The Problem of Overcrowding and a Proposed Solution
It doesn’t take a long look to realize that one of the chronic problems plaguing the mental health field, especially in the arena of clinical practice is overcrowding. There are unprecedented numbers of people seeking and receiving treatment for mental health, most of which are involved in outpatient therapy. Outpatient therapy takes place within two primary realms, that of private practice, and that of public clinical services.
For the intents and purposes of this article, when I say “private practice”, I am referring to clinical services that are privately owned (usually) for-profit therapists or therapy groups, that are not certified by governing bodies such as a state’s office of mental health. In a private practice setting, there are a lot less regulations or laws (usually provided by those governing bodies such as the office of mental health) for providers to brush up against, which typically allows for a little bit more clinical freedom in how these providers practice, document, and treatment plan. However, with clinical freedom in a private practice setting also comes clinical responsibility (or, more accurately, liability). This means that in most cases it is much less likely for private practitioners to take on cases of high acuity (aka, suicidal clients, clients with significant substance use problems, behavioral problems, psychosis, etc.). Additionally, private practitioners are usually able to be more “picky” with clients that they accept into their care. This further reduces the amount of private practitioners in mental health who are able to or willing to work with select populations such as children, adolescents, clients experiencing poverty, client’s with medicaid insurance, or populations who struggle with other forms of unique needs.
As a result, the brunt of cases which have a higher “acuity”, or unique needs, or even just who have one of those odd insurance companies that most people have never heard of, end up in the community mental health sphere. These cases fall to the community clinic’s that are certified by the office of mental health (and maybe your state’s office that deals with addiction issues) to provide clinical therapy “to the masses”.
The mandate that typically comes from governing bodies because of the higher severity of problems present in the client base–combined with the large range of problems, ages, and needs– tends to be “accept pretty much everyone”, and on a rushed basis at that. (re. The rushed basis that client’s are accepted: New York state requires OMH certified clinic’s to offer 5 day turnaround intakes to clients who are being referred by certain emergency services or their primary care doctor). After accepting “pretty much everyone on a rushed basis”, community clinic’s are also expected to provide these clients with helpful treatment and episodes of care that can last anywhere from 2 months to years on end.
Because of the high demand in services community clinics often struggle to have enough clinicians, who aren’t burnt out, and who are getting regular training, and who are getting weekly updates about high risk clients in meetings, and who are getting weekly updates from their leadership team about any new rules that the clinic now has to follow because the office of mental health said so, and stay up to date on all of the latest assessments that they will be required to to, and who are being supervised once a week, and who are documenting all of this stuff, especially for the clients who are high risk, which theoretically is a bunch of them who are coming from those previously mentioned 5 day turnarounds.
The picture I’m trying to paint is one of an overwhelmed system, leading to overwhelmed clinics, leading to overwhelmed clinicians, leading to overwhelmed clients, and the system repeats… So how do we solve this problem? Well, we could add more clinicians, more money into budgets, more clinics etc, which would probably be effective in some sense, but I don’t see that happening anytime soon. So here is my solution– less people in therapy. You read that right, less people in therapy. “But you can’t control that!”, “Mental health is important, how are you going to tell people not to go to therapy?!”. Because, in my observation as a clinician I’m willing to make a fairly bold statement– a lot of my clients don’t need me. They don’t need therapy, but they do need support.
Which brings me to my primary intention of writing this blog series. My thesis, the moment every reader (if they made it this far) has been waiting for– we need more mentorship. I believe that solid mentorship can replace therapy, in many cases (more on the nuance there later). In order to move forward with my if-I-do-say-so-myself profound thesis, we need a few working definitions first…
Definitions for the sake of this series.
First of all, therapy. Therapy for all intents and purposes of this blog series is to be defined as clinical services provided by a licensed mental health provider meant to support someone in dealing with a mental health problem, or with a mental illness. Essentially, if you (or your insurance, or some combination of the two) is paying for treatment where you sit in a space and talk to a licensed therapist (usually) for help with something that is classified in the DSM-5 as a mental health related diagnosis, this is therapy.
Second, mentorship. Mentorship is the process of gaining support from another human being; on a semi-regular basis; in the form of advice, comfort, accountability, and quality time. If you meet with a friend for coffee on a monthly basis and talk about what God is doing in your life, this is a form of mentorship. If you meet with a father/mother figure for advice on how to run a household or raise a baby, this is a form of mentorship. If you meet with a pastor to try to figure out what you can do about an addiction to pornography, this is a form of mentorship. If you pull aside a coach to gain advice about how to do a move or critique your form, or improve yourself this is a form of mentorship.
The third definition we need is that of mental illness. Mental illness is a variety of conditions experienced by some that require expert clinical guidance to resolve through therapy. Some examples of clear mental illness that jump to mind for me are severe depression (struggling with suicidal actions or thoughts), bipolar disorder, and psychosis (especially if these diagnoses are not managed well). But of course, it truly can take the form of any problem that falls in the category of “mental health” (see next paragraph) that causes such distress that quality of life is significantly impacted. If you experience mania and can’t sleep for days, this is a mental illness. If you have suicidal thoughts that have caused you to take action towards ending your own life, this is mental illness. If you see things that aren’t there, this is mental illness. If you are too afraid of going out in public to work a job and pay bills, (which often can be the result of severe phobias, traumas, or anxiety) this is mental illness.
Finally, there is mental health. Mental health could be defined as the current hygiene state of your mind. This flexes and changes, just like my physical health flexes and changes depending on the presence of a virus, what I ate that week, and how much I exercise. Ergo, some days your mental health will be “better”, and some days it will be “worse”. If you struggle with mental illness, your mental health would just about always be in poor condition (at least, I can’t see any ways in which you could have mental illness without also struggling with mental health– just like you can’t have a square that is not a rectangle).
The distinction between mental illness, and mental health (as defined here) is important, because I will be making the argument that mental health can be addressed through the use of mentorship, but that mental illness should primarily be addressed and cared for in therapy due to the severity of symptoms, the immediateness of potential risk, and the need for a higher level of expertise to address such symptoms and risks.
One of the most helpful analogies that I can make that should help to tie all of these definitions together, is that of mental health therapy, to physical therapy. I use this analogy consistently when I am doing intakes with new clients, and trying to provide a picture of what treatment in the community clinic that I work for will look like. The spiel I give my clients is as such:
Therapy is more like physical therapy, than like visiting a primary care doctor (PCP). When visiting a PCP, you go every so often, just to get a quick check up, make sure everything is good, and you go on your way. Maybe you’ll be back in a year, or maybe when a problem with your physical health arises, but basically, you always are on your primary doctor’s caseload, and probably should see them every once in a while.
On the other hand, when you go to physical therapy, it is usually because you have experienced a significant problem. You sprained your ankle, tore a muscle, you have chronic pain that is not allowing you to do an activity or sport that you love, etc. When you go to a physical therapist, you learn some skills to strengthen the part of your body that was damaged, maybe you are given a strict routine to adhere to that helps you to stay off of an injured knee, stretch a previously torn muscle, or ice an ankle consistently. But, in most cases, the goal of physical therapy is to learn these skills and routines, attend a few appointments to make sure things are going swimmingly, and then once the injury is healed, you stop. You don’t go back. You don’t check in (more than a few times), and you are no longer on your physical therapist’s “caseload”…. Unless of course you injure the other ankle, in which case you would repeat the process.
If I laid all of that out in a way that was hard to follow, mental illness is the sprained ankle (or the injury that one would need physical therapy for)– it’s the thing that happens or that you experience which keeps you from doing what you love until you find skills, strengthening exercises, and understanding that helps you to recover. The physical therapist is the role that the mental health therapist fulfills. The mental health therapist provides these skills, insights, and exercises to the client so that the client can recover from their mental illness, and go about living their best life. (It should be said here that there are some mental illnesses which are chronic, and may require lifelong therapy. In these cases, the analogy still holds up– there are certain physical injuries that one can suffer from which will require consistent and regular meetings with a physical or occupational therapist as well.)
Mental health on the other hand is your general physical health in this analogy. It fluctuates based on circumstances. When it starts to get really bad, you get help with it, but theoretically, you can do certain “at home” or “self taught” remedies to maintain it. (i.e. taking nyquil when you have a cold, resting more, or exercising are all ways to routinely care for your physical health, just like mindfulness practice, exposure, and ironically–taking care of your physical body in all of the ways previously listed– are ways to help and maintain one’s mental health.)
Which brings us finally to the last piece of the metaphor– the PCP as the mentor. The person who you can check in with when things are not going well, but also aren’t an emergency yet. The person who knows your history and can suggest interventions based off of that, and even the person who refers you to other people or places for more particular help if needed. I acknowledge that the analogy falls off a little bit here because PCP’s are experts in their own right, and can prescribe medications and treat medical problems if needed… but, when you really think about it, a good mentor figure also may have some hidden expertise that can be easily overlooked, just based on their own life experience. Lots of people know CPR or first aid and are not doctors, even so, you are extremely happy to have those people around when you need some help in those areas.
So, to get back to the thesis after my long-winded analogy, I believe that mentorship in many cases can and dare I say should, replace therapy. When someone meets with a mentor, typically they are seeking advice, looking to “process” an event or difficult situation, hoping to feel understood, or wanting someone to hold them accountable. All of which are roles that the mental health therapist plays, though at a more clinical level, in treatment. More specifics on how a mentor can meet these needs will be discussed in the next post.