Lessons From the First Two Years of Project Heartland, Oklahoma's Mental Health Response to the 1995 Bombing

The Oklahoma City bombing was a human-made, centripetal disaster (1) in which victims lived or worked in the affected area and the entire community shared in the assault. Such disasters tax local resources but also unite residents in the recovery process.

Project Heartland was established with funding from the Federal Emergency Management Agency (FEMA) through the Center for Mental Health Services. Its design, implementation, and management is solely a local effort, although federal guidelines dictate service priorities. Current funding is through the Office for Victims of Crime of the U.S. Department of Justice.

Disasters can be viewed in phases (2,3,4,5). Project Heartland staff used the model described by Farberow and Frederick (4) and Myers (6) because it is consistent with the federal response in structure and process. These authors describe a four-phase paradigm. The phases are called the heroic phase, the honeymoon phase, the disillusionment phase, and the reconstruction phase. The model provided Project Heartland staff with a framework for understanding and preparing to meet the public's needs over time.

The goal of Project Heartland was—and continues to be—to provide crisis counseling, support groups, outreach, and education for individuals affected by the bombing. Several concerns became evident in the first days after the bombing. ODMHSAS, the state agency selected to organize, coordinate, and conduct the mental health response, had no disaster plan in place. Furthermore, the Oklahoma Office of Civil Emergency Management had little previous interaction with ODMHSAS, and no interagency service agreement existed. Despite the lack of a formal agreement, work commenced, and by April 24 planning began.

The American Red Cross provides only immediate postimpact crisis services. The Compassion Center, the support and death-notification program established by the Red Cross in downtown Oklahoma City, closed within ten days. Unfortunately, tension among individuals and organizations involved in disaster response is not unusual. After the bombing, staff of the local Red Cross did not wish to transfer responsibility to Project Heartland as directed, and they resisted training ODMHSAS staff.

To decrease the likelihood of such conflicts over leadership during transitions and to provide consistency in leadership, it is prudent that the postimpact counseling and death-notification center be directed by specially trained staff from the state agency responsible for developing and maintaining the postdisaster plan. This staff should work closely with other agencies in predisaster planning and disaster response and should be knowledgeable about the various organizations involved in the response. This staff needs clear governmental authority to direct service delivery.

In May 1995 ODMHSAS sponsored a statewide forum in Oklahoma City to obtain community input in the development of service goals for the mental health recovery plan. This use of a quasipublic disaster relief planning workshop appears unique in the disaster literature. One-hundred stakeholders were invited to participate in one of five half-day facilitated workshops to develop specific mental health goals for disaster recovery.

The stakeholders made 15 primary recommendations to help ensure that the agencies involved in Project Heartland would enlist qualified providers and use a multidisciplinary team approach to deliver accessible, high-quality, culturally sensitive services to a variety of special populations affected by the bombing. The recommendations also focused on ensuring that the media would be educated about responses to trauma and that the needs of rescue workers, those already affected by mental illness, the homeless, and civilian workers in the area would not be overlooked. The needs of children were a special concern, and a companion paper addresses Project Heartland's services for children (7).

Project Heartland is located in a two-story multitenant office building within easy reach of public transportation. The project was initially staffed with 22 individuals, including a director, professional counselors, outreach workers, and support personnel. It became clear that it was a mistake to hire younger individuals, many of whom had no experience dealing with death or related issues. It is strongly recommended that each state's mental health department have a cadre of culturally sensitive and mature individuals trained in critical-incident stress debriefing and other interventions.

Vicarious traumatization was a problem, and exposure to the traumatic experiences and rage of survivors caused erosion of staff morale. This erosion became evident in physical illness and emotional distress and in increasing absenteeism rates. A psychologist with training in disaster mental health was employed to debrief and support staff and to provide clinical case review. We recommend that the consultant who provides support to staff should not also provide case consultation because the consultant's critical review of a therapist's work may discourage the therapist from openly sharing personal reactions.

Project Heartland contracted with eight partners—both state and private organizations—to extend services to predefined populations, including ethnic minorities, persons with preexisting emotional disorders, elderly persons, and children. We believe that this blend of state and private groups is both unique and highly desirable because it offers accessible services by experienced professionals and integrates postdisaster services with existing programs.

Subcontractors were functionally independent of Project Heartland. We recommend that other disaster response programs use the contract itself to address potential problems. For example, the contract should specify the amount of time to be spent in direct clinical service and expressly require all subcontracted clinicians to have at least a master's degree, to be licensed or licensable in a mental health profession, and to participate in ongoing training in areas such as outreach, evaluation and referral, crisis and grief counseling, and record keeping.

As Table 1 shows, in the first two years of Project Heartland, the greatest number of service hours were spent providing support services, which include support groups and client advocacy services. Providing programmatic activities accounted for the next largest number of hours; they included consultation, education and training, system support, and treatment team meetings. Following these services in number of hours were outreach services, which included door-to-door visits and mailings; emergency services and crisis intervention; counseling and therapy; and screening, evaluation, and referral services.