Mental Health GPS

If I start outsourcing all my navigation to a little talking box in my car, I’m sort of screwed. I’m going to lose my car in the parking lot every single time.  ~ Ken Jennings

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I love lighthouses.  I’ve never captained a ship, so I probably don’t love lighthouses as much as did the ships’ captains of the 18th and 19th centuries, whose lives and those of their crews depended very  literally on lighthouses, but nevertheless I’ve always admired those who built them and faithfully operated them.

Recently I began wondering if there were any belfries out there that doubled as lighthouses.  Turns out that there have been a few.

This little “bell tower”, which also doubled as a lighthouse, stood at the mouth of the Christiana River near Wilmington, Delaware in the late 1800s and early 1900s.  It no longer exists, but it must have been proud to do double duty while it lasted!

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Here is another interesting building!

This tower (the octagonal-shaped tower to the right of the picture) was built by the Romans just off the coast at Dover, England in the FIRST century, A.D.!  This means, obviously, that this tower is nearly 2,000 years old!  Amazing.  The Saxon-era church known as St. Mary-in-Castro, which stands alongside the tower, was built far later than the ancient lighthouse.  This tower was originally twice as tall as it is now.  Here it is about 4 stories high, but it originally was 8 stories tall, with the top level serving as both lookout and lighthouse, aiding Roman ships coming across from what is now France, or out of the Mediterranean Sea.  When the church was built, though, the top level shown here was turned into a belfry, and is still both a bell tower and has some lighthouse-type equipment for shining a light over the sea nearby!

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This next picture is a little change of pace!

See any belfries in the picture?  At first glance, we don’t, but …

These two gentlemen, Gary Silcock and Phil Lewin, are employed at the famous British golf course and club known as The Belfry.  The Belfry has implemented in their golf carts a new GPS method of tracking where you are while playing a round on their links.  This picture doesn’t do it full justice, but the GPS monitor shown here can give you an exact reading of how far you are sitting from the cup at any point on a particular hole.  It also gives you distance to water hazards and sand traps, which for players who actually possess golf skill (a condition extremely foreign to this writer!) can be very helpful in deciding which club to use on a given shot, and how to play it.  For avid golfers, this is GPS’ potential applied in the finest way possible!

Almost every time I have looked up pictures of belfries, I can count on there being at least one of The Belfry golf course and its beautiful main building (part of which is shown above in the distance).  And now I’ve finally had the chance to use one of these pictures in a post!  I’m very pleased with myself!

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I own a small GPS monitor that was given to me a few years ago.  I don’t use it anymore, as it was a fairly low-tech model, and the software was not really updateable (is that a word?).   Plus, being the arrogant, egocentric fool that I often am, I tell myself that I don’t need one; that I can find my way around no matter what.  And, if I know I’m venturing somewhere unfamiliar in my car, I’ll look up directions ahead of time and print them!

Unfortunately, though, there are times when having one would really come in handy!  Especially if the device can steer you clear of bottlenecks in traffic, construction, or other pitfalls, or if it can give you others’ recommendations about the best places to eat, to visit, or in which to stay.  I don’t know … maybe one of these days I’ll invest in a better one and try using GPS again.

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Mental Health GPS!:

So, what do I mean by the title of this post, “Mental Health GPS”?

By using this made-up phrase I am referring to how one might find their way around the array of mental healthcare services that are currently available in our society.  And, by “our society” I’m afraid I’m only speaking of the way things are in the United States.  I simply have no knowledge of how mental health services are laid out and delivered in other nations.  Sorry about that.

I often am approached by friends, family, even co-workers, who have either difficulties themselves, or know someone who is in need of help, asking for my advice about where and with whom and how to find that help.  It is a big question, very important for people who really need quality services that they can afford, especially when most people really are very unaware of how mental health treatment is delivered nowadays.  Finding the right care in a timely fashion can be lifesaving in some cases, can make a huge difference for good in many other cases, yet for some odd reason our delivery system is not well-geared to making this search easy.

Let’s talk about it.

Where do most people start?  Where do they typically begin when they start to realize that something is going on that they either can’t snap out of (feeling empty, sad, tearful all the time, tired all the time, sleeping all the time, or even hopeless or suicidal), can’t seem to control (feeling nervous, anxious, fearful, shaky to the point it’s causing trouble in one’s work, school, or social life), isn’t going away over time (grief, anger problems, etc.), or is alarming and scary (hearing voices, panic attacks, feeling paranoid all the time)?  To whom do they turn when they realize they can’t stop drinking or smoking pot, or other drugs?

 

The Tallest Hurdle:

Of course, the main hurdle lies in actually deciding that you are going to try to get help.  Most people I know will avoid seeking help for long periods of time, until they simply can’t wait any longer, or a major crisis arises from which there seems no other option.

 

Where to Begin (Word of Mouth):

Your experience may be different, but most folks I’ve seen have started out by talking to a friend, or occasionally a family member.  Usually most people have known of someone who had mental illness problems and have been told – usually in whispered or gossipy tones – where or how that person tried to get help.  If the result seemed to be positive, then they will be very likely to seek out help from that same source, whether it fits or not.  We don’t like to waste our time or money, and if your cousin was depressed and went to see someone at ABC Counseling Services, and seemed to get worse after 4 or 5 visits, it’s going to be very unlikely that you will call ABC.  If, on the other hand, if your coworker, Dave, was thrown out of his girlfriend’s house because he was constantly losing his temper, and then he went to Dr. X, a family physician in town, was put on medicine, and now swears it has “worked miracles in his life”, it is highly likely you might be looking up the number for Dr. X tonight, whether you have the same problem as Dave or not.

In other words, the most powerful influence in where most people start is “word of mouth”.   And the better you know the person from whose mouth the ‘word’ is coming, the greater the influence.

 

Your Doc:

However, not everyone has heard about places to seek help, and so they start looking elsewhere.   A lot of people will go and see their personal or family doctor to talk about what’s going on, and in MOST cases that is a good place to begin.  Most doctors do take mental illness problems seriously, though they won’t all actually take some time to sit down across from you and ask a few questions, or really listen to what you need to say.  And, most doctors and nurse practitioners do want to help you, and avoid hurting you.  They do, most of the time, know their limitations.  If you go to see them about feeling sad or empty fairly often, most of the time for more than the last two weeks, they might feel comfortable prescribing a standard antidepressant at low to moderate doses, and have you come back in 3-4 weeks.  If you start feeling better, no problem, and they’ll keep the medicine going for a while, knowing you’ll eventually either quit taking it on your own, or you will together decide it’s been long enough and it’s time to stop the med.  And, if there aren’t any major issues going on that contributed to the mild depression, that’s perfectly fine.  Same thing if you’re having a good bit of anxiety in social situations, or you get very irritable right before your period, or if you’re having difficulty getting to sleep.

On the other hand, if you’re seriously thinking about suicide, or your marriage is falling apart, or you’re kicking the dog and yelling at your wife and kids all the time, or they try a couple of different medicines and things seem to be getting worse rather than better, then most doctors will tell you what you likely already know:  it’s time to see a mental health specialist of some sort.  And, for most people in my experience, this is not what they hoped to hear.  It is extremely frightening for most people who have never been exposed to therapists or psychiatrists to think about going to see one, knowing you will have to, if you want to get better, open up some things you typically guard with great secrecy, especially from strangers or casual acquaintances.  But, if you trust your doctor enough, then it’s more likely that you’ll be able to overcome that fear and actually get in touch with whomever the doc suggests or, hopefully, recommends.

 

Yikes!  No doctor!:

Some folks, though, don’t have a primary care doctor.  If they also have no “word of mouth” references, then where do they turn?  There still are Yellow Pages out there, even in the well-established internet search engine age, and many people will begin looking there.  Or, they might sit down and search on the internet for mental health services in their area.  The problems here are that Yellow Pages, either printed or on the internet, typically have no reviews associated with them, and the listings and/or ads only tell you what the service was willing to pay to tell you.  That is, some clinics, counselors, and doctors aren’t even listed, and many others are only a name, an address (maybe), and a phone number.  A few will run ads listing various problems they can help with, or perhaps some of the types of therapy they are trained in and can offer.  Beyond this, you’re going to have to call them to learn anything else.

There are a few forums around on the internet in which various therapists and/or psychiatrists or psychiatric nurse practitioners are rated or reviewed by clients.  Unfortunately, here I really can’t offer much of an opinion.  In my experience the people who take the time to speak up about their therapist or prescriber are either feeling disrespected or ‘cheated’ by the (lack of) care they received, or they are subconsciously magnifying their good feelings about that care to a level that is simply too good to be true.  Not only this, but as you can imagine, with the wide variety of problems and issues that people come in with, one person’s experience with treatment for Post-Traumatic Stress Disorder may be completely irrelevant to whether you would have the same results if you go in to the same provider for relationship counseling, or for diagnosis and treatment of what may be ADHD.

 

The Insurance Nightmare:

Then, of course, once you begin making calls to providers the question inevitably arises, how much is this going to cost me, and how am I going to pay for it?  For those who have health insurance of some sort, the first place they might have to call is their insurance, and in many cases you might have to then call a “behavioral health management” company who contracts with your insurance to screen subscribers and then refer them to certain providers.  In the end, they’re going to send you to the place that will cost THEM the least payout money, and there is very little you can do about it, unless you decide to pay out of pocket for your care.  It’s kind of a mess, to put it mildly.

These days, for good or for ill, a LOT of therapists and psychiatrists are foregoing any kind of insurance affiliations at all, and asking people to simply pay cash for every visit.  Usually there are set fees:  so much for an initial evaluation, so much for follow-up visits, so much for 45-60 minute therapy visits, so much for testing, etc.   They will often file claims for you with your insurance, AFTER you pay them up front, and then anything you get back from your insurance is a kind of rebate.    This change is due to the fact that insurance companies have become systemically corrupt about their obligations.  They simply will not pay doctors, therapists, hospitals, and pharmacies until months or even years have gone by, and that is only in the cases in which they have not denied authorizing the services in the first place (sometimes, insurances have been known to wait until after the services have been given and THEN deny payment).  Insurance exists to help cover the cost of “medically necessary” treatments, but only THEY decide what is medically necessary in many cases.   These kind of practices will likely only get worse until finally some kind of scandal will erupt into the mainstream media, and then the entire industry will hopefully be forced to either change, or be eliminated.  The latter is not bloody likely.

 

Yikes!  No insurance!:

But, what if someone out there doesn’t have any health insurance?  Well, if this person has the resources (i.e., money) they can pay a provider as noted above, paying a cash fee at each visit, or alternatively work out an installment payment agreement, or perhaps in some cases negotiating a reduced fee based on what the person can actually afford to pay.

For others, that’s where companies like the one I work for come in.  I am employed by a community mental health center (CMHC).  This is a type of private but non-profit agency, most of which began in the mid-1960s after Congress passed its famous (among mental health practitioners, at least) “deinstitutionalization” legislation.  Basically, foresightful persons realized that with the advent of better medications for illnesses such as Schizophrenia, and better services to provide care for persons with mental retardation and brain injuries, we did not need to keep these folks cordoned off in state psychiatric hospitals, “asylums”, or nursing homes for the rest of their lives.  Community services, such as psychiatric treatment and case management, as well as residential and day treatment services, were thus put together based on huge grants of money so that every rural county and every urban neighborhood would have a CMHC nearby.  These agencies were organized to take care of these folks coming out of long-term care institutions, but also to provide mental health care for anyone who needed it, regardless of their ability to pay.  Most of the persons we now serve are already disabled in some way, and are covered, at least in part, by some form of Medicare or Medicaid insurance.  But, many who come to us have no insurance, and we typically see them on either a “sliding scale” fee arrangement, or in some cases for no fee at all.  States reimburse CMHCs for these indigent care services in the form of general fund grants or block grants.

Unfortunately, these grants and other forms of public funding are expensive.  Over the decades, federal assistance has gradually diminished to aid states, and thus many states have devised various managed care arrangements, or have even opened up bidding to “for profit” companies to come in and run their public mental health delivery systems.  The results have consistently been disastrous, unless you happen to be an accountant in that state’s budget office, in which case the results might seem more positive.  But, there are various ways to do balance sheets.  When you add in the costs of hospitalization of people who “crashed” due to the lack of service availability  in their community, and various other indirect costs stemming from the lack of affordable or free care, that bottom line might look a little different.

Over time, CMHCs have grown quite a bit from their original mission.  We still provide care for many who have severe and chronic mental illness, as well as any number of services for those with intellectual disabilities, to keep them living in the community.  However, now we also provide psychotherapy services for almost any form of mental health issue.  We provide therapy, school-based, clinic-based, and home-based, for children and adolescents, summer day programs for kids, and comprehensive case management for families when both children and parents have significant mental illnesses.  We provide, in many cases, assessment and treatment for substance abuse problems.  Some CMHCs contract with their localities to run DUI classes and monitoring.  Some provide methadone or Suboxone maintenance clinics for persons with heroin or pain pill adictions.  Some CMHCs have crisis stabilization units, where children or adults can go and stay for 1-7 days when they are in crisis but don’t need the extra security of a locked hospital unit.

Many CMHCs, however, faced with rising costs of employing all the people necessary to provide these broad services, and seeing declining help from their state governments, have now cut way back on what they will provide.  Many have had to close their doors altogether, and a number of areas in the U.S. now have no community psychiatric center around whatsoever.  In many other places the CMHC will only have therapists and psychiatric prescribers, with perhaps a few case managers, and often there is a dearth of all three.  There can be very long waits to get an initial appointment with a therapist, and even longer to see a prescriber, if you see one at all.

In urban areas there are often free clinics where indigent and homeless persons can find some help.  These are typically staffed by volunteers, working either in their spare time, or having already retired from active employment themselves.  These clinics are often lifesaving Godsends for some people for whom it would not take much to see them jumping off of bridges, or stepping out in front of a bus, due to the lack of help and medicine.

Beyond this, many people seek help from their pastors or priests, and some rare larger churches actually employ pastoral counselors on their staff.  Unfortunately, while the potential is high for this mode of service to be extremely helpful, as for so many people their mental illness issues greatly impact their spiritual health, and vice versa, this potential is seldom fulfilled.  The sad reality is that at present seeking help from clergy is often ineffective, misleading, or disillusioning.  Someone who is trusted and who is comfortable discussing the interplay between one’s faith, or struggles with faith, one’s concept and relationship with God, and one’s mental health or mental illness, and is a good listener, on a church staff would be an incredible gift to those parishioners of such a church.   There is a lot more I have to say to those clergy and others in ministry, to try to help them understand mental illness better, and how to better help those struggling with it, but that’s material for another post, another day.  Suffice to say that at present there is still a tremendous amount of misunderstanding and misinformation among the clergy I’m familiar with.  Hopefully we can help see that potential noted above turned around for the better!

 

So what’s going to happen to me?

Once someone locates a provider to whom they’ve either been referred, or whom they’ve heard good things about, or have identified as the one that seems most likely to be the right one for them, or else is the only provider around, the next thing to do is to make a phone call.  Typically, the best person to make the call is the person seeking help!  It might be very hard to pick up that phone or to dial the number and press ‘Send’.  But, hopefully, the courage will be there and it will happen.  Before you call, prepare yourself to ask some questions, and to give a little information about yourself and the type of problems you’re having.  If I were seeking help, I would want to know what the process is.  Who will I see first?  Will I continue to see that person, or will I be “assigned” to someone else after the initial assessment?  Will I see a doctor?  Do I need to see a doctor, or a therapist, or both?  How much will it cost me?  If I have insurance, do they accept my insurance?  Where are they located, and how do I get there?  (yeah, I know, wouldn’t be a problem if I would actually use my GPS!!)  Are they open in the evenings, or on Saturdays?  There may be other questions you can think of that might be important to you.  The person who answers your call, typically an office support person, will usually be able to answer most of the questions noted above.  If you decide during the call that you want to move forward, they should be able to schedule an appointment for you, and let you know what things you need to bring with you to that first visit.  Also, based on what you tell them, they should be able to tell you if it sounds like they will be able to offer help for the kind of problems you’re dealing with, or not.  If not, hopefully the person will be able to give you an idea or two of other providers or services in that area that might be better equipped.

In most cases, if we’re talking about “outpatient” help, in the U.S. your first appointment will likely be with a “therapist”.  Typically this is either a clinical social worker, a clinical psychologist, or a trained counselor of some type.  In some private practices, in which a psychiatrist or a group of psychiatrists, and perhaps nurse practitioners, have no therapists on their staff, then you may see a doctor from the first visit.  In other cases, especially if you have been referred by another doctor, you might see a doctor first, and then if deemed appropriate referred to a therapist as well.

The purpose of the initial appointment is to “assess” you and your problem.  There will be a number and variety of questions asked of you, usually most of them verbal and face to face, but in some practices a lot of the questions will be paper and pen.  Either way, questions will be asked about the nature of the problem(s) you’re dealing with and what or how you have tried to manage it so far, and the results of such efforts.  You’ll be asked about any past treatment you’ve had for similar problems, or any other mental health issues.  There will likely be questions asked about your social background, how life was for you growing up, any major life events or traumas that occurred, your educational and vocational history, as well as family and relationship experiences.  You’ll be asked about drinking and drug use history, with most focus being on current or recent past use/abuse.  You’ll be asked about which blood relatives might have had psychiatric problems or treatment.  There should be some questions about medical history, and any medicines you’re taking for any reason.  They should focus particularly on any neurological conditions you may have had:  seizures, head injuries, etc.  Finally, you should be asked about what your own hopes, goals, or expectations for treatment might be.

In light of the above, it is always helpful to think ahead of time about some of the areas I’ve outlined here.  The better and more quickly you can give information, the more time you’ll have to really spell out the main problem that led to seeking help.  And, while most of us who work in the field expect that people will not be ready to discuss very intimate details of their lives, their pain, their fears and insecurities on the first visit with a complete stranger, it is always best to be as honest as you can be.  As I have often told people I see, I don’t get upset about not being told the truth … I understand the drive to thought well of, and to hide when we’re fearful.  However, if I’m given an overall picture of what is really someone’s “pretend” life, or “pretend” problems, then the treatment I can offer will also be “pretend”, too.  Not intentionally, of course, but pretend nonetheless.

 

The Closing Discussion:

At the conclusion of this visit you should get some feedback.  You should expect to be told what the therapist or doctor thinks is going on, and possibly a “diagnosis”.  However, please be wary about placing too much emphasis on a diagnosis or label, especially in the psychiatric field.

The way I think about things for my patients is in terms of:

1) symptoms – things one experiences that are or could be “treatable”, maybe with medical treatments such as medicine;  This could be things such as depressed mood, panic attacks, difficulty falling asleep, hearing voices, or a tendency to have manic mood episodes at times.

2) issues – patterns, conflicts, social tendencies, longstanding resentments and fears, etc., that a person can learn to manage or resolve better, typically through learning better insights, strategies, self-talk, communication techniques, etc.;

3) prevention – that is, (and this is where knowing the diagnosis is or can be important) what near or distant future problems or recurrences or relapses is this person most at risk of, and how can we work together to prevent those problems on an ongoing basis.  In diagnoses such as recurring Depression, Bipolar Disorder, Schizophrenia, Panic Disorder, or Substance addictions, prevention is huge in the long-term treatment of these conditions.

At any rate, the person who assesses you intially should be able to give you a picture of where they think you should go from there.  If you clearly or very possibly could benefit from medical treatment, if it’s a therapist seeing you they should get you scheduled for an appointment with a prescriber (usually one in their own practice or clinic, and if not, someone to whom they frequently refer and with whom they are comfortable, given your presenting problems).  If it’s a prescriber you’re seeing, then they will talk about possible medication options.

They also should give you a synopsis of how they see your “issues” and how therapy might be able to help.  They could give you a few ideas of ways that you might begin to make helpful changes in your lifestyle or the way you address frustrations or conflict in your relationships, or setting better boundaries for yourself at work, for example.  However, in many cases they might wait on this kind of discussion until the next appointment(s), when the focus will begin narrowing to the main problems at hand, and less on getting a broad picture of you as a person.

Something just doesn’t seem right!

How will you know if the therapist or doctor you’re seeing is “right” for you?  This is a tough issue, as sometimes, especially if you go into therapy, this person may be helping you see things in your life that are critically important, but which you won’t be very comfortable thinking or talking about.  She or he may begin discussing defenses of yours, or tendencies you have, or patterns of self-talk you do, that will need to be changed or gradually eliminated, and this may be very frightening to you.  So you have to be careful about wishes to “try someone new”, when sticking with the caregiver you’re seeing is exactly what you need to do!

In mental health, as with almost any kind of situation in which we turn to a professional for help, there are three traits of such a professional that are most important in getting the help you want and need:

1)  Knowledge base of the kind of problem you have;  This refers to how well-educated this professional is about the nature of your particular problem and the best ways to treat it.  In therapists, for example, there is one form of therapy that has been shown again and again to be very highly effective for conditions such as depression, obsessive-compulsive disorder, and certain types of anxiety:  Cognitive-Behavioral Therapy.  Unfortunately, relatively few therapists really have been trained in how to do this (CBT) well.  They have all heard about it, and been given some basic information about how it is done and how it works.  But that is a far different thing than to have been really trained in the method.  In prescribers, knowledge must include a good understanding of how to differentiate between things that should be medicated and those that should not.  It should also include a good working knowledge of the various medicines one might prescribe, the risks of each, and possible interactions and other effects with other medicines and general medical conditions.

2)  Experience;  As with anything difficult, helping people with mental illness is something for which there is no substitute for experience.  It takes time and doing it a lot to become adept and really effective.  Unfortunately, again, in this field there are many people out there who have no choice but to start out their therapy, especially, with counselors who just finished a Master’s degree program, often with precious little actual experience doing therapy under supervision.  This can be a rough thing when you need help quickly and it might be too much to expect novices to be smooth and comfortable.

3)  The right fit!  I’ve listed this one third, but in reality it is THE most important factor, and is the one that often makes or breaks the “result”.  This refers to whether or not you can develop trust for the professional.  Does he or she seem to really understand what you’re dealing with, what your experience has been like?  Do they convey a sense that they can empathize with you?  Does her or his personality fit with yours?  Do they have good listening skills?  Do they seem confident that they can help you help yourself with the problem?  Do they seem warm, or cold?  Do they make eye contact with you?  Are they condescending, or seem to smirk when you talk about certain struggles you have?  If you come to them and sincerely tell them that a certain medicine is, or has been, really working well for you, does she or he dismiss this out of hand, and either want to take you off the medicine or eliminate it as a possible option automatically?  Do they make suggestions, give recommendations, or give ‘directives’?  If you are in crisis, but you tell the caregiver that you are deathly afraid of being sent to a hospital, do they work with you to find alternative ways to ensure your safety until the crisis passes, or do they seem unwilling to consider anything but hospitalization?  These are the kinds of things that can make a huge difference in both the short run and the longer term.

If you decide that you simply cannot work well with a particular professional, you have the right to ask for a change.  However, be careful, as you never know when such a request will be taken personally, and things can quickly become very tense in their office or clinic.  We in the field of mental health care, and in medicine in particular, have been trained to NOT take such requests or statements personally, realizing that such statements may be very healthy for the patient to make, and that not all helper-client relationships are going to be a good fit either way.  The caregiver may, and really should, ask to discuss the reasons for your change of provider request, just to help both you and they to see where there could be misunderstandings, false expectations, or perhaps areas in which the professional might improve the way they listen and interact.

The more difficult thing, though, is that people rarely want to hurt others’ feelings, and many recoil from asking  for a new provider for fear of making their current one “feel bad”, or “get mad”.  I understand.  I would feel the same.  But, it is your life, and if you need to see someone else, it is perfectly ok.  The sad thing is that, rather than asking for a referral to someone else, they will simply stop showing up for appointments, or stop setting up new ones.

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I hope this discussion will be helpful to you or to someone who asks you for advice or suggestions.  There is obviously far more to talk about that falls under the umbrella of “navigating the mental health waters.”   Knowing whether you’re getting “better”, how quickly or how much better you should expect to get, and whether the care you’re receiving is really the best treatment, not to mention talking about inpatient care, or about all of the auxiliary forms of treatment such as 12-Step groups, support groups, intensive outpatient treatment programs, and substance abuse rehab centers, are all fairly important discussions that are also both broad and deep.  Hopefully we can look at those in the future.

For now, though, I hope this has given you some direction, and some basic pointers of how to get off to a good start in treatment.  If you’ve seen any holes in what I’ve laid out, or have suggestions or questions, please feel free to leave a comment, and I’ll try to respond!

Craig Meek, M.D.

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