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?

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