1 the work, the work environment and access to mental health careAlaska vs California A tail of two jobs: the work, the work environment and access to mental health care The mental health care available to the populations I served Strengths and weaknesses of the two systems in which I worked Impact on my work/life balance Access to mental health care as doctor and as patient

2 Above Anchorage towards Mt. SusitnaLofty ideas for clinical practice – Learn local culture, custom and ways of being to add to the psychiatric lexicon and understanding of constructs of mental illness, distress and recovery bring empirically validated psychotherapies out of the ivory tower and to the people

3 Eagle Glacier Posted to ANMCRun by two Native Non-profits – ANTHC and SCF Out patient mental health clinic with psychiatrists, psychologists, master’s level therapists MSW’s worked in hospital and outpatient medical clinics and not comfortable with “psych” per se No inpatient unit, limited capacity to refer to inpatient as mental health treatment specifically excluded from “contract funds” used to send medical or surgical patients out of state to more specialized care Population with high rates of risk factors Major Depression, PTSD and/or poorer prognosis for all MH conditions: low SES, sexual abuse, early parental loss, substance use and accidents

4 We’re not in Kansas (or Seattle) anymoreThe reality of limited resources: 5 psychiatrists when I arrived became 2 No medical school, psychiatry residency, PhD psychology or MSW programs Grads from the two MFT programs of uneven quality

5 Bridge over Upper Eagle River, Crow PassLoss of other psychiatrist colleagues left me with no professional supervision in my field and “the weight of the world” on my shoulders Intrepid as ever, I tried to recruit and to work with what I had

6 Summer Green Reorganization with support from management, staff not supportive. Attempted to: Establish clinical pathways and guidelines to address the most common and most serious conditions we treated provide training to clinicians in the shorter term, empirically validated psychotherapies use groups to provide psychoeducation and general support minimize high no show rates and maximize access through a revamped intake structure utilizing bachelor level case managers

7 Winter Pale Almost none of it withstood a single change of the guard.Turn over rates amongst staff were high Recruiting a new mental health professional takes months to years. More positions than professionals to fill them - little incentive to stay aside from dedication to the Alaska Native population. Management also lost it’s taste for the process as their focus shifted

8 Blurry Alpenglow The crisis team (BURT) did “stick”.My only programatic legacy is a 24/7 urgent response team based out of the mental health clinic, but covering the ER, medical and surgical floors, and outpatient walk ins. Aim was not just to improve the quality of care provided to patients in those settings, but to reduce the burden on the other providers who did not want to do crisis work

9 Ordinary Moose I didn’t learn a single word in Athabascan and only two or three in Yupik, none of which relate to states of mind or emotion Some of the stories I heard do haunt me, and show me that the gap between the ivory tower and community care are as large as ever.

10 Roadside Moose I was stuck on one side of the berm for a while, unable to see a way to progress Problem was personal as well as professional. My PCM assessed me for workaholism and in truth, I was using work to avoid other problems Excuses for not seeking my own mental health care: Not enough time didn’t want to be seen in my own clinic wasn’t comfortable accessing care at the local MFT didn’t trust the private practice practictioners. Didn’t want to have to admit defeat and give up on something important to me – work, marriage, etc Didn’t want to have to change Earlier MH care might not have changed the outcome, but could have eased the transitions

11 Cross country skiing at lunchtimeResiliency factors built in to the setting as well: Natural beauty Easy access to outdoor exercise Compelling mission that kept me for 7 years

12 Benicia, CA approached by waterDavid Grant Medical Center, Travis AFB Hospital with fewer beds and fewer specialists than ANMC Bigger outpatient mental health clinic Inpatient psychiatric unit Serves ADAF, AD of other services, dependents, retirees, dependents of retirees

13 Mt Diablo across the freeway, industrial park, mothballed fleet and Carquinez StraitEverything is connected by interstate freeway, mostly along the I80 corridor. Still long drives and difficulties finding some specialists Child psychiatry and child psychology especially scarce

14 Mt Diablo observed from the Carquinez StraitPopulation is literate at HS reading level (vs. 3rd grade reading level) Funds are available to refer out for services we don’t have AD personnel can’t quit their job Makes for lots of “adjustment d/o” cases, but few unplanned departures from the clinic

15 Sunset ½ block from my houseMental illnesses are universal and less specific to circumstances than the general public realizes I see FEWER cases of PTSD at Travis than at ANMC Patients seem to respond better to standard treatments (safe housing, transportation, steady job and pay, higher level of education)

16 Another sunset from the closest shore access to my houseSimilar mix of professionals and services (SA, outpatient MH, urgent MH care) but: Greater stability to programs and structures Many procedures and services spelled out AF wide and not subject to local reorganization Less arguing amongst staff on best approach, more adherence to guideline and policy (for better or worse)

17 California Christmas colorsStill with high turnover which is disruptive for patients Session 5 of PE is not the time to switch therapists because yours is deploying or PCSing

18 Christmas time in my home townReport structure is clinical – i.e. physicians are supervised and rated by physicians to a point, and always by health care professionals up to a hospital commander level

19 My garden in winter Trainings are offered annually in the core psychotherapies for PTSD that guidelines state should be offered to patients with this disorder. Supervisors ensure supervisees attend the training Peer review does include adherence to clinical guidelines to a point (not solely Medicaid or JACHO driven check lists)

20 You can grow a lot of fruit in CA; not so much in AKLess flexibility but more clarity

21 Pomegranates ripen in winterWork seems more manageable More time to focus on other things Better work/life balance

22 Chilies and tomatoes “volunteer” from year to yearMental health care access with my patients: Within 5 business days, about the same actually AK and CA 90 minute intakes (same) Follow up frequency set by me not clinic

23 Ripe grapefruit knocked down by winter windEasier to refer patients to the network Harder to refer patients back to primary care

24 Dry hills reflected in Lake Herman reservoirAccess for me as a patient: Easy to get a referral off base to avoid dual relationships Many therapists taking Tricare (not as many psychiatrists) No hassles with billing or payment from my point of view as a patient

25 Mt Shasta observed from the Sacramento River ValleyOther resiliency factors for me in my current job and location: Near my family and familiar places Fresh fruit and vegetables Supportive psychotherapy for me to reflect and expand

26 X country skiing at Mt Lassen; not a lunchtime excursionNo shortage of recreational opportunities A friendly gym across the street from my house Creating a circle of friends outside of work as well as at work

27 Most California natives bloom in winterConsider your own work stressors, work/life balance, resiliency factors

28 How do you bloom where you’re planted?