Dr Aaron Meyer and Ann Marie Council: Bridging the Mental Health Gap: Policy, Psychiatry, and the Fight for Early Intervention

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Tony Mantor. This is where understanding begins. If this kind
of conversation matters to you, follow the show so you
don't miss what comes next. Joining us today are two
people who share the same mission on mental health, finding
better ways to help people who are struggling. Doctor Alan Meyer,
a physician based in San Diego who works closely with
individuals facing complex medical and mental health challenges. Also joining
us is Anne Marie Counsel, a retired senior Deputy City
Attorney for the City of San Diego and now a
founding partner and mental health policy advisor with Quarter Turn Strategies.
Thanks for joining us today.
Thanks for inviting me.
Anne Marie will be joining us shortly, so let's start
it up with this. When you're looking at behavioral health,
you have the clinical perspective and the policy perspective. Where
do you see the biggest gaps in the way the
community addresses it.
That's a good question. I see both, but I see
the policy impacting the clinical We've seen that in California
with our laws related to substance use disorder treatment and
people getting excluded because of with all their presentation chalked
up to substance use disorder. Or we have laws that
have said that dementia and cognitive disorders, neurodevelopmental disorders are
mental disorders. So then you get clinical decisions that point
to gaps or exclusions in the law as the reason
why this person can't come to a recommended destination like
an inpatient psychiatric unit.
Many people hear your name connected to this field, but
may not fully understand the work behind it. Can you
walk us through what you actually do?
Yeah.
So, I'm a psychiatrist that University of California, San Diego.
I finished residency in twenty eighteen, and since i finished residency,
I've worked at in patient psychiatric units. I've worked on
medical surgical floors, particularly for people who are admitted for
medical hospitalizations because they don't and they don't fit into
the psychiatric behavioral health world. Currently, I work with the
City of San Diego with their Fire Rescue Department, UH
the behavioral health officer for the city, and I work
with people who frequently utilized nine one one and sometimes
up to one hundred and two hundred times in a year,
and a lot of those folks have a combination of
substance use disorders, mental health, cognitive disorders, musical issues, and
because of their complexity, they fit in nowhere. So people
who cycle through the emergency departments and through the jails,
those are that's the population who I work with.
I'm really glad you brought up the part about the city.
Since you work closely with local government and have seen
things firsthand at the street level, what have you learned
learned about the role a city can play with mental
health services, especially on the things that people might not realize.
Yeah, so, I think in each state is probably different
on how they break down the responsibility for mental health.
And I think in cities often cities get the blame
for mental health crises. And in California, it's the counties
that get the money from the state for behavioral health
infrastructure and planning, and it's the counties that are authorized
by statute to carry the responsibility of public conservator, public guardian,
and so cities can help in terms of zoning laws,
cities can help in terms of housing, and that In California,
behavioral health is almost one percent managed by counties the
city county. Like in California, there's some counties like San Francisco,
where the city and county are together, but in the
majority of counties, cities and counties have separate governmental entities.
When you were doing this work on the ground, did
you ever feel a disconnect between what you were seeing
firsthand and what some of the people in city or
county offices might have misunderstood because they were sitting behind
that desk.
Yeah. I think there needs to be a lot more
recognition as to the I think the needs of cities,
and I think police departments and fire rescue departments understand
the gaps in the mental health system intimately because they're
experiencing it every day. I think when you're removed from that,
when your job is in contracting or your job is
in quality assurance, equality improvement, you don't necessarily see the
needs of people on the front line, and so the
systems that are built, especially in the public behavioral health setting,
don't address the needs of the most severely vulnerable people
in our community, and I think that's been a chronic frustration,
I think an age old frustration in California when.
You work with city, county, or state government. There are
policies that always sound great when they're on paper, but
when they're put into practice on the street, the reality
it can be very different. Have you seen examples where
that gap between policy and reality became very clear?
Yeah? I think in addition to that, you get policies
or you get laws that are passed then are described
and are different than what's described. So I think some
of the marketing doesn't always match up with what the
law actually says. Yeah, And so a case in point
would be the Care Act in California, where the Care
Act was a dean does like a court mandated treatment,
but it doesn't actually mandate treatment. It's court supervised, but
it's not court mandated. And so I think some of
the initial marketing in the Care Act led the public
to have a different opinion of what the law was
than what the law actually read as. And so you
get that too with implementation how counties would decide to
implement the law, Like, for instance, in the Care Act,
there's provisions for a court ordered mental health evaluation if
the person's safety is at risk. We did a Public
Record Act request on all fifty eight counties and no
county had processes that were in effect that created or
allowed for this court ordered mental health evaluation to happen.
And so you have laws that are passed that reference
these court ordered mental health evaluations, and no county has
operationalized it, even though it's been in existence since the sixties.
Yeah, I'm really glad you brought that up. Many states
approach this very differently. Some call it AOT and others
have different acronyms for it. In some states, if a
person is not considered a threat to themselves or others,
the system can't really step in even though that person
clearly needs help. How does California address that particular challenge?
So California's Assisted out Patient Treatment Plan is optional for counties,
and only twenty eight of the fifty eight counties have
implemented assisted out patient treatment or law law, and access
to this program is limited because while the Care Act,
you have a bunch of different petitioner entities that can
go directly to the court and say this individual is
someone who needs help. Only the county Behavior Health Program
director can make an application for assisted out patient treatment,
and so access is really limited on top of the
fact that it's optional and not implemented in more than
half of California counties.
So how do we move this from being available in
only half the counties to something that's available statewide so
everyone who needs help can actually get it right?
And so I think that's the hope with the Care
Act is it's in many ways take two on assisted
out patient treatment, and it comes with more funding for
counties to bill the state directly for outreach because one
of the issues is it costs more and it's more
time consuming for people for counties to care for folks
who are more difficult to engage, and so the Care
Act provides incentives for counties to engage the people who
need help the most. And so I think care Act
is an effort to realize that initial vision of Laura's Law.
So what do you see as the biggest challenge in
integrating mental health care with the rest of the healthcare system,
So this way, hopefully it can be treated more effectively.
Yeah, I think the I mean that's a multi layered question.
So federally. I think there's problems with how mental health
has been structured because of the sins of the past.
You know, we have institutionalization that happened in the sixties,
earlier than the sixties, and then in the sixties there
was an effort to deinstitutionalize, and with that there was
a federal disincentive to pay for mental health treatment in
standalone in patient psychiatric facilities. So there's a ban on
Medicaid reimbursement for beds that are more than were in
sixteen beds, and so you don't have the federal support.
And so, you know, mental health has looked at differently
than physical health, and so you've got that layered on
top of state issues where the preference is on community
based outpatient treatment, which it should be, and there's individuals
that are too severe for that level of care, and
so you get a small population of people who fall
outside the cracks of a public behavioral health system, and
it's really what to do with that group and how
do you pay for it and how do you build it.
So in California they had Proposition one, like a six
point four billion dollar bond for outpatient and inpatient facility development,
and the hope is that we can boost up an
area of care that's been severely underinvested in for decades.
Something that has always amazed me. We often separate mental
health from physical health, but the reality is they're deeply connected.
If your mental health isn't right, your physical health often
suffers as well because one affects the other. Right, too
often we measure health by physical signs, heart rate, blood pressure,
lab results that doesn't always reflect what's happening in someone's mind.
How do we help people understand that mental and physical
health are inseparable right?
And I think that gets to a very important point,
an issue that I see in the hospital system all
the time. Just because a person can walk doesn't mean
they can care for themselves, and so what does it
mean to care for yourself? And I think there's a
huge area that occupational therapy can play in healthcare settings
where we're looking at not just physical health, but someone's
ability to function. And we're looking at more than just
walking and whether or not they can use the bathroom
on their own, but whether they can take their own medications.
That's an area where we call it instrumental activities of
daily living, where you're looking at someone's independence with medications,
you're looking at someone's ability to grocery shop, to clean
their house, to take care of you know, what does
it really mean to be independent? And we don't do
that hardly at all. And I think if we took
more time to look at whether we're setting a person
up to succeed or not. By looking at assessing these
instrumental activities of daily living, I think we'd have less
people who return to the hospital. But you're right, we
have to We not only have to integrate the person's
physical health with their mental health, but we need a
holistic understanding of who they are.
We spend a lot of time talking about treatment, but
prevention is just as important. How can our healthcare system
start focusing more on identifying mental health challenges earlier and
supporting people for things reach a crisis stage? Right?
And I think getting more at root causes where instead
of looking first for what medication can I prescribe? What
assessment do I need to do to find out more
about the person? Because if I'm prescribing a medication, I'm
presuming that they can take it and that they'll take
it reliably. But if they don't have the cognitive functioning
to do that, I'm just adding one more minute. I'm
doing what's easiest, and I'm contributing to a mess, you know,
to disorganization, which can have consequences.
I've spoken with people on the autism spectrum and others
living with conditions like schizophrenia, and one thing I keep
hearing is that it can take ten years or more
to finally get the right support, treatment or medication. That's
a huge portion out of someone's life. That's a long
time to struggle through all the things that they go through.
Some go through homelessness, some go through drug addiction, some
go through every imaginable thing that we could think of.
So how do we get out of that ten year
journey so people aren't losing so many years just trying
to get the help that they desperately need in order
to of their life right.
I think we need to look beyond some of the
like superficial reasons. I see a lot of times people
leave the hospital setting and people say, well, people have
the right to make bad decisions and it doesn't go
deeper than that, or people get labeled as malingerers and
someone who's trying to manipulate the system but you have
to look deeper and say, well, why might the person
be making that decision, what's it due to? I think
the curiosity can help reduce that ten year gap because
there is a significant period before someone's diagnosed with dementia.
For instance, we have delays related to getting people involved
in the regional center. You talk about autism and if
they fell through the cracks before, you know, before they
were eighteen, and then finally get someone who who cares
and tries to get them involved in the system, but
they don't have paperwork before they were eighteen tried convincing
the regional center to get them an assessment, especially if
the person needs the help but doesn't understand that, you know,
understand the need for it, and doesn't agree to it.
I think it's really challenging, and I think some of
the system barriers and rules that are in place can
be an impediment.
Technology is evolving at an incredible pace. Do you think
these new tools, whether it's AI, better data, or new
medical research, could help shorten the long journey many people
face before the right diagnosis and treatment. Do you see
it becoming easier to help the people so they can
get back to living a better life.
Yeah, I think technology can be a very important tool
for access. I think the access points have been really constrained.
And the more that we can bring evaluation, bring assessment
to people who need it rather than requiring them to
come to a clinic or requiring them to come to
a building. The more that we can bring trained professionals
to where that person is at, I think, the quicker
we can get at treatment evaluation.
We often talk about government and healthcare systems. What role
does community organizations in grassroots efforts in helping people find
mental health support.
I think they're the ones who try to help the most.
I think traditional healthcare settings have a tendency to be
fairly monolithic. The more that we can partner with agencies,
with housing agencies, with shelters, with day programs, and embed telemedicine,
telepsychiatry and break down some of the barriers that separate
healthcare settings from housing settings, for instance, the.
Better perfect timing. Anne Marie has just joined us. Welcome
to the show. Thanks for joining us today.
Thanks for inviting me. I love this topic. I think
we can make a difference.
Anne Marie, Yes, we are trying to make a difference.
Before you joined us. We were discussing the growing concerns
of healthcare with so many professionals feeling overstressed and stretched thin,
with so many doctors, nurses, and providers feeling overstressed and
emotionally exhausted. Do you believe healthcare burnout has reached a
level of systemic crisis?
Absolutely? Our first response are medical professionals. You know, we're
talking about the people who aren't getting care, but how
many times is the caregiver the one who actually gets
something horrible happening because they're not taking care of themselves?
The compassion fatigue? You know, how long can first responders
respond to the same person over and over again and
then they pass away?
And it's heartbreaking.
A lot of the first responders I know that did that,
They do go to the funerals to show that this
was a person that they cared about and tried to help.
I'd like to build on doctor Meyer's thoughts. I'd love
to hear your thoughts on how you think this approach
should be sure. One topic I'd like to address is
the way we're thinking about crisis response and mental health
care based on what you have seen, what models or
approaches appear to be most effective in helping people during
these critical moments.
Are we talking in whether or not it's a peace
officer who's responding, or someone who's trained in psychological.
Treatment, anyone in the field that is properly trained.
Okay, I think that there are wonderful psychologists and there
are less wonderful psychologists, and there are wonderful peace officers,
and there are less trained peace officers. So I think
it's also about the person and not just the job
they're doing. Obviously, we want to move away from peace
officers being the primary fifty one fifty enforcer. However, I
want to make sure that people understand the role that
peace officers play. Because a psychologist who's meeting someone who's unstable, schizophrenic,
potentially prone to violence.
All of them are not prone to violence, but some
of them might be.
We want to make sure that everyone's protected, and so
by training our peace officers specialty units that can go
with trained psychologists and clinicians to meet them, that's going
to be our sefest bet and if we do it
proactively rather than reactionary, we're going to have a lot
better results.
Before we move forward, let's take a moment for our listeners,
Could you share a little about your background on your
role and the work you're involved in.
Oh? Sure.
So I started working with Aaron about four or five
years ago at the City of San Diego, where I
was a senior deputy city attorney.
I was a prosecutor for almost twenty years.
Then I worked on gun violence response or restraining orders,
especially for people who had mental illness issues and shouldn't
have a fire or within And then finally I got
moved to representing first responders who needed help navigating the
mental health system, and so in that way I was
able to help them through probate system, through the LPs,
secured conservatorship system, and other different avenues of care. Unfortunately,
you know, programs change, resources change, and so my role
was cut and so I was moved to a different department,
and so I decided to keep my work with mental
health going. I retired and now I serve as a
mental health policy advisor for municipalities, legislators.
Or lawyers.
But doctor Meyer still collaborates with me, thank goodness, because
we've been a team for a long time, know and
I think we compliment each other. So I'm pleased to
get to still write and work work with him.
Since you approached this from the legal side, what changes
do you believe need to happen. How do we help
policy makers and leaders at the state and local level
better understand that collaboration is essential not only for those
with serious mental illness that need the help right now,
they need to understand that by everyone working together, it
can help prevent these challenges from becoming even larger in
the future.
Well, I think it's already a huge issue.
But I like what you're saying, and I think programs
like yours are so critical. I think that grassroots effort
to start from the bottom up to say hey, we
don't like the way it is. When it comes to
what I think is going to get people's attention. I
think we really really have to force ourselves to look
at the number of people who are incarcerated who have
severe mental illness, and that if we could have gotten
them in voluntary care. And I am saying that in
voluntary care to care for their unstable schizophrenia or other
mental health disorder head of time, maybe they wouldn't have
committed that felony, or they wouldn't have been the victim
of that crime. And so I think we think of
vulnerable people. They might be the victim, they might be
the perpetrator, but all of it is because of a
failed system. And so if people can focus, we could
take some money, save money on the law enforcement end,
and reinvest it and I think would be better all around.
So hopefully we can get their attention in that way.
I'm glad you brought that up. I asked doctor Meyer
earlier about assisted outpatient treatment laws and how they vary
across states. We see some states implementing AOT, some doing
very little, and others struggling and having difficulty on how
to apply it effectively. How do we help legislators understand
that early intervention is critical, that waiting until someone is
a danger to themselves or others may miss the opportunity
to help them before a crisis escalates. How do we
get them to understand that this is not only helping
the person that needs the help now, but is also
helping prevent this situation to become a community crisis.
Well, I think that that's a great point to bring
up because a lot of people talk about AOT versus
care court right, because in California we have both, and
the problem with both AOT and Care Court is that
they have very very narrow criteria for who is eligible,
and so sometimes you have someone that has layer needs
but they're not eligible for either because of that narrow
criteria or if they get in.
These are both voluntary programs, So.
Don't make any mistake about it just because it says
assisted outpatient treatment with the Court, it is voluntary and
you cannot force someone to get medication through that. The
only way in California to force medication is under the
Lanternman Petris Short Act in the Welfare Institution's Code, which
is a different section for force medication and force treatment.
So I think when it.
Comes to AOT, honestly that should be the model voluntary care.
That's what we want, but we also have to have
compassion for those who are going to wind up in
jail or dead if we don't get them help.
That's a huge statement. I have to say. This has
been a really great session. Thank you so much for
being here today, and thank you for agreeing to keep
the conversation going. For those of you listening today, we
are actually recording more. Part two is coming next week.
There are many interesting subjects that we will be talking about.
So thank you for joining us. A sincere thank you
to our guests for sharing their journey. If today's conversation
helped you see the world a little differently, then we're
doing exactly what we hope to do. Until next time,
keep believing, keep learning, and most importantly, keep asking yourself,
why not me?