Fixing Mental Healthcare in America, An Interview with Dr. Nicole Eberhart and Dr. Ryan McBain
An interview with Dr. Nicole Eberhart and Dr. Ryan McBain from the RAND Corporation. Curt and Katie kick of their special series related to the problems and potential solutions in the mental healthcare system. We interview Drs. Eberhart and McBain about the study they authored related to the structural concerns in the mental health system as it is currently built and their recommendations for solutions and best practices going forward.
It’s time to reimagine therapy and what it means to be a therapist. To support you as a whole person and a therapist, your hosts, Curt Widhalm and Katie Vernoy talk about how to approach the role of therapist in the modern age.
Click here to scroll to the podcast transcript.Transcript
Interview with Dr. Nicole Eberhart, Senior Behavioral Scientist, and Dr. Ryan McBain, Policy Researcher, The RAND Corporation
Nicole Eberhart, PhD is a Senior Behavioral Scientist at the RAND Corporation and a licensed clinical psychologist whose research and evaluation focuses on mental health. She has expertise in health program evaluation, prevention and early intervention, health services and systems, and innovative care models including those that integrate primary and behavioral health care. Dr. Eberhart been evaluating mental health programs and policies in California and nationally for over a decade.
Ryan K. McBain is a policy researcher at the RAND Corporation. He focuses on the design and evaluation of health policies and programs meant to reach vulnerable populations—including those coping with mental health conditions, HIV/AIDS, homelessness, and poverty. To achieve this, McBain has utilized a wide range of methodologies, including econometric approaches for quasi-experimental analysis, cost-effectiveness analysis, and decision analytic models, as well as key informant interviews and focus group discussions. Internationally, McBain has worked with the World Bank, World Health Organization, Harvard University and Partners In Health, where he has focused on evaluating mental health, HIV, and primary care service delivery systems, primarily in sub-Saharan Africa and Haiti. McBain holds a Ph.D. and M.P.H. in global health with concentrations in health economics and health policy analysis from Harvard University, as well as a B.A. in psychology from Gordon College and Oxford University in the United Kingdom.
In this episode we talk about fixing mental health care in America:
- Introducing our new series on Fixing Mental Healthcare in America
- RAND corporation report on the mental health system
- Structural issues in the current mental health system
“One of the [structural issues with our current health care system] is workforce…There are just not enough members of the mental health workforce in the United States….There’s also a mal-distribution issue…The best data that are out there show that about half of people who have mental health issues just don’t receive care for it, which is…terribly unfortunate.” — Dr. Ryan McBain
- Work force issues, lack of professionals, poor distribution across communities
- Payment issues – Mental Health providers are not paid as well as other medical providers
- The problem of fee for service, government insurance programs, and private pay
- Culture problem – historical lack of value of mental health, stigma and de-prioritization of mental health
- Lack of educational programs for mental health, lack of consistent, effective crisis response
- The idea of increasing wages for entry level positions
- Peer Support Specialists as another way to expand mental health workforce
- The importance of lived experience and the professionalization of the peer support specialist profession (for example certification)
- The idea of paying for value rather than paying for services
- Focusing on prevention rather than costly emergency services
- The need for legislators to make changes
- The costs of not fixing the mental healthcare system
- An evidence-based continuum of care
- Taking a big picture approach (looking at the cost for services and the cost for society)
- Pushing back against the cost question – looking at how we are improving lives and the hypocrisy of asking this of mental health care and not medical care
- Using tools LOCUS (Level of Care Utilization System) to assess needs and enforce parity
- Mental Health education in K-12 curriculums, standards for mental health education, and promising places to start
“Health [education] can’t be isolated as one piece of you, as certain systems in your body and not other systems.” — Dr. Nicole Eberhart
- Mental Health First Aid – the problem one-time events and short-term effects
- How telehealth can be an engine for change and the importance of increasing and maintaining the momentum – looking at increases in access to both general and specialist mental health care
- Mental health crisis response as an avenue that has a lot of political will behind it (BLM, social justice, and policing that can be replaced by mental health providers)
- Mental health access needed to respond to the new hotline: 988
- Arizona’s Crisis Now program and the impact they’ve seen from replacing police response to these incidents
- Compartmentalization of different departments, budgets, etc. and the turf wars that can ensue
- Being able to go to programs that are really doing good work and improving lives and using these as examples for what we should be doing as a whole country
- The importance of advocacy at all levels
- Coordination at a higher level to improve the integration of and care coordination for mental health care
- Using the data from RAND to support advocacy
- The comprehensive nature of the RAND report
- The call to action for listeners to share their stories and experiences in the mental health system
- The hope for an impact and on-going conversations that make a difference
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Resources for Modern Therapists mentioned in this Podcast Episode:
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
RAND Report: How to Transform the US Mental Health System
Dr. Ryan McBain’s Publications
Dr. Nicole K Eberhart’s Publications
University of Michigan: Behavioral Workforce Research Center
Email them:
Twitter:
Relevant Episodes of MTSG Podcast:
A Living Wage for Prelicensees
Biden and Trump on Mental Health
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
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Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW
Music by Crystal Grooms Mangano https://groomsymusic.com
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe, and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm, and Katie Vernoy.
Curt Widhalm 0:15
Welcome back modern therapists, this is the Modern Therapist’s Survival Guide. I’m Curt Widhalm, with Katie Vernoy. And this is a new part of our podcast, where we are going to spend a number of episodes, taking a lot of what we have talked about over the last few years, and really placing an emphasis on fixing some of the problems in the American mental health care system. And through several of our upcoming episodes, we are going to be talking with people from a wide range of industries where mental health workers work. And part of this is really being able to explore a lot of the frustrations that we’ve expressed with our industry here on the podcast, our advocacy efforts, and actually moving this towards good mental health care that fits within our Modern Therapist’s Survival Guide values and mission. And by that we mean diversity, equity and inclusion. We mean good, actual clinical work that serves the people who need our work while taking care of our clinicians. This is a very special part of our work here at the Modern Therapist’s Survival Guide. This is putting together some action steps for us. And through this process we hope that you as our listeners will continue to share these ideas with your colleagues, as far as creating an action plan alongside of us to implement some of these things in action.
Katie Vernoy 1:55
When we were talking about doing this series, I was very excited about it, because I feel like it feels more practical. It definitely ties into all of our modern therapists, not solely our private practitioners and business owners. Because I think there are therapists who are certainly entrepreneurial and there are folks who entered the profession, to do work with the most impacted communities and do work where they can just focus on the clinical work and not on being a business owner. And so for me, looking at some of the work that has been done across different sectors to try to improve mental healthcare and having this initial conversation and the full Rand report. What happens within the whole mental health system impacts every single one of us. It impacts how we’re perceived, it impacts where the the access points are needed, it impacts who we’re able to work with, and what type of funding we receive. I mean, there’s, there’s such an interplay. And even as I look at a lot of the folks that we spend time with, I think we’re going to talk a lot about how there’s so many silos and that there’s not this integration of mental health care and even just mental health thought into daily life. We act like people only exist in the in the places where we intersect with them. And I think that is part of the problem. I mean, I could go off on a tangent on this, I won’t, but I think it’s something where truly taking a very high level approach to what is mental health care? What’s wrong with the system now and how do we fix it without having providers carry the weight of a broken system, or a underfunded system? I think is really exciting to me and it, it helped me to get kind of reinvigorated around mental health as a system.
Curt Widhalm 3:54
So one of the things that you mentioned there is the RAND report. And our first episode here to launch this is with the researchers behind a report from the RAND Corporation. If you’re not familiar with RAND Corporation, they are a policy encouraging institute that we’ll go into describing that here when we get to the interview part of this episode. But when you think, when you hear of, you know, those government think tank types organizations, the RAND Corporation is one of those it’s been around for a while. And in our interview today, this is a piece of research that when we came across it, we were like this is a fantastic starting place for really addressing a lot of the issues that we’ve been talking about and conveniently they have named this Fixing Mental Healthcare in America. We are joined today by a couple of really cool people helping us to put into a lot better words than we would have come up with ourselves. But it’s two of the authors of the RAND Corporation’s article on how to transform the US mental health system evidence based recommendations. We’re joined today by Dr. Ryan McBain and Dr. Nicole Eberhart to talk about how we can fix this whole system. And this being the first of several episodes that we’re having together about actually making mental health systems better for clients and for clinicians. And having some really cool people will be able to help us talk about what they’ve learned in their process and recommendations for where the US mental health care system can go. So thank you very much for spending some time with us and helping get this series launched for us.
Dr. Nicole Eberhart 5:44
It’s our pleasure.
Katie Vernoy 5:45
So we are so excited to have you here. Even in our pre conversation I just was like all over the place. I’m excited, so excited about this conversation. The first question that we ask each of our guests when they join us is: Who are you? And what are you putting out into the world?
Dr. Nicole Eberhart 6:02
Yeah, that’s a great question to start with. So we’re researchers at the RAND Corporation. RAND is a nonprofit, nonpartisan research organization. We conduct research and policy analysis in healthcare and in lots of other areas as well. As you said, my name is Nicole Eberhart, I’m a senior behavioral scientist at RAND. And I’m also a licensed clinical psychologist.
Dr. Ryan McBain 6:24
I’m Ryan. I am a health economist by training. I tend to do a lot of mixed methods research. So I find that with qualitative research, you ask a lot of questions, you’ll learn a lot more that way. And in terms of what we’re putting out into the world, generally speaking, RAND writes reports, and the reports are geared to policymakers. So in this case, how to transform the US mental health system, we really had in mind, the Biden administration, as well as policymakers at different levels of government. So a lot of policymaking, as I’m sure you’ve talked about in previous episodes is focused at the state level. But we were thinking along local, state and federal.
Curt Widhalm 7:07
Compiling this report, and we will include a link to this in our show notes over at mtsgpodcast.com. In all of the background work that you had done in coming up with these recommendations, what are some of the structural issues that you see with our current mental health care system?
Dr. Ryan McBain 7:26
Yeah, unfortunately, there’s there are quite a few. Maybe to pose a couple larger ones, I think that one of the first ones is workforce issue. On the one hand, there are just not enough members of the mental health workforce in the United States. So, I wrote an article a couple years ago, specifically looking at one segment, which is child psychiatrists. It’s an area that that I’ve done some work in. And over 70% of counties in the United States have zero child psychiatrists living there. So there’s a shortage piece. But we also found same publication that specifically in Massachusetts, there are as many child psychiatrists per child in Massachusetts, as there are basically in all states that one thinks of as the self. So there’s also a mal-distribution issue. And this isn’t just psychiatry. I mean, this is social workers, counselors, peer support specialists. The best data that are out there show that about half of people who have mental health issues just don’t receive care for it, which is, you know, terribly unfortunate. The second structural issue that I’ll mention, which is tied into this is a payment issue. So there’s a bunch of data that compare people who provide for physical health conditions. And compare that to people who have mental health conditions. And invariably, what the studies find is that mental health providers are not paid the same amount as physical health providers are. So part of that has to do with the way that the payment structure is set up in the US. I mean, most of the time, care is paid for fee for service. So the more services that you provide, the more money you make, essentially, which isn’t a particularly smart way of going about things. It doesn’t take into account, for example, the value of services that are being provided. And so oftentimes, the care that mental health providers are, are offering are incredibly valuable for individuals quality of life. And that doesn’t get factored into Medicaid fee for service schedules, for example. And so, generally speaking, the people who need care the most, people with serious mental illnesses who often are on Medicaid, the providers get paid the least. And it’s more people who are getting paid out of pocket that are making larger profit margins. And so it just doesn’t incentivize people to join the workforce as a result of that.
Dr. Nicole Eberhart 9:54
And we’ve discussed there being a culture problem that really underlies those other two problems. The workforce problem and the payment problem. Historically, our culture hasn’t valued mental health in the same way it’s valued physical health. We don’t teach mental health in our schools, like we do physical health education. That maybe an overgeneralization say we don’t teach it, we don’t teach it as much, I think would be more fair. There’s still a lot of stigma around mental health in our communities. We’re seeing slow change in that, and especially with COVID, it’s kind of been a great equalizer where we’re seeing, I think, what seems to be more rapid change, but stigma is still very pervasive. And we have health systems that don’t really prioritize mental health. And one example of that we’ve talked about is mental health crisis response systems. So if I call 911, for a heart attack, I can be pretty sure that a certain set of evidence based things are gonna happen no matter where in our country I call in from. But if I call with a panic attack, who knows what I’m gonna get, it’s gonna depend on where I am, it’s going to depend on who responds and, I don’t know if I’m going to get care that’s evidence based or even care that safe. And so that says a lot about how our country treats mental health, culturally, as compared to fiscal health.
Curt Widhalm 11:13
You’re bringing up a couple of my favorite talking points. And the first one is workforce issues. And really looking at this strange pairing of not enough therapists and not enough money to pay them at the same time. Being able to implement some of these changes takes in as far as your discussion goes, national taxes. It’s going to come out of out of the coffers of Medicaid, it’s going to need to fundamentally shift the way that not only the culture looks at how we can prioritize mental health care, but also attracting people to this. One of the great things that I love about this report is especially looking at the increasing the wages for entry level workforce positions, that a lot of the criticisms that we hear from our audience, from the students we talk about, from our own experiences, is really looking at how difficult it is to get into community mental health that serves these positions that’s also retaining and working on the retention aspect of these employees. What have you found in your research here that’s and what recommendations do you have to address this workforce component?
Dr. Ryan McBain 12:33
Yeah, so there are a few different recommendations that we bring up. But I’ll mention one as an example. It’s a particular segment of the workforce, which is peer support specialists. So one of our recommendations specifically hones in on this workforce group as an example of an entry level healthcare workforce provider. There are a few different pieces for for this group. So one, as I mentioned before, is a payment issue. So oftentimes, health systems aren’t sure how to integrate peer support specialists into their existing frameworks. And there’s not a large profit margin there for those practices. But oftentimes, what those providers offer are sort of frontline support for individuals who have needs. So if you have a mental health issue, and you’re trying to figure out who to call, a peer support specialist is sort of the first person that you might reach out to because they have that lived experience, they’ve been there, they know the sorts of resources that that they would go to if they were to look around. And unfortunately, what ends up happening is the health systems, they make more money if you end up at an emergency room or at inpatients. And so if the system were changed, so that payment were such that you are paying for value rather than for services, then the system would be discouraged from taking on the cost of an emergency room or an inpatient visit. And they would want to try to prevent those sorts of cases from happening by pushing care out into communities where patients are at an earlier point. So focusing more on the prevention end of the spectrum. Second issue that when I think about peer support, specifically, is a professionalization of that segment of the workforce. So you have a really fragmented system when you look across the different states. So, if you talk about things like certification, and the average peer support specialists has about 50 hours of sort of didactic training, but that varies dramatically across states. And in some states, they have very high amounts of hours that people need to contribute as a sort of practicum experience before they’re able to get certified. And the amount of time that that certification lasts for varies whether or not you’re able to use that certification across state lines. And so there really needs to be a coalescing, a coming together to say, you know, what are the core competencies for the peer support workforce? And SAMSA has these on their website. I mean, this is not like hocus pocus here. I mean, people have talked about this for a while. And it gets to one of the points that you brought up, Curt, which is that taxation as an example, right? I mean, people don’t like to talk about it, because it’s like, Oh, more taxes, like, that’s the solution. But at the end of the day, right, if you want to transform the landscape, there is not a technocratic way necessarily of doing it. You’re not suddenly going to develop new incentives that overhaul the way that care is provided. You need to be able to have a sort of grassroots movement to professionalize the workforce, to raise wages, to change the way that payment is structured. And legislators have the ability to do that, if it’s a priority. Unfortunately, it’s just not a priority enough of the time.
Katie Vernoy 15:48
I think of the conversations that I’ve had at different levels at different points in my career, I think the money issue becomes a big one. Because I think there’s huge cost. And whether you know, the medical providers get more money or not, there’s still a huge cost to society, when people are using the emergency room as their mental health provider, and a whole other segment of people who are using jails and prisons as their mental health providers. And so there’s huge cost. And so I think there’s a long term cost benefit to having all of these different levels of care. And I think that’s one thing in the report that I really appreciated was this idea of a an evidence based continuum of care, where there actually are steps along the way, including prevention all the way through hospitalization and crisis level care. But one of the questions that came to mind just thinking through, I’ve worked in some of these programs, I did a wraparound program where we had peer support and case managers and facilitators as well as therapists, we were wrapping around families trying to prevent some of the more dangerous things for these kids that were either going into hospitals frequently or into the DCFS system that the child and Child Protective Services. And so to me when I look at those services, and how cases might be prioritized or how funds might be used, and when we look at trying to both balance, cost to society, as well as professionalizing and paying these folks, I feel like there there always are ways that people can make it not work. I hate to be a pessimist, but I think about if we go to a values based system where providers are incentivized to intervene earlier, there also means that they are de-incentivized to work with folks who have a lot of higher level of needs, because the profit margin is lower. How are you guys looking at this idea around, seeing if this payment system works, seeing if we can get the system professionalized without blowing up the costs? Because I know for me with the peer support folks, sometimes it’s hard to find people who will claim lived experience and that’d be part of their job. So I think there’s there’s also a recruiting issue here. So, but what are you guys doing as far as how to ensure that this direction of payment and structuring mental health would actually get to the outcomes that you want? What are the the safeguards there? What are the thoughts around that?
Dr. Nicole Eberhart 18:20
Katie, there’s so much to respond to in your comment, and I’m gonna pick some pieces of it. And I bet Ryan might pick other pieces of it. It’s not in our recent report that we just put out transforming system of care. But Ryan and I have actually done some cost savings evaluation of those LA County wraparound programs that you were you were mentioning, and I think one important thing is taking a big picture approach, like you mentioned. That it’s not just about the cost of the services, but it’s about the costs for society. And so we look at things like the cost of inpatient hospitalization, and we look at the costs of incarceration. And we look at the costs of all that homelessness, and that whole universe of things that are affected by mental health, we can find that some of these programs that seem really expensive, actually can deliver cost savings. And we do take that more global societal approach. And indeed, we have found that with some of our research on other projects. The other issue is, as much as we do cost analyses, I’m always slightly uncomfortable with that question from the first get go. And the reason is, when we treat diabetes, heart disease, all those physical ailments, we don’t need to demonstrate that it saves money. We just need to demonstrate that it makes people well and makes our lives better. And so it always seems to me like a double standard we put on our mental health programs, that we have to save money in addition to improving people’s lives. When making people better is not just a means to an end, which I’m sure you all know and I’m sure all of your listeners know as well.
Dr. Ryan McBain 19:56
It depends on how much in the weeds you want to get. I mean there are issues like risk adjustment, for example, that can take into account the fact that you have people who have more serious needs than others and adjust prices accordingly. Unfortunately, there’s a lot of literature that shows that that sort of risk adjustment doesn’t end up doing the job that it’s supposed to do specifically for behavioral health care. And so there’s a lot of work that needs to be done at both the state and the federal level. That said, just taking a step back, right. So, one of the recommendations that we have is about using tools like LOCUS, which maybe folks might be familiar with, but this Level Of Care Utilization System, which essentially is a way of saying, you know, what is the appropriate set of services, given the sorts of needs that a patient has. And it’s a way of trying to enforce purity in mental health services compared to physical health care. So, depending on what your level of need is, for physical health care, you might have outpatient services and PT, or you might be an inpatient, there’s a whole range, but oftentimes, with mental health care, it’s sort of one end of the spectrum or the other, either you’re in the ER or as you said, you’re in a jail or prison. Or else you’re you’re may be receiving outpatient services. But you know, there should ideally be this continuum of care that includes, you know, more intensive outpatient services, residential services, fortunately, over time through the Mental Health Parity Act, and otherwise, there’s growing precedent for enforcing this, I think about, for example, a court case Wit vs. United behavioral health that was effective in setting some precedent for using tools like the LOCUS. And I’m not sure if folks are aware of this, but actually, one of the most recent pieces that passed through Congress, which is one of these COVID Relief bills, actually includes some really interesting language that specifically looking at parity and coercing different private practices into compliance by providing information so that government can have oversight as to whether or not these these level of care guidelines are being satisfied or not.
… 22:05
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Curt Widhalm 22:05
I’m gonna go back to one of the other pieces that you mentioned earlier, which is about the education piece about talking about mental health in, in K through 12 settings. And you identified a few states and a few programs where this is mandated, and is part of the education curriculum. And surprise, surprise, most states are not on that list. How do we see getting this into more of the curriculum as far as introducing this earlier and earlier, so that way, it’s not just children like mine, who are the children of therapists who are used to talking about anxiety in second grade? Right, making this a more accessible discussion for kids of all ages.
Dr. Nicole Eberhart 22:49
I think you’re right, that that’s a key issue. And we start with our kids talking about physical health, again, pretty much from the get go in elementary school. And we don’t treat mental health that same way. We treat it differently, we kind of signal you should find this stigmatizing and embarrassing, and we also don’t develop the skills that people need. So, both coping skills, as well as skills for knowing how to get help when you need it. And so I think there has to be some state educational guidelines. So a lot of our recommendations are really for the healthcare sector. This is a recommendation we have that’s really for the education sector, to have standards for mental health education, just like you have standards for physical health education, and integrated everywhere you’re teaching health. That health can’t be isolated as one piece of you certain systems in your body and not other systems. So, I think that’s where we’re gonna need the states to step in, and to create guidelines. And we do have in the report some ideas about what’s evidence based in terms of where to start.
Dr. Ryan McBain 23:54
I’ll just add to that, too, I just want to say that one of the things that we found in reviewing the evidence is that if you look at initiatives like mental health first aid, for example, oftentimes these are like one time events, right? They’ll they’ll go to a school system or college, wherever it might be. They’ll they’ll do a training and there have been studies that measure to see like, how does that change people’s attitude? Does it change, uptake and utilization of services? And they’ll often find that there are these like short term effects that they have. But the studies that look over a longer time horizon tend to find that it doesn’t stick. And so that’s where the school system becomes really interesting, right? Because you have the ability over a much longer arc K through 12, to begin sensitizing and educating on different dimensions of this, potentially even to do screening in school based settings as well. I think the reality is too that about half of pediatric mental health services ultimately, are delivered through school systems. Which has been a huge difficulty, I think over the course of Coronavirus to realize that as a schools shut down, but mental health services aren’t there as well. So I think there’s a recognition that if we’re already providing treatment in these contexts that, that it’s really fertile ground for for something that’s, that’s more comprehensive than than what’s typically being done in, in a lot of settings. And ideally, if we are able to look to some of the states that are really taking this to the next level, like New York, we’ll be able to over time measure what those impacts are for, for children.
Dr. Nicole Eberhart 25:27
And there is evidence that even a brief one week curriculum can be effective. But more commonly, the evidence supports even maybe a six week six session curricula that can help do things like reduce mental health stigma, improve attitudes toward mental illness, increase knowledge, help people figure out how they can seek help. So although I want to boldly envision mental health being part of K 12, I think we can start with something and it’d be better than nothing. And we could start with, say middle school, knowing that a lot of mental health problems have onset in adolescence, if we can’t envision moving it into the entire K through 12 curriculum. And there’s lots of models for this, like you said, lots of states aren’t doing it. But lots of states also are. So, they can serve as models for other states in figuring out how they want to mandate mental health education.
Katie Vernoy 26:20
And so we start with, you know, I’m just kind of imagining this whole continuum, both timeline as well as continuum of care. But we start with this prevention element, as well as a screening and identification of, of problems early on, as well, as I was reading the report closely for also prevention, meaning like skills training, and other things that will potentially help us as a society overall, actually, just incorporating those things into K through 12 and not just math and English and Science. But I think, actually, interpersonal skills and coping strategies, it’s exciting. It’s very exciting. And so I imagine that that is the most forward looking because that is planting the seeds early and allowing for that generation of folks and the coming generations of folks to kind of understand, decreasing the stigma, allowing for some of these longer term goals of, you know, a fully integrated mental health system that supports people at all levels, all stages of their lives. But it seems like there’s so many structural issues that you’ve identified. And it seems like the time is now. We talked about kind of how COVID has had an impact on our understanding of mental health and the desire, I think, for folks to solve some of these problems. What’s the low hanging fruit? There’s potentially pushback, because kids need to have time and we can only have so much or whatever. I think there’s pushback there. But there are true issues that we’re facing that I think may have some support. So where do we start with trying to solve these problems?
Dr. Nicole Eberhart 28:01
Right. And I would say, I would agree with you that mental health education is probably not quite the low hanging fruit. Here’s what I think is low hanging, or rather where I think there’s windows of opportunity right now. So one place where I think there’s a huge window of opportunity is telehealth, telemental health care. The COVID pandemic really revealed a lot of the cracks in our mental health system of care as we talked about, but it also created a lot of momentum for change. We’ve seen an unprecedented expansion of access to telehealth services for mental health. And it’s really helped deal with a lot of the issues we’ve talked about already. For instance, some of the geographical inequities and access to care, right. So it’s had a really strong impact in rural areas as well, where we don’t have a lot of specialty providers. I mean it’s been really important, especially in rural areas to have audio only coverage as well. And so it’s already been done. The cat is out of the bag. And now the question is, are we going to make this expansion permanent? And are we going to make sure that telehealth continues to be flexible. It would be really low hanging fruit to just make permanent the stuff that’s already happening right now, by compelling insurers to reimburse for tele mental health services, including those audio only services that are so instrumental for older individuals and in areas that don’t have good broadband access, as well as continuing to promote expansion of digital infrastructure in rural communities so they can have that access that does go beyond the audio only. You can’t really go lower hanging then something that’s really already been done. And just making sure that it’s still there for people after this crisis is over. And there’ll be another crisis, right. That’s the way life works. And we’ll be prepared if we already have this infrastructure set up, and we don’t roll back some of those expansions. I think, another window of opportunity, I don’t know if I call it low hanging but I would say that there’s a lot of political will in this area, has to do with mental health crisis response. And you know, I mentioned before that example of, you know, you call 911, for your your heart attack, you know what you’re getting. You call for your panic attack, who knows what you’re gonna get. And the reason I think that we have an important window of opportunity for changing that is twofold. One is that we have a lot of momentum around the Black Lives Matter movement right now. And so the nation is really attuned to issues related to social justice and policing. And that intersects with mental health because police are often the first responders in mental health crises. The other thing happening simultaneously is Congress recently passed legislation that set up the National Mental Health 988 hotline. So in my example, we’re calling 911. But starting next year, people are going to be calling 988. So now we have this window of opportunity, where we need to build up mental health access, because people are going to call that number, but then what? We need to have, we need to have a crisis response system that’s ready to deal with that increased utilization, right. So here’s our opportunity, we can build an evidence based crisis response system, we know some things about what works at the state and local level. And our report details this. We know that mobile mental health crisis teams work, and that they could involve police officers, but they also could involve mental health professionals, EMTs, a mix of them. We know to the extent that they do involve officers that law enforcement education programs can decrease the use of force, decrease arrests, increase connection to mental health care instead. And we know that it’s helpful to have stepped down psychiatric facilities, essentially, you know, psychiatric ERs, that can provide crisis care, that’s not in an ER setting. There’s a lot that we can do. And I think the time is really ripe to do it. It’s hard. It’s not low hanging in the sense that it’s easy, like the telehealth stuff, but I think everything is kind of keyed up to make this the moment to do that kind of work.
Dr. Ryan McBain 32:10
Yeah, there are some really good examples, too. Like Arizona, for example, has a really interesting model for Crisis Intervention response called Crisis Now, and they put together a few of the different components that Nicole mentioned. And in addition to it, generating really positive outcomes. They at this point, have saved themselves about a quarter billion dollars worth of police FTEs among other things. So, it’s, it’s a really unique opportunity that people could be looking around to say, what are the examples that we could adopt? The question is to go back time and again to this, where’s the money to come from? Right? So if 988 is going to be instituted, a year from now, and we have existing models that are somewhat archaic, how are we going to get from where we are now to where where we want to be a year from now?
Curt Widhalm 32:58
One of the challenges that you’ve brought up, and we’re going to continue to explore in this series is about the compartmentalization of all the different departments that would really make this a cohesive thing. And for example, if I’m in charge of a department of education in a state, I’m used to my budget being a certain number of dollars. But if some of those dollars are now being directed to Department of Mental Health in that state, that ends up becoming one of the difficult points in making some of these things take action. And, you know, taking this from kind of the rose colored glasses of what mental health care could be into practical steps for our listeners. What suggestions do you have for the people who are listening to this podcast to start being able to get our government people to listen to this? And I say that in the for those of us who’ve been looking at workforce issues, mental health care delivery issues, a lot of this stuff seems like stuff that we’ve been talking about forever. What can we do now to actually put this into place?
Dr. Ryan McBain 34:04
That’s a great question. I mean, not to belabor the point that we’ve been talking about this forever. But I think way back to 2003, with the President’s Freedom Commission, and you look at some of the rhetoric that’s in there, and it’s it’s no different from some of the rhetoric that’s in the Annapolis Coalition publications that have come out that have focused specifically on behavioral health workforce. And some of the issues that we’re talking about today, which I mean, at the end of the day, what I think of is needing to continue to advocate and it sounds self serving, but I think that from a research perspective, to be able to say, to sort of look at a distribution right and say, here are some states or here, some localities that are doing really well. So for example, the Arizona example that I gave, to be able to point to those and say, here’s an opportunity that you could really win, right. If you’re a governor or you’re a mayor and you’re trying to think about what you can do to really improve lives and while mental health is on the table to have a conversation while we’re all sort of going through our own mental health struggles over the course of COVID. Fear of, you know, financial distress and fear for loved ones and for our own health, I think that there is a potential window of opportunity to say, look around, figure out what models are best, and try to rally together to institute those. But I do think that the funding issue is one that it come back to time and again, and I think that unless you’re able to make it a priority, it’s it’s just not going to happen. I think about for example, during the Obama administration back in, I think it was 2013, or 2014, the president said, you know, what, we don’t have enough mental health providers in our VA system, and wrote a budget line through budget reconciliation added over 3000 members to the mental health workforce, specifically within the VA. And, you know, that’s, that’s major impact right there. But it needs somebody to be able to be an advocate for that. And for us all to be our own sort of mini advocates, even if we’re fragmented to see what sorts of professional organizations we can join, and to try to continue to make the argument that this is what needs to happen.
Dr. Nicole Eberhart 36:12
I think it’s challenging for sure. And I think one of the great things about our mental health system with care is it has been very grassroots and kind of bottom up. But some of these changes are really going to have to happen in more of a top down higher levels of government, because of the fact that they do intersect with multiple systems of care. So you know, when we have someone released from the jail at 2am, with some referrals and no connection to care, I mean, this person is not going to get their mental health needs met. And if they don’t, it costs more money in the long run. So forget about the budget for the jails, and the budget for the mental health system. Think about, you know, the state budget, or the county budget, or whatever the appropriate unit is for that person at that time. So I think we’re gonna have a coordinated system that does work across mental health, physical health, you mentioned the Department of Child and Family Services, I’m mentioning criminal justice, you will need to have some coordination that happens at a higher level for that to happen. And, you know, there’s some evidence that it can be cost effective. Again, we don’t need to necessarily throw more money at the problem, we need to organize that money differently. But that won’t happen if we’re at the level of the budget of an individual department, it’s going to have to happen at a higher budgetary level.
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Katie Vernoy 37:30
I like the idea of coordination of care. And I like the idea of being able to look at it in a bigger picture and have it happen at a more systemic level. Because I think there’s a lot of clinicians who have individually felt they need to solve this problem in one way or another and haven’t been able to do a lot, because the problem is so huge. The question I have, because Curt and I’ve done some some lobbying to try to even get additional mental health care providers on Medicare. And then it always comes back to well it’ll cost more money. It’s like, but but we need we need mental health providers, you know, so. So, I get that there’s, and I loved what you said earlier, Nicole about why do we have to prove that there’s a cost savings, we just have to prove that we’re helping people live better lives? And I’m like, yes. So I think there’s that. But I think the the thing that comes back to is that there are always going to be folks who want to know what the costs are, what the cost savings are, what it actually looks like. And there was some of that in this report. And I would recommend anyone who has any interest in this at all to take a look at the report or at the shorter article that kind of summarizes it because they there’s a lot of really great ideas here and and good information. But you had mentioned, I think, around different type of data that shows that there are cost savings. Is there a place that people can access that if they are interacting with their legislators or with policymakers? Like do you guys have, does RAND have some data that we can say, Hey, look at this, this is actually going to help you. Because that would I think would be helpful for our individual advocacy efforts if we had a kind of a compendium of data that we can pull out of our back pocket.
Dr. Nicole Eberhart 39:12
We do have lots of data. I don’t know if I’d call it a compendium. Maybe we need to work on that because we have data from like lots of different projects that Ryan and I have worked on, but also others at RAND. So I mentioned that we did do that cost savings analysis for the wraparound full service partnership programs in LA County because you mentioned that’s where where you’re located. But we’ve you know, we’ve done cost benefit analysis for California statewide stuff. We’ve done that stuff in New York state we’ve done it in a lot of different places. I can try to you know after this the show, we can try to pull some of it together and send it to you to share with your listeners because we have quite a lot but it’s not probably organized in the way that you would like. But the evidence is there that I can say
Dr. Ryan McBain 39:57
I thought about this before as well that, I guess, usually what I’ll do, if I’m interested to know about cost savings of something is I’ll go to pubmed.gov and try to find a systematic review that organizes a bunch of this information in one place. But it’s not a particularly useful tool, right, you need to be able to pay for the articles to see them a lot of times, like it’s not, aND it’s not particularly user friendly by any stretch of the imagination. So it would be, it’d be a really interesting idea If there were a place that anybody could go to, and type in a certain type of program and look to see what the evidence is on it. I mean, the closest thing that I can think of is the University of Michigan has a center that specifically on the behavioral health workforce, and they have a lot of different evidence there that goes through some of these dimensions, including some of these, these cost arguments. And the vast majority of the reports that they have are publicly available in the public domain. So, there’ll be one place that listeners could check out but otherwise, I like the idea, I like the idea of doing this as a follow on it’s an interesting thought.
Curt Widhalm 41:03
Where can people find out more about you and the work that you’re doing and your social media?
Dr. Nicole Eberhart 41:09
Well, if they go to www.rand.org, they can look up mental health, they’ll come across our report that we’ve been talking about today, as well as a lot of other resources. We did set up an email alias as well, we’ll you’ll reach our Ryan and me and some of our other colleagues. It’s just mental health. One word@rand.org. So that’s probably the easiest way to to reach some of the RAND experts. Gosh, Twitter handles and stuff I have to you’re gonna embarrass me because I don’t even remember my own Twitter handle. I’m gonna have to pull that up. Ryan might know where he might be adding while I while I do that, clearly, I’m not on Twitter enough, right?
Dr. Ryan McBain 41:46
Yeah, I don’t tweet too much. But you could, I mean, there is just @ RAND Corporation. And the RAND Corporation puts out a lot on Twitter, pretty much every day, we have over 200,000 subscribers, you should subscribe as well, if you’re interested in trying to understand some of the policy angles on on these sorts of issues.
Dr. Nicole Eberhart 42:06
And I found my Twitter handle, by the way, it’s, it’s @ Nicole K Eberhart. So N-i-c-o-l-e, capital K, capital E-b-e-r-ha-r-t. And so I do occasionally tweet out RAND oriented stuff about our research. But Ryan’s right, if you follow RAND on Twitter, that’s a great way to go.
Curt Widhalm 42:30
And we will include links to all of the stuff that we can source for you, including their Twitter handles at mtsgpodcast.com. What I love about this interview is that this does take a very comprehensive approach to looking a lot of different areas of industry within the mental health field. And while a lot of this emphasis is going to be on specialty things like Medicaid and Medicare reimbursed areas. I love that this is looking into education. This is looking at policy, this is looking at things like peer counselors that a lot of clinicians don’t find out about until their first day on the job.
Katie Vernoy 43:14
Yeah.
Curt Widhalm 43:16
But what I really like, Katie, from your experience is, and I’ve noticed this in some of the other interviews that we’re going to be publishing as part of this series is your experience of working in community mental health and saying, Look, this has some really, drastically detrimental effects on the clinicians in these things, more paperwork, more unfunded mandates. I appreciate the you’re bringing this in here. And I appreciate that the broad range of experiences, and I hope that our modern therapists audience will share with us as you go through this series with us is the experiences that you’ve had working in these kinds of environments. Because for us to really take this and make it have action is not just us thinking that we know everybody’s stories. That when we go and especially when we talk in our next episode with California State Senator Henry Stern, talking about talking with government officials about this kind of stuff. It’s these stories that make things practical. It’s these things that make these policies and these programs actually get held up to a certain level of scrutiny as far as what the practical effects are. So please share that with us on our social media or checkouts ways to contact us at our website mtsgpodcast.com.
Katie Vernoy 44:46
For me, the, thank you by the way, I’m glad my experience is helpful. But for me the thing that I’ve been really excited about and in this conversation with the RAND folks as well as the subsequent conversations we’ve had and that we’re planning to have. We’re in some ways kind of finding a way to be at the table with folks who are actually going to do something. So, after we finished recording Ryan, and I kept talking, and he commented to me, you’re actually talking to people about this stuff at a point when there’s decisions happening. I was like, Oh, my gosh, we totally are. And this is so exciting, because we talked to researchers at RAND, gave them some ideas, have set up that relationship, and we can start potentially having a tiny bit of impact on what they’re thinking about and adding to that Think Tank. Maybe not, maybe maybe I’m overestimating the impact we’ll be able to have. But even in the conversation with Stern that we’re going to have next week, I think it’s, it’s something where he was like, Oh, I hadn’t thought about that. And we have it recorded. And so I think the thing that I want for folks who are listening to this and are excited about this, as excited about this as we are, please join the Facebook group and join the conversations there. Send us an email, let us know what your experience is, or if there’s stuff we’re missing or things that we’re not getting quite righ. Because this is a dynamic continuing process and we want to continue to have these conversations, whether they fit into our cute little series or not, I want us to this is this is real for us. And we want to we want to actually have an opportunity to amplify these conversations, these stories and make a difference. That would be awesome.
Curt Widhalm 46:32
Tune in next week. Subscribe so you don’t miss any of the episodes in this series and continue to be a wonderful modern therapists. I’m Curt Widhalm with Katie Vernoy.
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Announcer 46:44
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