Concerns about the potential long-term mental health needs created by the Pentagon attack on September 11, 2001 and subsequent events raised concerns about the local system's capacity to respond. These concerns led to the establishment of the Mental Health Community Response Coalition, which has met regularly since September 23. The primary purpose of the Mental Health Community Response Coalition has been to provide vital opportunities for networking and information exchange between military service providers, the American Red Cross, local mental health agencies, and others. Prevention of duplication and overlap of services among different agencies has also been an important focus of the group. This paper outlines the structure of the coalition and lessons learned for the development of a coordinated mental health effort in response to a community crisis.
Introduction
Within hours of the Pentagon attack on September 11, mental health professionals from the metropolitan Washington, DC area were mobilized to respond. Through the efforts of the military, the local Red Cross chapters, local and state mental health systems, and others, mental health professionals were brought to the Pentagon crash site, the family assistance center, and the airport where American Airlines Flight 77 originated to provide services appropriate for the respective settings. These workers were soon supplemented by mental health workers from other regions under the auspices of the military and the American Red Cross (ARC).
Although the outpouring of assistance from mental health professionals was an effective short-term solution to the needs created by the terrorist attack, it quickly became apparent to onsite personnel that the potential long-term mental health needs created by the attack might easily overwhelm the local system's capacity to respond. In addition, the risk of duplication of some services while others remained in short supply was of increasing concern to the early responders. Addressing these issues prior to the departure of nonlocal service providers terminating their assignments was a primary focus for some of the local and nonlocal mental health professionals responding to September 11th.
As ARC disaster mental health volunteers addressed requests for crisis interventions in the community, the fragmentation of the mental health delivery system and the overlap of services provided within it became apparent. With this in mind, Red Cross mental health responders initiated a meeting with key personnel from a number of stakeholders in the affected community to discuss long-term mental health concerns and to develop strategies and networks to address them. The first meeting, on September 23, involved volunteers whose professional affiliations included the Washington, DC and Virginia Disaster Response Network, the Capitol Area Crisis Response Team, the National Mass Fatalities Institute, and the American Psychological Association. By its next meeting, this group had expanded to include representatives from the Pentagon and other critical stakeholders, such as local Community Service Boards and mental health professional guilds. Over time, this group named itself the Mental Health Community Response Coalition (MHCRC). It has met regularly since then, holding a total of 10 meetings before the 6-month anniversary of the event.
The Formation of the MHCRC
Within days of the Pentagon attack, requests for assistance began coming to the ARC from highly impacted groups such as civilian Pentagon workers in departments located outside of the Pentagon, subcontracting companies, and airline employees. During the week after the attack a group of ARC Disaster Mental Health volunteers were assigned to handle requests that were beyond the usual ARC disaster services, such as structured group interventions at worksites, but were still within ARC's purview. As the number of requests grew, however, a more comprehensive approach was clearly needed, including a better triage system to identify whom the ARC should serve, and how referrals should be made to other agencies. The need to determine what agency was serving whom, how referrals could be made, and how to reach out to 'hidden' groups formed the impetus for a meeting of stakeholders. The work at the crash site and the family assistance center had already brought many of the various local military and civilian mental health service providers into contact with one another, so it was relatively easy to identify key stakeholders who should participate in this discussion.
Once the need for a meeting was established, it was agreed that the foci for discussion should be coordinating services and addressing unmet needs. Considering the number of volunteer, public, private, military, and other government agencies involved in the immediate emergency response, fragmentation of services was an inevitable result. Some victims and families were almost inundated with opportunities to receive assistance through various mechanisms, whereas others were virtually ignored. Thus, a goal of the meeting was to avoid duplication of effort through developing a better understanding of what each organization was currently doing and how to facilitate collaboration and referral. The discussion of unmet needs focused on potentially overlooked groups such as children, non-English speakers, unidentified witnesses to the crash, and friends of the primary victims. Whereas the first meeting was initially planned as a one-time occurrence, the discussion of both of these topics made it clear that more people needed to be at the table, at a minimum, to facilitate future communication between all the parties.
The meetings were initially convened by individuals who functioned as representatives of the ARC national organization and were not themselves local stakeholders. In this way, the meetings were able to avoid being over-identified with a particular individual, organization, discipline, or population. This facilitated invitations to a broader spectrum of participants without raising the specter of territoriality, and the coalition was able to expand in successive meetings on September 28 and October 5.
Evolution of the Coalition
The first confirmed death from inhalation Anthrax occurred in Florida on October 4. On October 15, the White House verified that a letter containing Anthrax had been sent to Senate Majority Leader Tom Daschle. Within a week, two Washington postal workers were dead and 31 Capitol Hill staff had tested positive for exposure to the disease. The main Washington, DC post office as well as post offices at the Pentagon and other sites were closed after traces of the Anthrax spores were found in their equipment. These events, following so soon after September 11, heightened the level of anxiety in the metropolitan Washington, DC community. Consequently, the focus of the meeting expanded to include discussion of planning and preparedness with goal-directed collaboration taking on greater urgency. The list of attendees soon expanded to include representatives from groups such as the U.S. Air Force, the U.S. Army, Walter Reed Army Medical Center, the Pentagon Employee Referral Service, the Pentagon Operation Solace, Project Resilience Arlington, the Community Foundation for the National Capitol Area Region's Survivors Fund, the National Recreation and Parks Association, the National Education Association's Health Information Network, the Washington, DC Department of Mental Health, the National Association of Social Workers' Metro DC chapter, the American Psychological Association Disaster Response Network, the American Red Cross, the Washington, DC Department of Mental Health, the Washington Psychiatric Society, the U.S. Department of Health and Human Services, the federal Substance Abuse and Mental Health Services Administration, and the U.S. Senate Health Committee.
Although the situation faced by the Washington area was unique, the development of such a coalition is not without precedent. Many communities have established inter-organizational meetings to respond to emergent needs after a community crisis. In Oklahoma City, for example, the Resource Coordination Committee (RCC) was established following the bombing of the Murrah federal building, bringing together representatives from over 40 organizations to address unmet needs of disaster survivors.1 This coalition also developed after concerns of the community began to shift from immediate crisis needs to the long-term needs of people affected by the disaster. The RCC's effectiveness came from its ability to provide coordinated services and resources to individuals and families recovering from the disaster. Although not intentionally modeled after RCC, the MHCRC developed in a similar fashion.
From the beginning, the emphasis of the MHCRC meetings was on exchanging information and creating networks that would facilitate future collaboration between the parties involved. Initially, information exchange was the critical component of each meeting. Many of the individuals in attendance had limited knowledge of services provided by other organizations, skills of their personnel, and procedures to be followed to make referrals. The exchange of resources included dissemination of relevant research articles, informational pamphlets, and Internet sites to address topics such as Post-Traumatic Stress Disorder, children's response to disasters, school-based mental health services, and symptom checklists for professionals. Requests for specific kinds of information, as well as hiring needs for newly developed initiatives, were also frequent topics of discussion. While experienced leaders always chaired the meetings, the agenda was consistently set by the meeting participants. As a consequence, individuals were able to address identified emergent needs at each meeting.
The MHCRC met 10 times between September 23 and March 11, the 6-month anniversary of the attack. After holding the first two meetings at the ARC's temporary disaster headquarters in Arlington, VA, subsequent meetings have been held at a highly accessible location near Capitol Hill with an average attendance of 15 to 20 people. In November, the Coalition moved to a monthly meeting schedule. The military has been represented at every meeting since September 28, as have private and public mental health organizations. Despite the intense work commitments of the coalition participants, attendance has remained strong. Non-attendees regularly read and comment on the minutes. The Coalition has also begun preparing a document to help guide future community response efforts.
What Have We Learned?
Research on community groups suggests that certain factors are critical to the development of successful coalitions. In Oklahoma City, for example, opportunities for networking, fostering understanding of the function of each organization, having a leader with no direct involvement in the ongoing community disaster relief work, and having an inclusive atmosphere were key factors in the success of the RCC.1 Wolff2,3 emphasizes the importance of such variables as ongoing recruitment of new members, inclusiveness of membership, flexibility and responsiveness, and having collaborative leadership. Others have found that successful inter-organizational collaborations lead to higher rates of exchange of information and resources and development of joint ventures than exist in comparable nonparticipating organizations do.4
The characteristics highlighted by research on community coalitions are also features of the MHCRC, particularly networking, inclusiveness, ongoing recruitment of new members, nonvested leadership, and responsiveness to emergent needs. However, there are some ways in which this coalition is different. Although Wolff3 details the importance of financial resources and authority, the MHCRC has neither government mandate nor money. Yet it continues to thrive.
The reader is no doubt wondering why people continue to participate voluntarily in a group without financial resources or governmental authority. Some potential explanations may include the democratic and voluntary nature of the group's formation and subsequent activities that has allowed the MHCRC to be a continued priority for participants. In addition, the MHCRC is the only coalition in metropolitan DC that meets consistently to discuss these issues. Whereas other groups have met on an ad hoc basis, they have not had the consistency of this group. If agency representatives want to talk to each other on a regular basis, they have the opportunity to attend the MHCRC meetings. Furthermore, the coalition produces a wealth of information. In addition to what is shared at the meeting, comprehensive minutes are taken and disseminated to an extensive e-mail list. That e-mail list is also used to disseminate other information members of the coalition believe to be useful. To keep the number of messages within reasonable limits, the Chair manages the list. An unusual feature of this coalition, not often discussed in the literature, is its evolution via grass roots. This coalition was started by actual service providers at the Pentagon crash site and grew exclusively by word of mouth (and, more precisely, by forwarded e-mail). Communication and attendance have always been voluntary, even though groups such as Substance Abuse and Mental Health Services Administration, which administers all federal emergency mental health dollars, have been supportive of the coalition and encouraged others to attend. This grass-roots perspective has kept the group in touch with and focused on the needs of the community and has enabled it to be responsive to emergent needs. Finally, consistent with the current literature,3,5 the MHCRC has had member capacity (i.e., skills/knowledge/motivation), organizational capacity (i.e., leadership, communication), and programmatic capacity (i.e., responsiveness to community needs). These capacities have enabled the coalition to serve a vital function in the community even though it had no official power of its own.
Despite the initial success of the MHCRC, there are, of course, still obstacles to navigate. Obviously, it is important to remain flexible and responsive to the needs of the participants without falling into mission creep. Although it is tempting to tackle other issues, the primary focus must remain the mental health needs of the Washington, DC community following two terrorist events: the Pentagon and Anthrax attacks. Second, whereas the early involvement of Pentagon personnel was critical to the establishment of the coalition, it would have benefited from early involvement of local government and public mental health agencies as well. Their mandate to provide services to the community has made them essential partners.
The primary lesson learned was simply that such coalitions need to exist and they need to exist before a crisis occurs. Inadequate planning and collaboration prior to a crisis can result in problems from which the community members may take years to recover. Pre-established community coalitions allow for efficient, effective mobilization of resources to assess and respond to the disaster-related needs. Resources can be identified, communication channels and referral processes agreed upon, and decisions regarding chain of command can be estabfished prior to the occurrence of a disaster. This facilitates a timely, focused, and successful response. The literature suggests that staff and leader involvement in interorganizational coalitions is an important part of creating integrated social service delivery systems but it simply does not occur as often as it should. This coalition has served a vital function by bringing these disparate organizations together and facilitating discussions about how to provide a coordinated, comprehensive mental health response to a community disaster.
The Mental Health Community Response Coalition brought stakeholders together initially to address the needs created by terrorist attacks in the nation's capital. Resources have been identified, needs have been identified and assessed, mutually beneficial information sharing has occurred and processes have been discussed that will facilitate a timely, comprehensive, and effective response from the mental health community in the event of a future crisis. The Coalition has maintained a special focus on efficient and comprehensive information dissemination and exchange and has been successful in accomplishing this by its use of electronic mail. A secondary benefit of the MHCRC is that leaders from a variety of agencies and organizations have formed relationships as a result of participating in the coalition's monthly meetings. This continues to be an important factor in ongoing efforts to improve and enhance interagency communication and collaboration. The MHCRC has therefore not only provided an avenue for the mental health community to address post-disaster needs, but it has established the foundation for an on-going coalition of community stakeholders to better prepare for, respond to, and recover from any crisis that may be endured by the Washington, DC metropolitan area in the future.
[Reference]
References
[Reference]
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[Author Affiliation]
Guarantor: Daniel Dodgen, PhD
Contributors: Daniel Dodgen, PhD*; Lisa R. LaDue, MSW^; Rachel E. Kaul, LCSW^^
[Author Affiliation]
*American Psychological Association, Washington, DC 20002.
^National Mass Fatalities Institute, Cedar Rapids, IA 52403.
^^Pentagon Employee Referral Service, Arlington, VA 20310.
This manuscript was received for review in June 2002. The revised manuscript was accepted for publication in June 2002.
Reprint & Copyright (C) by Association of Military Surgeons of U.S., 2002.
