*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following the perspective of an individual who is found in the future but who was a child. We invite you to meet Alex, who will begin their journey at age 18 and over the month of May Alex will reflect on the benefits gained from living in a system with preventive mental health policies.
*When we hear from Alex this week, they will have graduated from their undergraduate studies and been living in a medium size city after finding a job in their field. Alex has been in a serious relationship over the last six months and writes this journal entry reflecting on that relationship.
“What an amazing few months it has been! Meeting Frankie has really been a dream come true. I had no idea I could feel this way about a person. The first few months were of course our honeymoon stage, not the “I do” kind of honeymoon, but the most romantic and on cloud 9 I have ever felt. I may as well have said I do! I knew to expect those kinds of feelings though when it started. Sam, my therapist, talked to me over the years when I met with her for my annual appointments. I met with Sam a few more times when I was in some of my first relationships just a few years ago and she taught me a lot about what a healthy relationship looked like. What stood out the most in our conversations was the importance of being treated with respect and having a balance of yourself and your own interests plus the relationship in your life. In other words, when I felt myself getting pulled into a relationship too deep, she would remind me to stay involved in the parts of my life that make me who I am as an individual. For example, keeping up with my school work, my hobbies, and spending time with my family and other friends are all part of who I am as an individual. It is easy to get sucked into that one relationship and have it sort of become your entire world, but I think after our annual, and sometimes more, meetings I finally understand. I think those talks really helped me be a better partner from the start with Frankie too.
My relationship with my parents also really was stronger because of those meetings with Sam. Not only have I seen my parents have a strong relationship with each other, but our relationship changed as I got older and somehow though they were not as involved in every decision I made, our relationship seemed to grow stronger. Sometimes my parents would come to my appointments with Sam. She helped us navigate our relational boundaries so that they learned to trust my decisions more, and I also learned to stay open to their feedback without feeling defensive. I think even this lesson in boundaries has helped my relationship with Frankie have a healthy balance.
I just continue to be amazed how those meetings with Sam over the years have really had a lasting impact in my life. Knowing what to expect in a healthy relationship before you get into a relationship at all has been super helpful. Who knows, maybe Frankie will be the one, but I know I stand a better shot at making sure this relationship is healthy and strong thanks to those conversations with Sam and my strong relationship with my parents.” – Signed Alex
*For the month of May, honoring Mental Health Awareness, the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership and Innovation, will host a series of blogs following the perspective of an individual who is emerging into adulthood and received preventative mental health services as a child. We invite you to meet Alex, who will begin their journey at age 18 and over the month Alex will reflect on the benefits gained from living in a system with preventive mental health policies.
by Dr. Lisa Tyndall, LMFT, Dr. Amelia Muse, LMFT, and Mrs. Sara Herrity, MS, LMFT
*Alex recently graduated high school and is a first-generation college student at a University approximately two hours from home.
“Whew, the last few months have been an adjustment. Never having been away from my family longer than a week before, and not having them around at the end of the day has been hard sometimes. Not sure I quite fit in here with so many people around me having a lot more than me, at least cars and nicer clothes. I have met a few people who I like from towns and backgrounds like mine and that has been helpful.
I have to be honest though, there have been times I just want to hide out in my room scrolling on my phone or trying to study in the library. Sometimes things can feel so out of my control and I can feel really small. Studying or playing my video games or scrolling can seem like the only thing I know to do in order to feel okay. I knew getting my head in the books and in classes would help for a bit, but I was also glad to remember some of the things I learned over the years with my therapist and pediatrician.
Dr. Johnson and Sam were so helpful at my annual appointments each year. I honestly cannot remember a time that they were not in my life. One thing I remember is they said the same thing, but would talk about it differently. Dr. Johnson would talk to me about staying active for my health. Sam would talk to me about staying active too, and it seemed to reinforce what Dr. Johnson said, but would then add how it helped with my stress and mood. I learned that sometimes when I went through times that I felt anxious or down about life, a good workout was always something that helped, and I was able to really get out of my head. Sam would share with me how talking out the stress, like with her, my parents or my good friends, also helped. My check-ins with both of them gave me the coping tools and support to take charge of how I feel.
I am grateful though that I had the benefit of talking to Sam and Dr. Johnson both because I know it was not always this way. My parents have said that no one used to go to therapy unless things were really bad, then the pandemic of 2020 happened, and some things changed. I am grateful that there is not stigma any more around people talking to their therapist, that even my friends have talked about having to go to therapy sometimes, and that my insurance has made it possible for me to get that support before I technically needed it. Now, along with other tools that I learned over the years, I check in with the student counseling center on campus once a month or so just to get grounded again. My parents say that now it seems like finally the systems around us have acknowledged how important it is to take care of all the parts of our health. I’m glad I do not have to wonder what it would have been like to grow up without people like Dr. Johnson and Sam.
From the frontlines: Thoughts from a therapist on Suicide Prevention Awareness Month during a pandemic
by Dr. Rebecca Levy, LMFTA
September is National Suicide Prevention Awareness Month. In the past year and a half, we have experienced a great deal of tragedy, especially when considering the impact of this pandemic on mental health. Prior to the pandemic, researchers reported that approximately 50% of people who attempted to kill themselves went to their primary care doctor a week before their suicide attempt. With the impact of this pandemic, there was about a 50% increase in the use of a suicide hotline. As demonstrated by recent studies, COVID-19 has had a profound impact on mental health due to our increased isolation, stress, and fear of illness.
As a mental health provider, I am left with many thoughts; but here is my take on some of the major considerations of dealing with mental health issues during an international health crisis.
Telehealth
Helping people who struggle with suicidal ideation has been different this year for many reasons. As a mental health provider, I have had to provide therapy to patients over the phone or over video more than in person. Teletherapy can feel different, disconnected, or even scary, especially with a high-safety-concern patient. What if they are in a different city or even a different state? Before the pandemic, this geographic difference was almost unheard of.
Managing my own stress in conjunction with the increase of patients presenting with suicidal ideation over telehealth has been challenging. This increase in mental health concerns, combined with the physical distance between patients and providers, has been a recipe for mental illness to rear its head. Yet, there are some positives to telehealth for patients struggling with suicidality. Having a virtual option for patients we might not have typically reached has allowed for more access to those populations in need. There is also something to be said about having an emotionally charged conversation with your therapist in the comfort of your own home.
The Secondary Pandemic
As a society, mental health is something we have struggled to address. There is stigma attached to each diagnosis, as well as barriers to getting care. Historically, the importance of mental health has not been viewed as on par with physical health; however, suicidality is the pinnacle of illness because it can result in death. Dare I say that this pandemic has a brought a necessary focus to addressing poor mental health as the crisis it is?
This pandemic may have caused great distress and loss, but maybe it brought us where we need to be in recognizing the importance of taking care of our mental health. The biggest question is, what we do in times like this to help ourselves and our loved ones?
What To Do
What has mattered to people in helping them through a tough time, such as struggling with suicidality?
Normalize. A lot of us do not talk about having thoughts about not wanting to be here, but they are more common than we think. Having that de-stigmatizing perspective, and reminding people that those thoughts and feelings are normal when we are feeling very low, is helpful when talking to people who are having thoughts of suicide.
Ask. As mental health providers, and as friends and family of loved ones, we are doing a disservice by not asking the hard question: Have you had thoughts of hurting yourself in some way? By asking this question, we are normalizing the fact that we can talk about suicide and allowing space for those who are in that place to talk about it.
Listen. During this tough time, it should be everyone’s responsibility to check in on each other and their loved ones. Go ahead and ask that tough question or the easy question, ”How are you?” But take the time to be patient and wait for a real answer, and then truly listen.
Acknowledge –This pandemic is life-changing. The COVID-19 pandemic is overwhelming. Our worlds have been turned upside down. I think one of the most invalidating things I have seen done to people who are struggling with suicidality is telling them that they “need to be grateful” in some form or another. It is more helpful to validate them in their pain (i.e., “It sounds like you are having some really scary thoughts”) or risk emotionally isolating them further.
Get help. There is help if you, or a loved one, is struggling with mental health.Therapy, it can do wonders! A lot of therapy offices have walk-in hours to help patients in crisis. There are also a lot of medication options (e.g., antidepressants) you can discuss with your primary care provider that can bring relief from symptoms of feeling down or hopeless. If you are worried about a loved one, there are options available to help them. Your area may have a Mobile Crisis group that will go to a person’s home and assess for safety, or work collaboratively with the police department to complete a welfare check (which can be requested anonymously if you are nervous to do so!). In addition, you can research your local behavioral health crisis centers to see what services are available. And finally, the Emergency Department of your local hospital is available in cases of severe crises.
It has been a difficult, but enlightening time, supporting patients, providers, and families with mental health and substance use needs throughout the pandemic. When it comes to awareness about suicide prevention, please remember that it is okay to directly ask the hard questions, and there is help available.
If you or someone you know needs help, call: 1-800-273-8255 or Text HOME to 741741
Please call 911 if you sense immediate danger.
Dr. Rebecca Levy is a Medical Family Therapist and the Director of Behavioral Medicine at Cone Family Medicine. She holds a bachelor’s degree in Psychology, a master’s degree in Couple and Family Therapy, a doctorate in Medical Family Therapy, and an associate license in Couple and Family Therapy (LMFTA). Her areas of expertise are suicide assessment, integrated behavioral health care, cultural humility, and family medicine resident wellness. She sees her role in clinical practice, research, and education to advocate for underserved populations and health equality.
The Foundation for Health Leadership & Innovation Secures Funding to Improve and Advocate for Behavioral Health Needs of North Carolina’s Children and Adolescents
The new program, funded by The Duke Endowment, will be led by FHLI’s Center for Excellence for Integrated Care team
CARY— The Center of Excellence for Integrated Care (COE) — a program of the Foundation for Health Leadership & Innovation (FHLI) — has received a grant from The Duke Endowment to lead a three-year program focused on child and adolescent behavioral health. The emphasis of the project is on advocacy for mental health check-ups for children, as well as on training for behavioral health professionals to provide pediatric and family assessments and interventions.
“North Carolina’s health care workforce is doing amazing work every day with well-child exams and preventative services for children and adolescents,” said Dr. Amelia Muse, COE’s Program Director. “However, after the hardships of the past year, it’s time to answer the call for more support for providers, families, and communities on preventative and interventive behavioral health care.”
With a dual emphasis on advocacy and workforce development, The Duke Endowment has provided support for this program that will include partners from the i2i Center for Integrative Health and the North Carolina Area Health Education Center (AHEC) Program.
The COE team will partner with i2i to convene a workgroup of family members, advocates in children’s welfare, and representatives of practitioners to develop a sustainability plan to embed annual behavioral health well-child checks into medical protocols and practices, with a focus on the need for insurance coverage. This additional focus on behavioral health during or in conjunction with the well-child check will bring North Carolina alongside other leadership states, who have worked to support pediatricians, children, and families with additional behavioral health emphasis.
“With our more than 34 years of collaboration and advocacy experience addressing behavioral, I-DD, SUD, and primary healthcare, i2i is well-suited to lead this advocacy effort,” said i2i Executive Director Ann Rodriguez. “We are thrilled to partner with FHLI, COE, and NC AHEC on this critical initiative. The pandemic and North Carolina’s Medicaid transformation efforts have created an opportunity to ramp up integrated, preventative care practices across the state and strengthen whole-child care.”
Simultaneously, the COE team will partner with North Carolina AHEC to address workforce development issues by offering a continuing education opportunity for a cohort of 45 licensed behavioral health providers and ten graduate student interns currently working with youth and families. The one-year specialized training program will focus on mental health and substance use prevention, assessment, and intervention for children and adolescents and their families.
The second year of the program will train a second cohort of behavioral health professionals, with the first cohort of graduates acting as peer supervisors to assist with oversight and case consultation. The training curriculum will be informed by evidence-based literature, as well as by information collected from regularly held workgroup meetings of child and family advocates, youth, family members and providers advising on policy to support child and adolescent behavioral health wellness.
“At the Foundation for Health Leadership & Innovation, we are committed to cultivating a culture of innovation, experimentation, and risk-taking,” said Kelly Calabria, FHLI’s President and Chief Executive Officer. “Given how COVID-19 has exacerbated an already-dire need for behavioral health services for all North Carolinians, we believe this work — led by our team behavioral health experts — is the type of innovative thinking that is needed. We thank the Duke Endowment for recognizing this need and for trusting FHLI to drive a solution.”
About FHLI’s Center of Excellence for Integrated Care The Center of Excellence for Integrated Care (COE) — a program of the Foundation for Health Leadership & Innovation — supports the clinical, operational, and financial transformation of health systems to provide whole-person care. COE’s integrated care experts support communities in providing whole-person care and reducing the stigma of behavioral health for patients and providers. Learn more at www.coeintegratedcare.org.
About the Foundation for Health Leadership & Innovation The Foundation for Health Leadership & Innovation (FHLI) is a nonprofit organization that envisions healthy communities across North Carolina where everyone can flourish. FHLI develops and supports innovative partnerships that build a healthier North Carolina through collaboration and respect. With a long history in the state — and a deep understanding of its health care needs — FHLI scales solutions that benefit the entire state. FHLI staff are thought leaders and experts who bring communities together for a better, healthier North Carolina. Learn more at www.foundationhli.org.
About i2i Center for Integrative Health The i2i Center for Integrative Health is a non-profit 501(c)3 organization whose mission it is to foster collaborative and evidence-based initiatives for improving the quality and efficacy of the behavioral health, intellectual and developmental disabilities, and substance use care and support service systems within a comprehensive system of whole-person care. Learn more at https://i2icenter.org.
About North Carolina AHEC The North Carolina AHEC Program provides and supports educational activities and services with a focus on primary care in rural communities and those with less access to resources to recruit, train, and retain the workforce needed to create a healthy North Carolina. Learn more at https://www.ncahec.net.
About The Duke Endowment Based in Charlotte and established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment is a private foundation that strengthens communities in North Carolina and South Carolina by nurturing children, promoting health, educating minds and enriching spirits. Since its founding, it has distributed more than $4 billion in grants. The Endowment shares a name with Duke University and Duke Energy, but all are separate organizations.
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For more information, contact: Marni Schribman, Director of Communications & Public Relations Foundation for Health Leadership & Innovation (FHLI) Marni.schribman@foundationhli.org 919-259-4547
Seven helpful tips from a therapist (who has been to therapy herself!) on navigating the decision to start the therapy journey.
by Sara Herrity, MS, LMFT
If the last 15 months have taught us anything, it is that:
Social media is the best and worst thing ever (hello Tiktok dances, but also political debates)
Banana bread has finally been recognized for the ultimate comfort food we never knew we needed, and
Our mental and emotional health matters.
In the beginning of the pandemic, we all were there with feelings of hope and optimism. The thoughts that crossed our mind were along the lines of, “This will just be two weeks, four weeks tops.” These thoughts were soon invaded by feelings of confusion, frustration, isolation, anger, and so much fear of the unknown, and of the virus itself. Gratitude floated in and out depending on the moment. And, for many, survival mode kicked in – just put one foot in front of the other, do what you need to do this minute, and worry about tomorrow… well… tomorrow. And just as we were concerned with our physical health and contracting COVID-19, we were increasingly noticing the toll the pandemic was taking on our mental and emotional health. Added onto all of this was a highly contentious election cycle and an increased discourse surrounding the racial injustices present throughout our systems as a nation.
For myself, I was making every effort to be cautious to protect and care for my physical health while maintaining my mental health. Despite two years in graduate school to become a Marriage and Family Therapist, having worked in behavioral health for more than nine years, having many close friends who were also therapists, and having just wrapped up my own personal course of therapy two weeks before the pandemic hit, I found myself still struggling as this last year moved on.
A good friend told me recently that in tech engineering they say, “If you do not schedule system maintenance, the system will schedule it for you.” The same thing goes for our bodily systems – if we do not schedule time to take care of all parts of ourselves, it will force us to schedule it. This last year has served as a wake-up call for some, and a reminder for others, that our mental and emotional health matters as much as our physical health. We must take time to nurture and care for our bodies, minds, and relationships.
As vaccine distribution increases and restrictions slowly begin to lift, we are preparing to re-engage into our new normal. Despite the feelings of relief and joy this brings, many of us will find ourselves still struggling with feelings of depression, anxiety, fear, confusion, and so forth. If that is the case, and you’ve started to wonder what to do, might I suggest therapy? Here are some helpful tips that can hopefully make navigating the decision to engage in therapy a bit easier:
THINGS DON’T HAVE TO GET “THAT BAD” – I cannot explain to you the number of times I have heard, “Well, I don’t think it’s bad enough that I have to go to therapy.” But that is the point. You can go to therapy when things are going well to process changes, build emotional or relational skills, or get support. Or, you can go to therapy when you feel utterly distressed. A good therapist will meet you wherever you are in your journey and help you get closer to truly living your best life, however you define that.
FIND A FIT – Once you have made the decision to go to therapy, the next step is finding a therapist. Psychologytoday.com is a great resource to find therapists in your area (or online) while allowing you to filter searches and be as particular as you would like – many people prefer a therapist who is a certain gender or race, or of a certain faith background, or offers teletherapy appointments or in-person, only takes sliding fee scale, or perhaps will bill through insurance. Clinicians provide a picture, short bio, and information regarding their services on the site to ease in selecting a therapist that could be a good fit. If you have insurance, you can also contact your insurance company via phone or their website to find a list of credentialed providers. Finding a clinician who is a licensed provider helps ensure that you are seeing a professional who has been through appropriate training and supervision . Lastly, one thing to keep in mind is to ask about any additional training or certifications the therapist may have earned. For example, if you are seeking therapy to address your experience of childhood abuse, it is important to ask the therapist you are considering about any additional training and/or experience working with this issue. The same way you would not want to go to a cardiologist for an ankle sprain, you would not want to go to child psychologist for coping with your adult complex trauma concerns.
I REPEAT, FIND A FIT – The number one predictor of success in therapy is the relationship the client has with the therapist. If you have a couple of sessions, or even just one, with a therapist and you feel like you will be unable to connect with the person, just let them know! I promise, the therapist will not be offended if you tell them it is not a good fit. Therapists know the importance of the relationship and fit and they are ethically obligated to provide you with referrals. Of course, you are welcome to find a new therapist on your own. My friend and colleague Lisa says, “You don’t stop ever getting your hair cut because the last hairstylist gave you a bad cut – you find someone you like better.”
DON’T GET HUNG UP ON DIAGNOSES – In the first session, therapists often complete what is called a “comprehensive clinical assessment.” This generally is comprised of an overview of your mental health, substance use, family and medical history, understanding your strengths and supports, and beginning to understand what your goals are for therapy, and most likely providing a provisional diagnosis. While a diagnosis is typically required if therapy is being billed through your insurance company, it is also a category that helps provide a directive to the therapist for the most effective, evidence-based treatment and approaches for your care. Though not every reason to attend therapy results in a diagnosis such as depression or anxiety, receiving a diagnosis can be an extremely validating experience and your therapist can talk through your diagnosis with you.
RELATIONAL WORK IS POWERFUL – If you are seeking individual therapy and find that it would be beneficial to include a partner, friend, or family member, let your therapist know. Most therapists will encourage relational work if they recognize the need, but you can always ask for a support person to be involved in your treatment, whether for just one session or several. We are relational beings, not independent but interdependent, and thus having the skilled support of our loved ones who are learning some of the tools you are learning in therapy can make a world of a difference. For example, my fiancé knows to start deep breathing when he sees me in distress, often before I have realized I am even in distress. Because of his cue (thank you mirror neurons!), it is a reminder to myself to take a pause and focus on my breathing to calm my system before I proceed to problem-solve. He learned this through me teaching him and also from joining me in therapy.
FIND COMFORT IN THE DISCOMFORT – More often than not, therapy might not feel good at first. Change and growth and healing can be HARD, but it is the GOOD hard. Consider the beautiful butterfly and its humble beginnings of the caterpillar; we often forget the mucky, hard, process it takes for the caterpillar to turn into that butterfly. That hard work usually does not occur solely in the one-hour session you have once a week. To really see change sink in, that work happens mostly in the other 167 hours that occur in the week between sessions. Therapy is a space to slow down, reflect, process, gain insight, and learn skills, but the time in between sessions is where the practice of these skills are put to work and become part of ourselves. So give yourself and the process grace when it feels uncomfortable, angry, scary, or slow. Often times, it means the treatment is working.
GET THE BEST OF BOTH WORLDS – Just because you choose to see a therapist does not mean you cannot also engage in other types of therapies. In fact, many therapists can incorporate art, yoga, music, biofeedback, and more into their approaches. If these seem like approaches you would benefit from, talk to your therapist about this or you can find a licensed art therapist, Trauma-Sensitive Yoga therapist, and more. Additionally, medication for your mental health condition(s) has been a game-changer for many. We don’t bat an eye at providing insulin to people with diabetes when it is needed, so we must remove the stigma of asking for pharmacological help for mental health when it might be helpful. Please talk to your doctor and/or therapist if you are considering medication, and they can walk you through your concerns and needs to find the best medication for you.
The first time I decided to go to therapy, I was scared, but had the support to guide me through the process. I hope this information can provide some support and comfort to you, because taking this action step is worth it, as are you.
Friday, September 25th is recognized as “National Psychotherapy Day” in the United States. In healthcare, we have observed that some patients, clients, and providers seem to have an aversion to the idea of psychotherapy, probably due to the stigma associated with the term or related terms. As a team of therapists working to promote behavioral health integration and whole-person care, the Center of Excellence for Integrated Care staff wanted to use today as an opportunity to promote a better understanding of psychotherapy.
The term “psychotherapy” comes from the ancient Greek word roots of “Psyche” which means breath, spirit, or soul, and “Therapeia” which means healing or medical treatment. Those root meanings are a long way from the often stigmatized vernacular term of “psycho.” Additionally, the historically popularized image of therapy — during which clients lay on a couch while a therapist proclaims hypotheses about childhood experiences and current mental illness — have contributed to a misunderstanding about the expectations and outcomes regarding psychotherapy.
What is psychotherapy?
In the context of mental health treatment, psychotherapy is often used interchangeably with the terms “therapy” and “counseling.” Though some professionals in the mental health field have highlighted distinct differences between psychotherapy and counseling, psychotherapy remains the name of the service of providing talk therapy. At COE, we advocate that there should be a common understanding of the language used to describe any therapy services, outpatient or integrated. However, we think that whichever term feels most comfortable to clients/patients and their care team is appropriate. Most important is that the client is well aware of the service they are consenting to receive.
What happens in psychotherapy?
Therapy could be beneficial to most everyone; you do not have to have a serious and persistent mental illness to benefit from therapy. Many people participate in psychotherapy to work on challenging relationships, cope with stress, adjust to new life situations, and explore self-identity.
Once you identify a therapist with whom you feel comfortable working — see this page about identifying a behavioral health provider — you will work toward developing a safe and trusting working relationship with your therapist. The therapist’s role is to help you walk through your challenges, versus the commonly held assumption about offering direct advice or making decisions for you. You and your therapist will work collaboratively to set goals, and both you and your therapist will establish boundaries about the work you will do in therapy. Sometimes therapy will primarily involve talking. Other times your therapist may introduce various activities into therapy, such as creative expression or role-playing to help practice talking through relational issues.
The COE team hopes that this discussion has helped improve awareness and understanding about psychotherapy — and provided some normalization about the therapy process — in honor of National Psychotherapy Day.
If you would like to learn more about providing whole-person care involving psychotherapy, please reach out to us!
The COVID-19 pandemic has pushed providers, patients, and organizations toward — and beyond — their limits of discomfort, with the potential to remain this way for the foreseeable future. The healthcare system braced itself as the COVID-19 pandemic shocked our nation. Moreover, the world of integrated care sighed as it looked as if another hurdle was in front of us. In the integrated care space, something has changed.
Integrated care is the practice of treating the whole person, including physical, emotional, spiritual and social aspects of health. Mental health is a considerable dimension of integrated care. The movement toward treating the whole person has faced challenges since its birth, including the stigma around mental health, policy and payment system hurdles, and the healthcare system’s siloed approach to healing the patient. During the COVID-19 crisis, increased physical distance between healthcare team members — and challenges related to payment systems and service delivery — have weighed heavily on the integrated care field. However, through this challenge, innovation, resilience and increased awareness have emerged.
Healthcare has faced a grueling opponent in COVID-19. Some clinics have found themselves against the ropes, narrowing — and some closing their front entrance — just to discover that the leaders of organizations have found a way to open new points of entry. Those new pathways and adaptations established include telehealth, policy regulations changing with sharp and timely intent, and innovative programs, such as Ready Responders COVID crisis teams, acting to preserve hospital capacity. These efforts were established to win this battle against COVID-19, but have led to refining healthcare system practices that will go beyond the pandemic. There is hope to have a lasting impact on healthcare beyond the COVID-19 pandemic. Monica Williams, MSW, LCSW (Northfield, CT), seems to think so:
”During these unprecedented times individuals (and entire families) are needing clinical support, guidance, interventions and coordination of care. The ability to provide these services face-to-face and virtually (visual and audio) has proven to be essential for many individuals for different reasons. In order to meet the greater capacity of individuals and their families, these options are essential for overall quality improvement, as there will be longer and larger impacts beyond this epidemic.”
Mandated quarantine orders across the country have required healthcare facilities and providers — including behavioral health providers — to be creative, flexible, and innovative. A heavy dose of hope, grace, and loved ones’ support has carried behavioral health clinicians to keep their heads up, move forward, and do what they do best: provide an emotionally safe place to patients, and sometimes colleagues, in the midst of emotional distress, procure a solution when a patient is feeling lost, and partner with their healthcare team to innovate and meet patients’ whole-person care needs. We know one thing for sure…the world needs behavioral health professionals now more than ever.
Organizations have launched or expanded their telehealth programs and found creative ways to reach clients. Rebecca Levy, LMFTA (Winston Salem, NC) and East Carolina University PhD candidate describes her perspective as a clinician:
“Anxiety has increased overall in this pandemic. More people are willing to reach out to get help because it’s accessible via telehealth. I think therapy has become less stigmatized.”
The battle against mental health stigma is still ongoing, with a long history of stigma dating back as far as ancient Greece, when people thought those who showed mental health symptoms were possessed by demons. We have certainly come a long way, but a lot of work remains. Today, leaders such as Governor Andrew Cuomo (NY) and Governor Roy Cooper (NC) have taken a strong stance on recognizing the importance of behavioral health as a part of whole-person health.
Governor Cuomo has created funding to expand mental health services and publicly commented, “You know, we’re all concerned about the immediate critical need. The life and death of the immediate situation, which is right. But don’t underestimate the emotional trauma that people are feeling, and the emotional health issues.”
Governor Cooper reinforces this message to North Carolinians as he states, “This pandemic has put a spotlight on the need for more attention to mental health. Taking care of your mental health is just as important as your physical health, and there are newly expanded opportunities to seek telehealth during this pandemic.”
This pandemic has inspired leaders to take the opportunity to advocate for the importance of behavioral health. In the face of COVID-19, the stigma is breaking down.
As stay-at-home restrictions loosen across the country, the emotional impact of COVID-19 will last far beyond this season. Whether you are a provider in an outpatient behavioral health setting, integrated care primary care office, or another setting, the way providers are supporting patients has changed. Meghan Lacks, PhD, LMFT (Greenville, NC), expands on this:
“Patients have expressed immense gratitude for adaptations to provide services rather than discontinue them during this unprecedented time. They are especially grateful to have continued access to mental health providers because so many people are experiencing increased depression, anxiety, grief, sleep disturbances, etc. Providers are also needing to be a lot more adaptable and flexible during this time because a lot of patients have increased distractions at home. It is not the same as coming into a quiet, secluded therapy office – folks are in the midst of homeschooling one or more children, working remotely, or just trying to manage general family chaos while attempting to engage in therapy simultaneously. Most patients do not have the luxury or privilege to step away from their families and engage in a 45-minute therapy session with no distractions right now.”
Behavioral health as a profession has found itself carving its niche in the whole-person care space, demonstrating the major role of emotional and mental health, and substance use, in a person’s overall health. COVID-19 has created an opportunity for this role to be punctuated and amplified. Let’s examine this growth. Neftali Serrano, PsyD (Chapel Hill, NC), CEO of the Collaborative Family Healthcare Association (CFHA), a national organization that supports healthcare professionals in integrating physical and behavioral health, offered his insight regarding the status of behavioral health during this pandemic:
“Behavioral health is clearly being seen as a value. This is a moment for behavioral health, and for behavioral health integration in particular.There is a tremendous opportunity to solidify the role of behavioral health as a standard part of healthcare provision.And on top of that, you layer on the access innovation, patients have a much easier time accessing today than they did three months ago. With this innovation, this provides us an opportunity to distribute care in the future. There is a lot of really good stuff happening in the middle of an extremely painful time for a lot of us.”
Something is absolutely changing in the resiliency of integrated care. The change is unquestionably a difficult process. Amidst the plethora of changes that COVID-19 is influencing, there is going to be something different about integrated care after we get through this. Leaders are openly discussing and normalizing issues around mental health and this is tremendous growth. Hospitals and clinics have built new paths to accessing healthcare, including behavioral health. The nation, its people — including providers, hospital systems and patients — have been stunned by the COVID-19 pandemic. We have been forced to address issues with healthcare access, funding, and service delivery. We can only hope that these changes endure past the pandemic as our sights are set on the full embrace of equitable, whole-person care.
Maintaining Mental Health During a Pandemic by Brady Blackburn, MA
COE was pleased to collaborate on this blog post with the North Carolina Oral Health Collaborative (NCOHC), one of our partner programs at the Foundation for Health Leadership & Innovation, on a discussion of the intersection of mental health, the oral health care world, provider well-being, and COVID-19.
“This pandemic is a perfect storm,” said Dr. Lisa Tyndall, an integration specialist with the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership & Innovation (FHLI).
As North Carolinians navigate COVID-19 and its various impacts, NCOHC decided to sit down with our partner program at FHLI to discuss how the pandemic poses significant mental health concerns, for patients and providers alike.
Tyndall, a licensed marriage and family therapist, said that the wide range of impacts caused by COVID-19 — from financial stress to anxiety and isolation — are serious stressors that negatively impact mental health.
“The fact that we can’t be with each other absolutely negatively impacts the coping mechanisms most people use of reaching out and spending time with friends and loved ones,” said Tyndall. “We are wired to connect, and right now we are limited in those personal, face-to-face relationships.”
For the provider community specifically, Tyndall worries that we tend to forget that they are humans, too.
“I think that we forget that the frontline providers are facing a lot of the same uncertainty that the rest of us are,” said Tyndall. “Especially for those providers who live alone or are caregivers in their personal lives. If a provider doesn’t have a support system, or if their support system is already stretched thin, it is an especially difficult time. There’s a physical as well as an emotional toll to the stress, and it builds up. Providers manage the stress of patient caregiving every day, and then still go home to manage their own households, potentially adding an additional layer of stress.”
“As doctors, we are trained to be the rock,” said Dr. Zachary Brian, NCOHC’s director. “We’re trained to be the provider, there to serve the community, sometimes at the expense of our own physical and mental health.”
Both Tyndall and Brian described a juggling act for providers, balancing service to their communities, personal and family safety, as well as financial well-being.
“It can feel as though you are navigating a sea of conflicting resources, literature, and research to determine the safest way to move forward with your practice,” said Brian. “Given that this is a novel virus, it is not uncommon to see this type of response. The issue arises in that there’s no one clear authority to look to for guidance, which makes informed decisions on behalf of your patients and staff ever more challenging.”
As health experts learned more about the novel COVID-19 virus in recent months, guidance from the American Dental Association, the Centers for Disease Control and Prevention, and other state and national regulatory bodies were released, but were not always in exact agreement with one another.
“The resources for providers that we have seen, although very helpful, have not necessarily always been in parallel,” said Brian. “This has created a surge in confusion.”
What can you do about the uncertainty?
Dr. Brian says, “While the provider community as a whole may be very isolated during this time, forced to make decisions with so many unknowns, there is support within your regional communities. Don’t be afraid to reach out to your colleagues. People need to be very open and transparent, so we don’t have to navigate this crisis in a vacuum.”
Dr. Tyndall says, “We have to lift ourselves up and we have to lift each other up. We don’t have to talk about it all the time, but we also should give a voice to it and not minimize the stress. It is important to have outlets to express uncertainties, fears, and concerns.”
Dr. Tyndall also shared a couple of resources for providers who need help managing their own mental health needs during this time.
The Hope for NC Helpline is a free helpline for people who need assistance coping and maintaining resilience during COVID-19. The number for the 24-hour helpline is 855-587-3463.
For first responders, the University of Minnesota, the Minnesota Department of Health, and the University of Minnesota College of Education and Human Development have released a First Responder Toolkit to help those deployed in emergency response maintain their own physical, emotional, and social well-being. The app can be accessed here (note: a login is required).
Financial uncertainty is another stressor impacting many oral health care providers. This is especially salient in the private sector, where most dental practices are small businesses. On top of figuring out how to keep everyone safe and healthy, while still providing necessary care to the community, providers must also navigate out how to stay above water financially.
“Even though it seems like practices would be bustling during a health crisis, we also know that there is a side where providers aren’t seeing as many patients,” said Tyndall. “So that financial stress — especially for smaller practices, rural practices — is very real.”
Brian said that the oral health profession is on the low patient volume side of the equation. Largely due to the use of aerosolizing instrumentss, dentists, and hygienists in particular, are near the top of the list of most at-risk professions for COVID-19 transmission. In response to the elevated risk, most dental offices have only seen patients for urgent needs during the pandemic.
Brian said that in the oral health care space, safety net practices are facing profound and lasting financial impacts, as well. Practices that see patients regardless of their ability to pay, and who offer care on a sliding fee scale, have very thin to nonexistent margins to begin with. Nearly completely cutting off their revenue stream can be catastrophic.
What can you do to navigate financial uncertainty during COVID-19?
Dr. Brian points to the ADA’s resources for providers, especially the following the guidance:
Additionally, the North Carolina Division Health Benefits has issued temporary modifications for telehealth billing, and NCOHC has launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation.
If your practice is a safety net provider in need of teledentistry software, please reach out to ncohcinfo@foundationhli.org for information on how to apply for funding through the NCOHC Teledentistry Fund.
Please note: The aforementioned guidance documents are only to serve as a resource, and are not necessarily founded in scientific evidence, or endorsed by NCOHC or COE.
According to Brian, it is important for providers to be aware of oral signs and symptoms that can alert them to potential mental health needs of their patients.
“You have parafunctional habits such as clenching and grinding that can develop as a result of stress, and from this you can see detrimental effects on teeth and other oral structures, such as extensive attrition and fractured teeth,” said Brian. “I saw that a lot with my patients when they were going through stressful events in their lives. They would come in with three or four fractures in their teeth, sometimes where the fractures extended past the gumline requiring surgical interventions.”
Brian also said that dietary changes due to stress and anxiety can negatively impact oral health. Increased sugary food and carbohydrate intake, as well as alcohol consumption, can both increase risk of tooth decay and gum disease.
“One thing that we’re not talking about enough is that we’re only seeing emergency patients right now,” said Brian. “There are people who are delaying appointments or not seeking care, and by the time they come in, what could have been a simple filling previously has now advanced to the point where it requires a root canal or an extraction. This is also particularly important for routine oral and pharyngeal cancer screenings.”
How can an oral health provider look out for mental health strains in patients?
Dr. Brian says, “Look for attrition patterns from clenching and grinding, fractured teeth, and TMJ pain.”
“As an oral health professional, having a relationship with someone in the mental health space is vitally important, also. You need to have a sounding board to discuss mental health concerns of your patients, and a trusted referral source to help route that patient to proper care.”
“It is crucially important that you have deeper conversations with your patients. Make sure that you take a whole-person care approach by including the mental health of your patients into the patient experience.”
Both Tyndall and Brian agreed that taking time to reflect and take care of yourself is incredibly important for providers during this pandemic. Taking steps to interact with family, friends, and colleagues is an important way to cope with the isolation and stress we all are experiencing.
“Dig deep into your resource and faith buckets, and be kind to yourselves,” said Tyndall. “Take time to make sure that you’re taking care of yourself, too.”
“This too shall pass,” said Brian. “Dentistry remains a profession that allows us to impact our patients in direct ways, see immediate results, and change lives. That doesn’t change with the pandemic.”
Am I stressed, or do I have a mental health disorder?
by Ricky Caliendo, LMHC
It was 2014, a fresh box of tissues sat on the coffee table and steam dissipated into the air above a warm cup of coffee. A screech from the opening of the lobby door traveled into my office as a wave of anxiety set in. Immediately, I remembered a not-so-encouraging joke that my clinical psychology professor overused throughout one semester: “Every student should prepare a sorry card for their first patient.” Why was it that this poorly placed joke has found itself cornered into my thoughts as my first patient eagerly waits outside my office?
A professional, middle-aged man sat down across from me, looked at the box of tissues, and offered me a cunning grin. He understood that I was younger than him. Nonetheless, I sipped my coffee and started the session. After obtaining informed consent, and just about finished reviewing the laundry list of office policies, he stopped me with a distinct purpose. He said, “All I want to know is if I am just stressed out or actually going crazy?” I jokingly assured him that there is a thin line between the two. He gave a small chuckle as we both felt the ice in the room breaking. He eased back into the couch and began to disclose the recent detour his life had taken. Between a divorce, cancer diagnosis, and his mother’s deteriorating health, I thought to myself that he had a lot more resilience in him than he realized.
Through the years in practice, and navigating through diagnostic and treatment recommendations with colleagues, the answer to the question that my first patient had has changed. Although humor has sustained, with a more sincere explanation now, I would not jokingly hint toward this line between stress and mental health disorders as thin; on the contrary, the line is thick yet permeable.
Is stress common? Definitely. We all experience good stress, such as excitement, and then there is stress that challenges us. This is a normal part of life.
Do mental health disorders exist? Of course. Mental illness can mean many different symptoms and experiences, but we do have a way of capturing the range of mental illness through diagnoses.
Making a diagnosis is very important in guiding evidence-based interventions and psychopharmacology. However, the person, and their uniqueness, exists before the diagnosis. A diagnosis can blind the individual differences in patients. Understanding the person, their experience, unique stressors, and even more importantly, how they respond to those stressors, will always exceed the importance of a diagnosis.
Our body and mind have a fundamental response to uncomfortable internal or external conditions. Stress is the umbrella of responses that can occur in relation to this, although this experience is hardly uniform. And, while every human being on this earth has experienced stress, everyone has not experienced a mental health disorder. So, what is the real difference?
Rather than dissecting the 5th edition of the Diagnostic Statistical Manual of Mental Disorders and providing a quiz at the end of this blog, let’s look at this in a different way. The size of the stressor may influence the size of the response. For example, a global pandemic that creates media hysteria, economic crisis, broken routines, and social isolation is likely to create a more persistent and intensified stress response compared to running late for work and burning your toast. However, there are variables — such as genetics, traumatic occurrences, and biological influences — that can make these stress responses less predictable and proportional, and even alter the likelihood of developing a mental health condition.
Given that we have already established that everyone has experienced stress, one may imagine that there are some shared manifestations of stress. Trouble with sleep, concentration, appetite, drive and motivation toward pleasurable activities, and irritability are some common internalization responses to stress. The intermittent slam of the door or giving someone the silent treatment may be common externalized responses. These can also be signs of depression. But the severity — how it impacts your functioning — and other symptoms need to be considered before naming a mental illness. Some of the more concerning symptoms related to clinical depression may include hopelessness, trouble with memory, increased alcohol and substance use, and suicidal ideation, to just name a few more concerning experiences. Certain things like good self-care, support, and treatment, can impact the degree of permeability of the line between mental health disorders and stress.
Remember, if you’re having a bad day, or your environment is providing you with an extra stressful situation, it is normal to not be at your best. Allow yourself to have a stress response and remind yourself that this is uncomfortable, but it is normal, and there are coping techniques that can help reduce your stress. If persistent, disproportioned emotional or behavioral responses continue — with a negative influence on your quality of life, relationships, and functioning — it may be time to dig a little deeper to explore support for your mental health.
For Mental Health Awareness Month, we wanted to bring attention to this important distinction between stress and mental health disorders, and remind our partners and communities that there is help and support available for both. Connecting with a behavioral health professional — such as a counselor, psychologist, therapist, or psychiatrist — can help you determine if what you’re experiencing is stress or a mental health disorder. Additionally, your primary care provider will be able to support your whole-person health needs, including your mental health. Many primary care offices are homes to behavioral health professionals, and providers work together as a team to deliver whole-person health. You may be able to speak with a behavioral health clinician right at your primary care office!
We hope you all are staying safe at home and in the community. Take time to care for yourself and your loved ones. Feel free to explore our resources and blog posts related to Mental Health Awareness month.
In the midst of COVID-19, most mornings I wake up unsure of how the day will find me. I know what I am supposed to do, and how I am supposed to feel. The experts say I should slow down, take time to be grateful, some say to meditate during the day, and we have all heard the ever-present suggestion to get outside and exercise. Don’t get me wrong, I like all of these suggestions – it is just that ironically sometimes it feels impossible to do these tasks that are supposed to make life easier right now. How hard is it to just take a time out for 10 minutes to breathe?
Turns out that 10 minutes can actually be hard to find indeed. Everyone has different working situations right now, some are working more than ever on the front lines of the healthcare system, some are working remotely, some are dividing their time between the office and home, some have been furloughed, and some have lost their jobs entirely. Our work environments have changed dramatically. Clinics can be deserted, and some may be overrun. Co-workers can become second family if they were not so already, and those at home may be squeaking out a somewhat professional and quiet work-space that invariably will compete with the other life demands peeking from behind the cracked door. For me it is a new “work from home” environment, which includes children home from school but yet somehow still in school. While there have always been best practices as far as remote working is concerned, these days I come across even more “work from home” tips floating around various websites and depending on the day I am either fairly receptive or I want to tear them up into little pieces.
If you are at home, be sure to keep a schedule. Shower and get dressed every work day. Wherever you are, be sure to take a daily meditation break. Be present with your family, either in person or through a glass door. Slow down but meet your work expectations. For those of us with kids, don’t forget to add to that parenting, refereeing fights, fending off questions about hanging out with friends, teaching, and don’t forget to flagellate yourself for the increased screen time.
You get the picture – there are a million potential directions a day could take and often does take – during this time where we are supposed to be adjusting to the “new normal.”
When you read all of the advice columns – it seems like it should be simple. And yet, what we are often missing is the layer of uncertainty that drains the energy from each of us like an app open on your phone which can never close. It isn’t the same right now. We aren’t just working from home some, changing our clinical workflows, having lots of zoom calls and for some, working in pajama bottoms. Whatever your environment, a large percentage of our energy is going towards emotionally processing the uncertainty that looms over the entire world. What will it be like when the world re-opens? How long will it look like this? Will we get back to celebrating life’s milestones? Or will we even get back to being able to be at someone’s bedside during their last moments? Surely the basic human needs for touch and connection won’t be forever gone from our reality…will they?
I do believe that this collective trauma will eventually be settled. What “settled” looks like I am not sure – but I know that developmentally and all through life when the hardest of times has come as people and as a country, there is a pendulum of reaction and response that swings but eventually finds the middle and settles. We all wish for the return of the freedoms we once took for granted, but are currently hazardous, to stop being afraid of seeing people in masks in the store, to wish to start seeing more people in masks, to learn how to work from home while missing live human interaction with others, we all want to feel productive and balanced again. As human beings, we always want to rush through the uncomfortable parts – and it is very uncomfortable right now to say the least. How in the world do we sit in the waiting for this pendulum to settle?
In those moments where I feel guilty for not being more productive, guilty for not parenting better, guilty for still having a job, yet afraid of the very clear temporary nature of jobs we never deemed temporary, there are so many conflicting emotions and states of being. In these moments, I do my best to choose grace. That also sounds simple – but it isn’t. It takes my village of people to remind me to choose grace for myself. It takes my spiritual practice to remind me to choose grace. It takes what I know as a therapist to choose moments of grounding and gratitude to eventually get lead back to grace. The irony here is that I also have to forgive myself for the moments I forget to choose grace, when my pendulum swings too far to one side or the other.
There are enough suggestions out there in the world for how to handle and cope with the current situation, both personally and professionally, a few even on our own website! And with May being mental health awareness month, we are particularly aware of the importance of taking care of not only our mental health, but our behavioral and relational health as well. My experience has been that those, as well as our physical health of course, are all connected. Keeping those connections in mind, how you choose to manage the swings of the pendulum is up to you. But overall I would say listen to your heart, give yourself and others large amounts of grace, and take it one day (even one minute if need be) at a time.
Stay tuned for more from the COE team during Mental Health Awareness Month 2020!
