Reforming Mental Health Care Begins with Rethinking Provider Engagement

Harvey Rosenthal
Executive DirectorNew York Association of Psychiatric Rehabilitation Services (NYAPRS)

Last week, Harvey Rosenthal shared why he believes the answers to improving mental health care for individuals with more serious conditions lie in bringing state of the art engagement, services, and supports to scale, as opposed to expanding civil commitment programs. In this post, Mr. Rosenthal provides details about what these approaches and innovations should include.

Meeting individuals where they’re at
We need more accountable, aggressive action by providers. If a person does not fit into our current treatment paradigm—that is, if they don’t come into the office on time or take the medicine that is prescribed—they are typically considered noncompliant and often eligible for outpatient commitment.

Instead, we must shift our focus to a much more proactive, engaging, person-driven model. This approach starts with meeting the individual where they are both in terms of what they want and where we can best find and serve them. This increasingly involves getting out of the office, and getting out to the streets. And it increasingly encourages many of us to come out of the closet and share the lessons of our own lived experience.

Even when people demonstrate major symptoms and difficulties, it is possible to find out what they want and to what they will respond. But it takes great patience, persistence and time to demonstrate empathy and caring, offer hope, and gain trust.

After all, our work . . . our craft . . . primarily centers around our capacity to develop strong, positive relationships, and deliver personalized offerings that serve rather than service each individual.

The starting point for developing helping relationships with ‘at risk’ individuals does not typically begin with our own agenda: to get them to identify as ‘mentally ill,’ take medication, and go to treatment.

For example, the New York Association of Psychiatric Rehabilitation Services (NYAPRS) delivers peer bridger services to thousands of ‘high needs’ Medicaid beneficiaries on the streets of New York City. From this experience, we’ve learned that relationship building often starts with meeting more basic needs. These can include the need for housing, safety, food, caring relationships, or advocacy. Demonstrating our willingness to keep coming back enables us to earn the trust that is basic to the success of our work.

These approaches are already showing very promising results. One of our managed care contracts offers peer bridging to individuals just prior to or after relapses and readmissions. This approach saw a 50% reduction in relapses that led to inpatient and detox readmissions for individuals who had twenty-five hospital or seven detox readmissions in the previous year.

However, engagement cannot succeed from a one-approach-fits-all model. We need to tailor our outreach to address a variety of vastly different people. We must have the capacity and team diversity to support people with trauma and varied racial, ethnic, and linguistic backgrounds, as well as individuals with differing cultures, spiritual beliefs, gender identifications, and age-specific needs across the lifespan. Recognizing and appreciating this variety requires much more specialized recovery-focused training and supervision.

Successful engagement requires a full appreciation of the need to work with families and in the community. Access to services must be available within faith communities and places of worship, libraries, homeless shelters, food pantries, Meals-on-Wheels programs, and nursing homes. Given the number of tragedies that involve troubled youth, meaningful engagement certainly involves a much greater presence on college campuses.

Engagement involves being able to manage our own discomfort with others’ profound distress and despairing situations. However, when there is indeed a risk of harm to self or others, it requires us to respond immediately and offer real-time crisis support to both individuals in need and their families.

Focusing so much of the discussion on mental health care reform around outdated and inaccurate understandings of privacy laws is a distraction. In truth, the sharing of personal information when health and safety are threatened is and has been a legal reality for a long time. Instead, let’s focus our attention on reforms that can make a real difference in the lives of the people we serve.

Your Turn

  • Why should (or shouldn’t) legislators encourage the kinds of individual approaches to treatment that Harvey Rosenthal describes here?
  • What steps should policymakers take to improve the delivery of mental health care treatment, especially to those considered noncompliant?
  • How feasible are the kinds of changes in treatment delivery discussed in this and the previous post?

[poll id=”21″]


Facebook Comments

11 comments
afish
afish

stephen:  thanks for your response to pnelson48 about his comments below regarding social workers.  I hope my response to pnelson48 clarified the issue and made sense.  The majority of us trained social workers are already doing what Rosenthal is proposing.  Of course it may vary from city to city, community to community.  but i think i'm on the same page with most of Rosenthal's ideas.


af

kimgallen
kimgallen

I agree that engagement cannot succeed from a one-approach-fits-all model. I also agree that we need to tailor our outreach to address a variety of vastly different people. For this reason, having team diversity is very important, so we need to make training and supervision opportunities available to the peer workforce, for one. Online trainings for peers helps with this, as many people cannot afford to attend Conferences etc. to gain certifications and the like. In terms of providing care, another way of doing so is through telemedicine versus going into the streets. This approach offers help to people who live in rural areas, for example. Those individuals would have to drive miles to attain care, so this is a potential solution for individuals and families to attain psychoeducation and other life-saving conversations with doctors and with peers.  This also helps people with chronic health conditions who may be immobilized by their conditions, including depression. In terms of what legislators can do, they need to provide continued support and funds for key components in the Excellence in Mental Health Act for example, as well as other MH and addictions legislation. Congress needs to protect access to care. 

StephenBonin
StephenBonin

@kimgallen In response to your comment that many people cannot afford to attend conferences, etc., let's take this opportunity to thank proactive DBSA for generating the funds to offer partial and full scholarships for next weekend's training. Likewise, as advocates we will build relationships with private entities and government agencies for funding our endeavors. Let's be realistic and reasonable here. To chart a course for our visions, we always need to ask: "How can we encourage and assist the people we need to build relationships with?" Money will be an element, yes--but not the only. Some of the others include: Frequently initiating affirmation and constructive criticism, and consistently thinking about the people we want to professionally befriend so as to generate even more dynamic ways of reaching them.

kimgallen
kimgallen

I agree that engagement cannot succeed from a one-approach-fits-all model. I also agree that we need to tailor our outreach to address a variety of vastly different people. For this reason, having team diversity is very important, so we need to make training and supervision opportunities available to the peer workforce, for one. Online trainings for peers helps with this, as many people cannot afford to attend Conferences etc. to gain certifications and the like. In terms of providing care, another way of doing so is through telemedicine versus going into the streets. This approach offers help to people who live in rural areas, for example. Those individuals would have to drive miles to attain care, so this is a potential solution for individuals and families to attain psychoeducation and other life-saving conversations with doctors and with peers.  This also helps people with chronic health conditions who may be immobilized by their conditions, including depression. In terms of what legislators can do, they need to provide continued support and funds for key components in the Excellence in Mental Health Act for example, as well as other MH and addictions legislation. Congress needs to protect access to care. 

StephenBonin
StephenBonin

@kimgallen Per the value of online training, I agree. This blogging experience since January has helped tremendously. Per Telemed, the clinic where I receive treatment instituted this over a year ago. I learned simultaneously that  if I was not pleased with a psychiatrist, I could opt for a  different one--a choice that I did not know was available for many years with the psychiatrist in person. Per the Excellence in Mental in Mental Health Act, I need to read more about that right now. Thank you, Kim.

pnelson48
pnelson48

While I feel that "meeting people where they are" is a good idea much of what you're proposing could be handled by good social worker. We all know how underfunded and overworked they are in most jurisdictions. I would also ask how a trained psychiatrist could bill for his services and how likely it is that local and state governments would adequately fund those services?

afish
afish

@pnelson48 I know that you sent me an email about my comments and they were not included in this blog.  To restate my comments, I am an excellent licensed clinical social worker with very high professional standards.  I certainly agree that we social workers have been left out of the picture as it relates to salaries largely due to NASW and most of us not pushing for them to help increase our pay.  Regarding trained psych docs, their training is much different then social workers in that we look to treat the entire family if possible rather then just focusing on the individual patient.  The majority of psychiatrists today have opted out of Medicaid, Medicare and even insurance, so that patients are paying them out of pocket after each session and/or psych docs are having their patients submit their claims to their particular insurance company.  As such, local and state governments are not involved in the funding for outpt mental health service by psych docs in private practice, psychologist and social workers who are charging up to $300+ per session.


Hope this provides a better and/or clearer response to your comments/questions.


A.Fisher

StephenBonin
StephenBonin

@pnelson48 Thank you for contributing. You did not think carefully, however. Therefore, logic is flawed. Specifically, in your first sentence you assert that a good social worker could handle "meeting people where they are." In the next sentence you write that they are too busy and not funded enough.
What do you think needs to happen so that social workers actually enact Rosenthal's ideas?

afish
afish

As a professionally trained social worker/clinician, one of the basic tenants for social workers is to start tx where the patient is at along with involving family members if appropriate.  That's why we social work/clinicians differ so much from psychiatrists and psychologists in our approach to therapy.  I have loved doing home base tx and getting out of the "board room/office".  it has allowed me to learn and see what's really going on in someone's home and/or other environment, observe family interactions, cultural differences, etc., etc.  When one is in private practice, no matter their background and training, most clinicians don't get out of the office and that's just the way it is.  However, it doesn't mean that one can't make a home visit or two in order to see "what's on the other side" and help with outcomes and goals set for treatment.


I'm not sure that doing home visits/home base treatment needs to be something that policy makers need to get involved with.  A lot of how this is handled is with the particular agency one is working for, i.e, CPS;APS; Headstart;  Family Services.  I don't believe most agencies are against getting out of the office and having worked for CPS; Head Start and another small agency in D.C., doing home visits was part of the treatment plan.  I get a bit concerned (paranoid!!!), that bringing in legislation to keep home visits going may in fact result in less positive outcomes and what we have set up as our treatment plan for the individual and their family members.

StephenBonin
StephenBonin

@afish This community has heard me talk about my therapist Lennard, whom I decided to cease sessions with in July. He is part of a clinic system, government funded. The thought of him offering to make a home visit when I was in depression in June is interesting. I plan to contact the clinic about their policy.

StephenBonin
StephenBonin

Thank you, Harvey Rosenthal, for asserting a radically different approach! I feel thrilled; indeed, you help me contine thinking about the paradigm I wrote about last week, that of providers emerging from indoors and taking the treatments to the people. You show respect by acknowledging the need for diversity. Therefore, there still exists room to validate some current methods. I agree with you that our attention to privacy laws is distracting. On that similar note of secrecy, my depression was triggered in June, and I did not tell that I was out of control with carbonated beverages. A diagnosis of Type 2 Diabetes followed. For several weeks, I felt shame that two types of providers are coming to my place; however, now I feel grateful, and I have improved stupendously. They are very kind people. Let's all be willing to accept beautiful relationships with valuable people as we surrender to our conditions.