Reducing Post-Hurricane Distress in Baton Rouge, La., With InCourage Mental Health Services
In 2006, the Baton Rouge Area Foundation created and implemented InCourage, a pilot program to provide mental health services to adults in Baton Rouge La., in the aftermath of Hurricanes Katrina and Rita. Five foundations provided support.
InCourage is a 10-session manualized intervention developed to address a range of cognitive, emotional and behavioral reactions to disaster. (A manualized treatment is a set protocol of actions; if a therapist follows that series of steps then a particular result can be expected.)
InCourage was designed to fill the gap between short-term crisis counseling funded by the federal government and mental health services for the chronically mentally ill available through state and local community organizations. The 10 treatment sessions are divided into three main areas: psychoeducation, coping skills and cognitive restructuring.
An evaluation team led by Fran Norris, Ph.D., director of the National Center for Disaster Mental Health Research, reported that:
- Of more than 400 clients that were referred to InCourage from December 2006 to September 2007, 176 (44 percent) enrolled in the program.
- Most had high scores on seven or more psychological symptoms, including core symptoms of post-traumatic stress disorder.
- Overall, clients experienced a significant reduction in distress after treatment, compared with before, according to an analysis of 51 clients for whom the researchers had complete data.
In a separate evaluation, Kermit A. Crawford, Ph.D., of the Center for Multicultural Mental Health, Boston University School of Medicine, and Dow A. Wieman, Ph.D., of the Human Services Research Institute, concluded that:
- The InCourage program design was appropriate to deliver high-quality mental health services to individuals in need.
- The design was effective for developing a major program intervention in a vast emergent mental-health crisis.
The Robert Wood Johnson Foundation (RWJF) provided $500,000 to support the pilot project. Four other foundations provided an additional $2.8 million.
In the aftermath of Hurricanes Katrina and Rita in 2005, thousands of people experienced symptoms of post-disaster distress—including anxiety, headaches, depression and increased conflict with others—that affected their ability to function in daily life.
Many of these people had no previous history of mental health problems, so they were not eligible to receive treatment through the state's services for people with chronic mental illness. And their treatment needs went beyond what was offered by the short-term nonclinical services of the federally funded crisis counseling program.
This group of people, often referred to as "subclinical," remained at particular risk for more serious mental health issues over time if their immediate needs were not addressed, according to experts.
The Baton Rouge Area Foundation's Mental Health Initiative sought to create a mental health service intervention to fill this gap in the continuum of care.
In the wake of Hurricane Katrina, RWJF designated funds for immediate relief and longer-term efforts. Increasing mental health services capacity was a stated objective of the relief and recovery funds. This project fits that stated goal by: (1) providing a program of mental health care for those whose lives continued to be affected by the storm's aftermath; and (2) building capacity to support the provision of mental health services in Louisiana through the training of mental health clinicians on evidence-based practices. See In the Eye of the Storm for an account of RWJF's grantmaking after Hurricane Katrina.
The Baton Rouge Area Foundation created and implemented InCourage, a 16-month pilot project to provide mental health services to adults in Baton Rouge in the aftermath of Hurricanes Katrina and Rita.
The project provided clients up to 10 free confidential counseling sessions with a licensed and insured mental health practitioner trained to provide disaster-specific counseling services.
Based on estimates of the number of people in need of treatment, InCourage aimed to train some 110 therapists who could potentially treat 2,500 clients over the 16-month period.
InCourage adapted its program from a treatment model called Cognitive Behavioral Therapy (CBT) for Post Disaster Distress developed by Jessica Hamblen, Ph.D., and colleagues at the National Center for Posttraumatic Stress Disorder (PTSD), a division of the U.S. Department of Veterans Affairs, in Washington. The model was used previously in New York after the September 11, 2001 attacks and in Florida following hurricanes Ivan, Charley and Jeanne in 2004.
InCourage is a manualized intervention developed to address a range of cognitive, emotional and behavioral reactions to disaster. A manualized treatment is a set protocol of actions; if a therapist follows that series of steps then a particular result can be expected.
The treatment is intended for individuals who show more than normal transient stress and who require more than traditional crisis counseling. It was designed as an intermediate step between crisis counseling for individuals immediately after a trauma and longer-term mental health treatments.
The treatment entails 8–12 sessions divided into three main sections:
- Psychoeducation—Clients learn to understand common reactions to disaster.
- Coping skills—Clients learn immediate ways of managing their distress.
- Cognitive restructuring—Clients learn and practice a five-step process for dealing with negative emotions.
Clients receive a workbook and complete assignments to reinforce the skills they have learned during the sessions.
More detail on the treatment model can be found in the article "Cognitive Behavioral Therapy for Prolonged Postdisaster Distress." (Hamblen, et al., Journal Of Clinical Psychology: Special Issue: Crisis Intervention, Vol. 62(8), 1043–1052, 2006. Abstract available online.)
Working with Hamblen and colleagues, project staff recruited and trained 110 licensed and insured clinicians in the Baton Rouge area to deliver the treatment.
In addition, project staff trained approximately 200 clinicians working in public and private agencies across the region to use the model and encouraged them to implement it in their respective organizations and private practices.
Project staff also trained 16 local mental health professionals to train others in use of the model. This "train-the-trainers" program was designed to increase the capacity of the community to respond to disasters.
Hamblen and Fran Norris, Ph.D., director of the National Center for Disaster Mental Health Research, (see Evaluations), summarized their work with the project in an article, "Cognitive Behavioral Therapy for Postdisaster Distress: A Community Based Treatment Program for Survivors of Hurricane Katrina," published in the May 2009 special issue of Administration and Policy in Mental Health and Mental Health Services Research. (Article abstract is available online.)
Administration and Billing
Project staff worked with the Baton Rouge Crisis Intervention Center, the medical billing department of a local regional hospital and a local accounting firm to develop and implement a process for providers to invoice and receive reimbursement for their services. The Louisiana State University (LSU) School of Social Work assisted the Crisis Intervention Center in certifying invoices submitted for payment through the program.
Publicizing the Project
Project staff subcontracted with Zehnder Communications, a Baton Rouge advertising agency, to develop print materials and radio and TV commercials to direct people with symptoms of emotional distress to call the Baton Rouge Crisis Intervention Center, the program's point of entry to access services.
Zehnder staff gave some 70 training sessions to inform service providers and people active in their communities about when to refer potential clients to InCourage and how to access services. One Zehnder staff person served for three months as the liaison to corporate executives, informing them to direct employees affected by the hurricanes to the InCourage program.
The Baton Rouge Area Foundation contracted the services of two persons to serve as full-time InCourage program staff. The InCourage program coordinator gave some 70 training sessions to inform service providers and people active in their communities about when to refer potential clients to InCourage and how to access services. To support the efforts of the program coordinator, a part-time staff person was hired for three months as a corporate liaison. The liaison was tasked with gaining access to corporate executives to share information on the InCourage program and the benefits of directing their employees affected by the hurricanes to access the available services.
The Baton Rouge Area Foundation commissioned two research evaluations of the project:
- Fran Norris, Ph.D., director of the National Center for Disaster Mental Health Research, led a research team that conducted an evaluation that provided qualitative, quantitative, process data and outcomes. It described the:
- Demographic characteristics and reported symptoms of more than 400 people referred for treatment from December 2006 to September 2007.
- Factors influencing whether they actually enrolled and remained in treatment.
- Their treatment outcomes.
- Kermit A. Crawford, Ph.D., of the Center for Multicultural Mental Health, Boston University School of Medicine and Dow A. Wieman, Ph.D., of the Human Services Research Institute, conducted an evaluation in which they attempted to answer a number of key questions, including:
- Was the program design appropriate and was it implemented effectively?
- Did the methods used to measure need for services produce accurate estimates?
- What factors may have affected the enrollment rate?
In addition to RWJF support, four other organizations provided grants to support the $3.3 million program. These were:
- AmeriCares: $263,000
- Baton Rouge Area Foundation: $2,000,000
- Sandra H. Lund Foundation: $250,000
- I.W. and C.B. Pennington Foundation: $40,000
In their report—InCourage: Third Quarter 2007 Evaluation Report—Norris and colleagues reported the following findings:
- The Baton Rouge Crisis Intervention Center referred more than 400 clients to InCourage from December 2006 to September 2007. InCourage reached substantial percentages of White (32 percent), Black (63 percent), male (23 percent) and female (77 percent) evacuees and residents of Baton Rouge.
- Most of those referred had high scores on seven or more psychological symptoms assessed on a screening referral tool. These included core symptoms of PTSD (intrusion, avoidance, numbing and arousal) as well as depression, social difficulties and difficulties tolerating stress.
- Of those referred in this time period, 176 (44 percent) enrolled in the program. Once referred, Whites were more likely to enroll than were Blacks or other groups. No other demographic characteristics or symptoms had significant effects on the likelihood of enrolling.
- Of the first 100 people to enroll in InCourage, about 90 percent completed two sessions, 80 percent completed at least three, and approximately half had attended at least eight.
- Overall, there was a significant reduction in distress after treatment, compared with before, among a subset of 51 clients for whom the researchers had complete data. Participants experienced significant decreases in a number of specific symptoms, including:
- Depression: Whereas 87 percent of the group reported intense depression before treatment, 21 percent reported it afterward.
- Arousal: Some 75 percent displayed intense arousal before treatment, while just 17 percent did so afterward.
In their report, Meta-Evaluation of the InCourage Program for the Baton Rouge Area Foundation, Crawford and Wieman report the following key conclusions:
- The InCourage program design was appropriate to deliver high quality mental health services to individuals in need. The design was effective for developing a major program intervention with a vast emergent mental health crisis. The InCourage program design was developed and implemented as a model based on evidence-informed practices.
- It does not appear that there were any gross miscalculations or errors of judgment on the part of anyone involved in the planning that affected the estimate of need for the particular services the InCourage program offered. Although the pool of hurricane evacuees from which many referrals were expected proved to be smaller than estimated, the epidemiological data suggests that there was still considerable unmet need for services such as InCourage program offered.
- A number of factors may have contributed to lower than expected enrollment in the InCourage program.
- Some area social service agencies may have felt threatened that the Baton Rouge Area Foundation, a community grantmaking organization, was now delivering social services, a function not traditionally in their domain.
- While the marketing campaign appeared to be an "artistic success," it was inconsistently presented and would have benefited from a more appealing message to the target population.
- The term "subclinical" does not have broad usage in the field of behavioral health crisis counseling. Some social service agency providers reported thinking that it meant "case management." As a result, some community providers may have been unable to differentiate the "gap" in services InCourage was designed to provide, limiting referrals to the program.
- The scope and magnitude of the disaster meant that many people were focused on meeting their immediate and basic needs for food, shelter and clothing and not on their mental health.
- The evaluators also suspected that many people faced other barriers to accessing the program, including not having a phone to make a call to a crisis hotline, or a car or other means of transportation to attend a workshop.
- A community foundation may lack the credibility to act as a direct service provider. The project director speculated that individuals in the community may be more familiar with the work of social service organizations than that of community foundations. She recommended that community foundations partner with a social service organization that people are familiar with to deliver mental health programs. (Project Director/Lewis)
- Media and outreach efforts must be culturally relevant to attract clients to a mental health program. The InCourage media effort may have been out of sync with the people most likely to need services. Twanda Lewis, the project director, wishes they had been in a position to take the time to do focus groups with the intended target audience beforehand. (Project Director/Lewis)
- Sometimes urgency precludes doing the kind of "spade work" that would ease acceptance of a new program in the community. The situation in Louisiana was dire after the hurricanes and the project director said the group had to move quickly to set up InCourage. "We did not have the time to do a lot of things that we would have normally done, such as focus groups," Lewis said. "If we had not had such a situation of urgency, we may have done a more in-depth job…But I am proud of the work we did."
- Partnering with other organizations that provide similar services may lead to an unintended competitive atmosphere that makes true partnership difficult. Although the Baton Rouge Area Foundation did not compete directly with area social service organizations for funding from state and federal sources, social service agencies viewed the foundation as a competitor because the foundation's work in similar domains forced them to further justify their own funding requests from the state and federal sources. "It took us some time to understand that they felt that way. Prior to development we convened community partners and stakeholders to gain consensus. We walked away from the convening with a consensus to move forward," the project director said.
AFTER THE GRANT
Family Service of Greater Baton Rouge, a local human services agency that serves some 14,000 individuals and families each year, replicated the InCourage program and has integrated it into its menu of mental health services.
Many of the clients who completed InCourage asked to repeat the program or for follow-up services. To help address that need, a local outpatient substance abuse clinic has agreed to partner with Family Service of Greater Baton Rouge to provide support groups to "graduates" of the InCourage program.
In 2009, the Baton Rouge Area Foundation funded a collaborative of regional family service organizations to support their efforts to formalize, and incorporate their partnership. The Alliance for Children and Families in Louisiana wished to formalize their partnership in order to increase the member agencies' capacity to leverage resources and incorporate more programs that serve as best practice.
The Baton Rouge Area Foundation has partnered with the alliance to replicate the InCourage program statewide. The member organizations will incorporate the InCourage program into the menu of services they offer. In addition, the alliance has agreed to partner with the Baton Rouge Crisis Intervention Center to offer Cognitive Behavioral Therapy for Post Disaster Distress training to mental health clinicians in various regions across the state.
Funding received from AmeriCares and the Sandra H. Lund Foundation will support the Baton Rouge Area Foundation in its continued efforts to replicate the InCourage program and provide Cognitive Behavioral Therapy for Post Traumatic Stress Disorder training to mental health practitioners across the state of Louisiana.
GRANT DETAILS & CONTACT INFORMATION
Increasing the capacity to screen and treat post-disaster distress in Louisiana and promoting awareness of the services available
Baton Rouge Area Foundation (Baton Rouge, LA)
Dates: March 2007 to June 2008
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Hamblen JL, Norris FN, Pietruszkiewicz S, Gibson LE, Naturale A and Louis C. "Cognitive Behavioral Therapy for Postdisaster Distress: A Community Based Treatment Program for Survivors of Hurricane Katrina." Administration and Policy in Mental Health and Mental Health Services Research, 36(3): 206–214, 2009. Abstract available online.
Crawford KA and Wieman D. Meta-Evaluation Of The InCourage Program for the Baton Rouge Area Foundation. Boston: Center for Multicultural Mental Health, Boston University School of Medicine, Boston University School of Medicine, 2008.
Hamblen J. Moving Forward After A Disaster: A Step-By-Step Guide To Overcoming Disaster, October 2006.
Hamblen J and Gibson LE. Cognitive Behavioral Therapy for Postdisaster Distress: Hurricane Version, October 2006.
Hamblen J and Gibson LE. Cognitive Behavioral Therapy for Postdisaster Distress Trainer's Manual. VA Center for PTSD, June 2008.
Norris F and Hamblen J. InCourage Final Evaluation Report. Dartmouth University and The National Center For PTSD, 2008.
CBT Training Slides, PowerPoint® slides to support the Cognitive Behavioral Therapy for Postdisaster Distress Trainer's Manual. Jessica Hamblen, Ph.D., 2008.
TV Commercial InCourage, "Love You," Zehnder Communications. Available on YouTube.
TV Commercial InCourage, "New Day," Zehnder Communications. Available on YouTube.
Report prepared by: Kelsey Menehan
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Andrew Hyman