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. 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, and Manhattan residents reported increases in smoking, alcohol consumption, and marijuana use. 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. 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. 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.” 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. The Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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; 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. 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. For example, the agency obligated about $13 million and $129,000 for Texas and Washington, respectively. At SAMHSA’s request, VA’s National Center for PTSD (NCPTSD) conducted an evaluation of CCP and provided its report in June 2005. 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. 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. 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; the total amount awarded to each individual state ranged from about $105,000 to about $200,000. 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, and DHS provided about $12.1 billion in grants to states and localities for broad preparedness efforts. CDC and HRSA require that states document how they plan to engage in certain mental health and substance abuse preparedness activities, 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. 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. 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 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. 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, 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. 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. 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 stronger partnership for planning and response among state mental health and substance abuse services agencies; an increased number of unified plans that encompass both mental health and substance abuse services issues; stronger partnerships with key stakeholders such as emergency management, public health agencies, and voluntary organizations that are active in disasters; and clearer identification and articulation of the disaster response role of state mental health and substance abuse agencies. 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. 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. 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. 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. 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. In response, HHS organized U.S. Public Health Service Commissioned Corps officers 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.) 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. 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. 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. 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. 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. 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 caused difficulties for state CCPs. They also described the need for expanded crisis counseling services and cited additional concerns. 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. 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. 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 and Hazard Mitigation Grant Program. 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. The Inspector General recommended that FEMA review its policy on reimbursement for indirect costs. 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. 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. 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. 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 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 2008. Mississippi, which focused on providing expanded services to adults, 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. 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. 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. 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. 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. 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. 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. 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. 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. 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: determine what types of expanded crisis counseling services should be formally incorporated into CCP and make any necessary revisions to program policy, and revise CCP policy to allow states and service providers that receive CCP funds to use them for indirect costs. 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, 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. 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. 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. 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 bascettac@gao.gov. 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. 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, 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; 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. 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. 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. 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 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. To identify other federal programs that have supported mental health and substance abuse services in response to catastrophic disasters, we reviewed GAO reports, Congressional Research Service reports, 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. 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. 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. SAMHSA awarded funds through its Emergency Response Grant (SERG) program following Hurricane Katrina. 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. 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. For example, following the 2001 terrorist attacks, New York used Project SERV funds to provide counseling and after-school mental health services. 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. 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. 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. 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. 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. (See table 2 for information on the amount of claims submitted by states, including four states that were in our review.) 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. 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. 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. We have previously reported on the progress of these programs. 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. These services included assessments, individual counseling, group therapy, specialized substance abuse treatment, and case management. 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. September 11: Problems Remain in Planning for and Providing Health Screening and Monitoring Services for Responders. 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. 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. 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. 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. GAO-07-193. Washington, D.C.: March 28, 2007. Public Health and Hospital Emergency Preparedness Programs: Evolution of Performance Measurement Systems to Measure Progress. 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. 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. GAO-05-514. Washington, D.C.: May 31, 2005. Hurricane Katrina: Status of Hospital Inpatient and Emergency Departments in the Greater New Orleans Area. 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. GAO-02-813. Washington, D.C.: August 22, 2002.

Summary: 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. 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.