuals received nearly
690,000 individual crisis counseling sessions. Almost 550,000 individuals were
provided public education on trauma.
Just under 700 counseling and educational sessions were provided in
September 2001, and the number of sessions each month almost doubled through
April 2002. The project reached its peak during May 2002, during which 41,000
sessions were provided to individuals by Project Liberty counselors. Service
utilization remained near that level through August 2003, when the project
began its phase-down in preparation for its cessation at the end of 2003 (see
For those with mild to moderate symptoms, "crisis counseling"
under Project Liberty ranged from informal sessions with counselors that
included simply discussing and validating a patient's feelings to more
structured sessions focusing on recovery skills, coping mechanisms, and
reliance on social-support networks.
By early summer 2002, it became apparent to Project Liberty staff that
there was a group of individuals who were repeatedly showing up, looking for
help. Felton and his colleagues decided to seek permission from federal
regulators to expand the scope of Project Liberty to offer more intensive
crisis counseling. Regulators approved offering enhanced services, which
included a cognitive-behavioral intervention that was specifically developed
to treat posttraumatic stress (see article on facing
In total, 753,015 counseling and educational sessions were provided between
September 2001 and December 2003.
"We found that as part of putting together this large, overall
infrastructure supporting a very-large-scale public health initiative, it was
in fact feasible to collect anonymous but key pivotal data from thousands of
people who served as crisis counselors," Felton told Psychiatric
News. "Those data were important to us in many different ways as we
tried to manage the ongoing program, and hopefully in the longer term, [we
will all be] more prepared for disaster response in the future."
In a "Taking Issue" column in the September Psychiatric
Services, Betty Pfefferbaum, M.D., J.D., a professor of psychiatry at the
University of Oklahoma Health Sciences Center, and Bradley Stein, M.D., Ph.D.,
a visiting associate professor of psychiatry at the University of Pittsburgh
School of Medicine and Western Psychiatric Institute and Clinic, wrote,"
The reports from Project Liberty in this issue of Psychiatric
Services attest to the wealth of experience and the explosion of
knowledge and understanding gained in work associated with the September 11,
2001, terrorist attacks.
"Disaster mental health care has evolved, and its growth is reflected
in the ability to respond to succeeding disasters of increased dimensions in
the context of more complex and devastated environments. Research is also
"The reports from Project Liberty show us how far we've come,"
Stein told Psychiatric News. The field of disaster response has
significantly improved compared with where the field of disaster response was
10 years ago, he said.
"In particular, the federal response has matured," Stein
explained. "When you get federal regulators, researchers, state
officials, and counseling providers together, it is indeed possible to build
quality indicators into a disaster response program."
Project Liberty was the first FEMA-funded disaster response program to
include quality assurance/quality improvement measures.
Felton, Essock, and their colleagues requested that the federal Substance
Abuse and Mental Health Services Administration (SAMHSA) specifically allocate
funds for program evaluation.
"The data analysis was as close to real time as we could get with a
paper-based reporting system," Felton explained. Every two weeks,
Project Liberty leaders got a new feed of data from the service
"We were able to use that information, not just centrally as the
state mental health authority administering the program," added Sheila
Donahue, M.A., who served as the director of Project Liberty, "but also
to provide the data to the counties and at the individual provider level on an
The federal investment in the evaluation structure needed to collect this
information and use it in proactive ways was absolutely vital and led to a
significant pay off, said Donahue, who is currently the director of data
analysis and performance measures at the New York OMH.
"Of course, we were pleased with how the quality assurance measures
in Project Liberty worked," Felton noted. "But one of the things
that is not mentioned in any of the Psychiatric Services articles is
that today, if you look at SAMHSA's Center for Mental Health Services toolkit
for crisis counseling programs, you will see that some of the Project Liberty
assessment tools are now included as recommended tools."
The Psychiatric Services special section on Project Liberty
is posted at<www.ps.psychiatryonline.org>.▪