Mental Health Matters
Todd Weatherly, Therapeutic Consultant and mental health professional hosts #MentalHealthMatters. Interviewing doctors and therapists, treatment professionals, organizational leaders, and other members of the mental health community about the importance of mental health awareness, treatment and the future of addressing mental health in the US. Discussing how to support mental health in our communities from hospitals to the dinner table and what to do when crisis arises.
Mental Health Matters
Compassionate Care with Dr. Christopher Fowler
What if there was a way to redefine mental health care for individuals with complex needs? Join us as we sit down with Dr. Christopher Fowler, the Executive Clinical Director for The Monarch Community, to uncover the transformative power of compassion in mental health treatment. Discover how Therapeutic Communities (TCs) can profoundly enhance quality of life for those challenged by severe and persistent mental illness, and why family involvement is pivotal in the recovery process. Through Dr. Fowler's lens, learn how patient-centered approaches, as opposed to intensive clinical environments, foster meaningful attachments and create a safe space for healing.
Dr. Fowler sheds light on how emotion regulation and co-regulating affect play crucial roles in therapeutic settings. Discover how the techniques used to manage and defuse crises reduce the frequency of emergency room visits and prevent long-term mental health impacts. We explore the success of integrated care models and discuss the potential of nationwide implementation. Dr. Fowler shares insights into the challenges and benefits of sustainable long-term care models, emphasizing the need for comprehensive community-based support. Tune in to envision a future where improved mental health care models can prevent homelessness and offer dignity and hope to those in need.
Welcome folks once again to Mental Health Matters, with Todd Weatherly, your host. This is WPVM 1037, the Voice of Asheville. I'm glad to be back with you today and I have a wonderful guest who I'm excited to have on the show Dr Christopher Fowler. Dr Fowler is the Executive Clinical Director for the Monarch Community, a compassionate residential therapeutic community fostering an enrichment of a quality of life. That's something I want us to really get into, because I know that web language is what it is, but at some point in time I think that's got a little deeper meaning for you guys. But Dr Fowler completed a PhD in clinical psychology from the University of Tennessee. We won't hold that against him.
Speaker 1:After an internship a year at Harvard's Cambridge Hospital and a four-year postdoctoral fellowship in clinical psychology at the Austin Riggs Center, he advanced to clinical leadership positions, serving as director of clinical research and clinical team leader. During his 16-year tenure at Austin Riggs, another therapeutic community, he learned the critical role families play in the recovery process. In 2011, he and his family moved to Houston where he served as Associate Director of Research and Director of Psychology at the Menninger Clinic. In 2018, he joined Houston Methodist Behavioral Health as Director of Professional Wellness. Dr Fowler currently holds academic appointments as Professor of Psychology at Houston Methodist Academic Institute while Cornell Medical College and Meneker Department of Psychiatry and Behavioral Science at Baylor College of Medicine. He has over 140 publications in the areas of personality disorder, suicide, neuroimaging and treatment outcomes and is internationally recognized personality researcher. Now that's an interesting thing, personality researcher Currently serving on several editorial boards, including Journal of Psychiatric Practice and Psychotherapy. Dr Fowler, welcome to the show. Thanks for joining us.
Speaker 2:Thanks for having me, Todd.
Speaker 1:And I'll lead off with that piece because this is having worked. You know, you and I haven't known each other that long, but I feel like all of my interactions with you are incredibly genuine and you tell me the exact thing that I'm looking for in terms of what's going to be the quality of care for a person that we may be trying to put in your care or working with currently, you know, compassionate residential therapeutic community. I would say that we might call that a generic statement you might find on anybody's website, right? What are words? Fostering and enhancement of the quality of life. I know for a fact that you know the individuals you serve are fairly complex. They've got largely multiple treatments in their background. They may have suicidal attempts and ideation, they may even have violent behavior that have happened for them in the middle of a psychotic break.
Speaker 1:They've gone to other places, been unsuccessful and they've come to you, and they've come to you in an environment where they've found an ability to achieve some level of independence, some even long-term independence, and the latter levels of care that you offer at Monarch Community and what I notice that's particularly heartening and works well for some of the clients that we've sent your way is that you're not in a hurry, that you know we're just we're going to take a minute here and we're going to calm down, because I find that a lot of clinical environments are like a pressure cooker and not everybody responds well to that. Could you speak to that for me? With all your years of wisdom and experience Austin Riggs being a therapeutic community, menager Clinic and Houston Methodist being assessment centers what brought you to this method of treatment that you find that I personally hold so dear?
Speaker 2:Patients' response to these different modalities and different timeframes is probably the biggest thing. That brings me here. I think almost everything I've learned in clinical experience with patients is from the patient. I've learned a lot from supervisors and reading and doing research, but, my goodness, listen to the patients and see how they respond.
Speaker 2:So, rigs, longer-term treatment, time and treatment is a very important part of it. Menninger, short-term model when I went there it was eight weeks and there was that pressure cooker, just as you described. It's perfect, right? Everyone the clinical staff, the patients, the families feel an urgency to get something done and if the individual patient is of a higher functioning, less acute, less pathological, a lot can be accomplished in that timeframe. Acute, less pathological, a lot can be accomplished in that time frame.
Speaker 2:However, for people that have high co-occurring disorders a lot of SMI, psychotic spectrum disorders, personality disorders that really take a great deal of time to untangle and get to understand what makes this person tick the eight-week model actually can create a lot of problems and so they can struggle a lot because of all the pressure.
Speaker 2:So, longer-term treatments, the ones that you know, where you have time for the individual to get somewhat attached to the team, for the team to really get to know the inner workings of not only the individual client we call them residents the inner workings of not only the individual client we call them residents. The families, the family system, I mean all of those elements take weeks, months to really get a good handle on. And so, once we have a good model of the mind of the resident, we have a sense of how they work, what in fact can cause them having iatrogenic effects like becoming more symptomatic, what actually works to help them soothe, calm and get into a space where they can learn, they can really open their minds up to not only the social milieu of the culture there, but also to what the therapist has to offer, what the different groups have to offer. Then, once they are able to open their mind a bit and feel a bit safer, then the real therapeutic action takes place.
Speaker 1:Yeah, you know, in particular, a recent person that we were working with, I think that you know safety was a big, huge piece, and part of an inability to feel safe in other environments caused the social environments to be a strain. So there was conflict there, there were issues that would arise and things like that, and you know some resistances to treatment and those sorts of things and and you know, kind of the one of the results was they were able to get comfortable. They had several messages from other people. They were able to kind of get right with something they felt like that was really healthy for them and then you know, emerge as a person who was a member of community, which I think is something they were really missing. And you know, from your time at Austin Riggs, community is a huge, I mean, it's a huge component of somebody's care.
Speaker 1:When you this, you know in this one in particular and and many of the others that you have served, you see them coming from a variety of environments. They've done, they've done, you know, assessment of stabilization and assessment environments. They've done multiple hospitalizations. They may have done residential programs for even longer, longer terms six months, nine months a year. They've done, they've tried to do transitional living programs and maybe they didn't work out so well and that sort of thing. You're a person. Now, especially with this population, you get to look at, all right, where did this not quite go well for this person? You know the hospital or this program or that program. As you were a person who kind of delivers this clinical model for Monarch, what is it that is different and separates you from other models of treatment? Do you think what's the? You know what's the.
Speaker 2:The key there? Well, I think one, you know a simple one is just what is the culture of the staff and how do they react to the differing psychopathologies, tension points, hot points for the individual person? Having a staff that does not have expectations that the person coming in will suddenly be transformed and be a healthy person or behave themselves in reasonable ways? I think that that is something I've seen across different institutions and it's a slippery slope. If our thinking is that because we are great, the patient, the resident, should come in and begin to manage themselves in a different way, then we are reacting to them as if they're doing something wrong when they are simply being themselves, when their symptoms are emergent and when they're having struggles interpersonally, symptom-wise struggles, power struggles over medications, et cetera we really have to kind of take a step back and say we're going to start with this person where they are and not expect a great deal from them, certainly not in the beginning, because they don't have any sense of trust or safety with us. And why should they?
Speaker 2:You know, some of them have had very bad experiences. They report bad experiences in hospitals, and so our job at the outset and this may be two months, three months is, in part, earning their trust and developing a mutual trust across so that they can feel a bit safer. Now, while this is going on, of course we're encouraging medications. If they come in on taking medications, we continue with that. But some people come in and they absolutely refuse medications at other institutions, and so our job is to help them if they need those medications, to get the right ones and get the stabilization started. But very often the stabilization starts with interpersonal relationships and development of attachments.
Speaker 1:Right, yeah, well, you know, healthy attachment is a cornerstone to proper care and a satisfying life, honestly. So I mean, with these folks they've, they've been through so many environments a lot of times that either didn't work or maybe they they worked for a while and they blew out at the end. And so this I think that, um, you know, from a from a treatment standpoint, the more a person experiences a model that doesn't work or they have some conflict and it kind of blows up that they, they expect the next place, next place, to do the same thing and and they'll, they'll cultivate this behavioral pattern where they'll even come in testing, testing your metal, testing your limits, seeing if you're going to abandon them, seeing if you're just going to be the next program. Who you know says that they're too much and everything else and what so.
Speaker 1:And I would say that in a lot of treatment environments you know, other than, say, hospitals or stabilization environments that are, you know, contained and even locked in some cases or what have you, they've got an ability to contain behaviors in a certain kind of way, but it's more of an acute approach. Your approach is not, I wouldn't say it's not an acute approach, but you're really serving individuals long term. What's the difference between your response to what others might call inexcusable or rule out behavior in a program versus what they've experienced before they got to you? Like, how do you manage that the kind of high-ended, maybe an explosion, or somebody who's very loud or even potentially, like I wouldn't say fully aggressive but loosely, you know, threatening like I'll hurt someone or I'll do something. They'll say all kinds of things to get the reaction? You've got a staff that's trained to deal with this and you yourself have got this model that's able to kind of absorb that a bit.
Speaker 2:Like, tell me about that treatment approach for you as a staff absorb that a bit Like tell me about that treatment approach for you as a staff, sure, so yes, our system is open, completely open. We don't have locks on any doors. So we really do have to rely upon good staff to help de-escalate situations, to help a person restore their ability to think clearly, and that includes a lot of work towards emotion regulation, down-regulating of emotions and using a whole variety of techniques to do that. But for staff to do that, they have to be able to regulate their own emotions as well. Right, so we spend an enormous amount of time in clinical meetings, also taking the temperature of our own staff, helping to restore our ability to reflect on what's going on with the individual resident, because it's very easy to slip into a cognitive style where we know exactly what they're doing and why they're doing it. It's usually not for good reasons, you know, like, oh, they're manipulative or they're trying to be Call it maladaptive, you know.
Speaker 2:And so our staff spend a lot of time, you know, taking a pause, taking a breather before reacting to the resident and then really trying to mentalize the individual, try to reflect on what's going on with them now, ask questions, as opposed to immediately move into redirecting and managing behavior, especially if it's not at a critical juncture. We're not kind of across the red line, so to speak. There's a lot of effort to try to say hey, what's going on? Let's think about this together and co-regulate the affect with the individual resident who's becoming upset or overwhelmed. And by doing that we're teaching them co-regulation of affect, we're teaching them about mentalizing and we're also teaching them to be mindful of other people's internality, their intentions, their efforts, and that goes a long way to help bring down the temperature fairly early on in these kind of rupture repair scenarios.
Speaker 1:Right and say a little bit more about co-regulating. And you know my experience with there is the. There's the idea about approaching someone who feels in crisis and, and you know, part of co-regulating is also matching. So you're matching to a certain extent their level of wow. That sounds really terrible that you're going through that and you kind of work your way down, like in your experience, is it and I'm sure it's not one answer but is it better to stay level in one place, or is it like, do you do some of the rise and match and then help work them back down? Like, what's your, what's the approach that you find to be the most effective?
Speaker 2:okay, well, this I I borrow this very, very heavily from peter fonegy and john allen. They're both attachment and mentalization based experts, and so I work towards marked contingent, which, which really is a complicated term, for I want to match and mirror their level of affective experience, but do so with a bit of a difference from them, so that I'm not if they're overwhelmed I'm not matching an overwhelmed state, but rather recognition that they are overwhelmed and then I try to offer them something in addition, and then I try to offer them something in addition. So I tend to move and our staff tend to move fairly quickly from hey, I get it, think I understand. Let me see if I understand too Well, I get how you're really upset about this. Now let's take a moment to see if there's any other way to think about this particular interaction that got you so upset or the way that you're thinking about something so it's an invitation.
Speaker 1:Oh yeah, it's an invitation for them to begin to put the frontal lobes back into motion and, you know, down regulate that limbic system a bit well, I mean what you're doing is I mean from a therapeutic standpoint the more often that person even even with somebody helping them does that, the more likely they can do it for themselves and the more likely they're going to be successful long-term. They acquire that as a skill. It's a skill that I think maybe an average person takes for granted, but in mental health it's know, I don't know. You've probably seen the simulation they do for a person who suffers from thought disorder or might suffer from psychotic features. Where they've got I've seen it at a conference and they put you in a set of headphones and the headphones actually have a, they have a olfactory stimulation. You know it's pitching, smells out at you and you're hearing voices inside the earphones and and the whole nine yards, as much as you can. For a person who doesn't suffer from this kind of symptoms. It's like, okay, now what I want you to do is try to hold a conversation with this person while all that's going on and it's you know, the compassion I think that you gain for a person. I I've always felt like it was something I understood. It's like, wow, if I was having to walk through the world but somebody was screaming in my ear, how would I be able to navigate the world? It sounds very distracting.
Speaker 1:And that leads me to a little bit of a question from your standpoint. With the number of years you've gotten research and looking at diagnostic profiles and everything else. When you see a person that they come in with this profile you know I look at a person who suffers from from thought disorder and maybe they even on medication they have persistent delusions. So they've got this voice that's still talking to them and it's hard to get away from it. And they they test out with, say, ADD or ADHD. It's like, well, maybe that's true or maybe they were testing at a time when they were hearing voices and they were distracted, and then you're getting what I would call, maybe, a false positive. Do you find, like, what is it that you see with the people that you've been serving, not just there at Monarch, but over time? How much misdiagnosis do you feel like is really going on out there and what's the solution to it?
Speaker 2:Well, yes, as simple as it's. Yes, and you know, it can happen very, very often in the more acute settings. We're trying to kind of come to a formulation of the diagnosis quickly. The person is in crisis and so you're seeing the manifestation of psychotic symptoms. Let's take an example of like in an emergency department, the psychiatrist, the evaluating physician, is not incorrect. This person is having delusions or they're having hallucinations, manic, et cetera. But then five days later they've calmed down. It's not just a medication issue but the stimulus that got them activated. That way is now settled.
Speaker 2:And now they're presenting in a very different way, and so that's a very common thing that occurs and so not surprising. One of the most inaccurate diagnoses and differential diagnoses in our field is diagnosing bipolar disorder and differentiating that from a personality, particularly borderline personalities. And so the biggest factor there is do you have time to observe them? And observe them in different states of affective arousal? Because with the borderline patient they can downregulate, not quickly, but relative to someone with bipolar disorder they downregulate in an hour, two hours, three hours, whereas a person with bipolar disorder will be, you know, revved up, manic, etc. Four days to, despite every effort to do anything or longer sometimes right exactly, yeah, absolutely and that's
Speaker 1:also true, for, I mean, I think most of the disorders can operate yeah, and you know the um when you're dealing, you know the, the fact that you take the time and that you're looking at this and I think, with your clinical expertise and the kind of partnership Monarch has with Houston Methodist as well, you have to look at something and say maybe that's true. You know we're going to take everything with a grain of salt as we work with this person and I you can correct me if I'm wrong, but I think that the DSM is trying to go in this direction, this bucket. And you have borderline personality disorder, bipolar disorder, what have you and you? You know they're taking things. We've got neurotypical versus. You know it's even taking the place of spectrum.
Speaker 1:These days you can't use a polysub as a diagnosis anymore. You've got to list each substance and its level of significance. You're seeing a lot more of this teasing out of of clinically significant symptomology. As does it and does it qualify as something that is requires treatment, requires attention and not necessarily bucket defining people, and they're trying to. They're trying to go in this direction, do you think? And? But the other thing is and you just named it is time Like a hospital doesn't really spend the time it takes to really look at someone, see if they regulate.
Speaker 1:Do these symptoms disappear? Was it a manic episode? Is it personality disorder and mood regulation issues, all these other things? And our mutual and good friend, dr Alotin Don is a person that I've had on the show and love him dearly and we talk about this as well Like what's the solution in the world that brings? I mean, I think that if we could take a syringe full of what you got and pump a dose of it into the hospital system, we'd come up with something that was pretty good. Pump a dose of it into the hospital system, we'd come up with something that was pretty good. What's the solution in your mind for acute care and bridging over to what we see as what works in long-term kind of community-based compassionate care?
Speaker 2:Good question. You know one. I think that what is happening in most hospitals acute care diagnostic workups can be very good for probably 80 to 85% of the individuals going in right, so they get those right. It's really the really truly complex cases where you know the physicians themselves know that they're in the ballpark. You know the physicians themselves know that they're in the ballpark but they may not have it exactly worked out.
Speaker 2:And that's where I think secondary and tertiary care, like the step-down programs when people get out of a hospital or leave the ED and they go into an IOP or a PHP then you have, you know, you do have a longer period of time to sort out some of those diagnostic conundrums. So I think that's valuable for the vast majority of people just to take the diagnosis they might receive in an emergency department and take it under advisement and then continue to explore it right, rather than reject it or accept it fully, but rather take it as a jumping off. Okay, my doc here thinks that I have this disorder. I very well might have it. Let's continue to study it and invite the team of clinicians to help them study that very problem.
Speaker 1:Well, and you know, and part of the part of what we're talking about, of course, is also getting insurance companies pay for it it. So there are dollar signs in the answer to this equation, somewhere in that mix. But you know I post there's a gentleman we handle the show, dr Comrade. It's out in Maryland and he teaches at the university and I post this question to him and I'll post it to you as well. You know we've got there's a here in Asheville, in our Asheville area that's now where Cooper Reese is housed was Highlands Hospital.
Speaker 1:Highlands Hospital was designed to be a unit with an acute care model and then you step and everything was connected. So you go from one building to the next building and you would step down from acute care to another level of care and you could even go from there to another level of care, and so your length of stay couldn't be anywhere. It wasn't three days, it was weeks to a month or two months, and so the acute care model they were running and this is in the 50s, 50s and 60s they were running, and this is in the 50s, 50s and 60s. The acute care model that they were running out of this hospital was really, I mean, for the time, truly avant-garde and something you just didn't see. It was kind of the preeminent treatment centers in the country. Then you had, you know, first of all it burned down this is where the famous Ella Fitzgerald died because the building was not sound in the ways of fire protection. So we get known for that in Asheville.
Speaker 1:But more importantly, we had the 1970s deinstitutionalization and so you know now the protocol for involuntary commitment, and you know I'm not a big fan of taking people's rights unless they're really really having a hard time. Um, involuntary commitment is danger to self or others, right, and there are a few pieces of places in the country Florida, I say Colorado pretty strong involuntary commitment laws and you can, you've got some leverage in there. But there's also the rest of the country which is okay, they're a danger to themselves or others. They come in, they spend two days in the hospital, hospital sends them to the street and gives a referral to the IOP. We all know that's not going to work and it's going to, it's going to fail miserably. And so they get in the they do the revolving door. So if you were going to adjust the way that we have oriented our mental health, our acute care and emergency care, mental health system and design its rules. What would you? What would you adjust, if anything?
Speaker 2:Well, uh, you're really giving me a wide open. What would you wish for, kind?
Speaker 1:of thing At a magic wand.
Speaker 2:All right. Well, it would be fairly simple. They are investing good money in extended treatment for that very small select group of patients 5% to 10% of individuals who are the high utilizers of things like admissions to EDs. They end up in the jail systems. There's all of the costs that go into having them come out of the hospitals quickly, as opposed to giving them time and respite and helping them get connected to services. So beautiful model by Jeffrey Brenner Some years ago.
Speaker 2:He called these individuals super utilizers and he set up a clinic I think it was in New Jersey and he was the medical director of this unit. And so he would find people that were coming through the ED with 10, 15 ED admissions in a year. And he said to the hospital administrators you know, give me a small budget and I will get wraparound services for these individuals and we'll see what is their utilization of ED visits, their incarceration rates, et cetera. And it took really a small PAC team, essentially, and a good second interest, and they were very different citizens at the end of one year. That worked as a kind of a demonstration model, as a proof of concept, but it's been very difficult to convince insurance companies that this is money well spent.
Speaker 1:Well, as you've got the Medicaid system, investing in PAC models or ACT-E models but they are, you know, medicaid rated.
Speaker 1:But they are, you know, medicaid rated. They're overtaxed and understaffed and you know you've got a lot of repeat. I mean staffing issues that are at least in where I live and I notice in other places that you know keeping an ACT team staff with regular staff, especially your ground level folks, the folks that are doing direct care, running to crisis and responding to those things, docs in charge of it and you've got a program director, but these folks are the ones running the streets trying to find people.
Speaker 1:And you know, what I find is that you know we've got, we've got ACT and PAC team models like like Ellen Horn and Westbridge and a few, a few others I would call yours. You know, at the, at the, your second or third levels of care, probably very much like a very functional and and operational actor pack team model. Would you agree with that?
Speaker 2:Yes, I mean that that's the design of what we call enduring care. That's long-term care, low costs, relatively low costs. It's long-term care, low cost, relatively low cost. And yes, we have a functioning PAC team that hopefully will be with us for 10, 15 years so they get to have that continuity of care all the way through their treatment with the same kind of providers.
Speaker 1:The thing that they're getting not to toot your horn here is they're getting you not to toot your horn here is they're getting you as a person who's providing them with support, who's monitoring staff burnout, who's monitoring, you know, compassion, fatigue and all these things that impact people. What I see in kind of community mental health is you know, sink or swim, you know they sling you out there and maybe you're good at it and if you are great, but after a little while you're going to burn out pretty hard because the more you can handle, it's not that you get a lot of reward, it's that you get a lot more work. So it's one of those things that is very it. The money's an issue. The model exists is what I hear you saying.
Speaker 1:Model, we've seen it, we've got examples of where it's worked. Um, we know that, if you know, we're not trying to say you need to throw money at everything and that's the solution, but you do need to, you do need to exercise what we would call appropriate and adequate care for individuals that are these. You know, I think our clients are the super users, so the people with multiple hospitalizations under their belt. So, um, I, I, so I love your model for doing that, the one you know.
Speaker 1:I thought that maybe, you know, maybe the law should be changed because getting a person let's say it's a person who's suffering from psychotic features, but they're not a danger to themselves or others, their delusions are not something that's causing, they're not out there causing harm. And I've got a couple of folks that I'm trying to help get care that are in this situation right now. They're not committable, you know, and they're not hurting anyone. They are kind of coalescing and and, of course, since they are delusional and psychotic and not on medications and just, you know, isolating God knows what it's doing to the brain because they continue to just be in that condition, how do you serve that person better?
Speaker 2:Well, I think a really helpful model is harm reduction.
Speaker 2:I borrow this a lot from the substance use world because it's a good model.
Speaker 2:You can't do everything, you can't always protect every aspect of the person's mind functioning relationships but you try to find ways to reduce the impact of their illness, bolster their sense of community.
Speaker 2:And this could be even in like some of the community models that are out there, where there's, like you know, clubhouse models, great examples of that, where you give a person you know some exposure to things that can be meaningful to them, you provide them with some degree of community, so they have something that feels like a village, because the isolation and the loneliness of being that ill, even if you don't know it, it's very isolating. And so you give them things like this low cost, it helps to reduce some of those impacts and then maybe you can get them in to see a psychiatrist and maybe you can get them to take medications. You know, the other model is have a lot of folks in the community with guardianships and so families get to determine the medication. But that's a very steep road and the laws really aren't designed. They're designed, as they should be, to protect the individual's rights and freedoms designed.
Speaker 1:They're designed as they should be, to protect the individual's rights and freedoms, civil liberties, but for you know, you see, people who are falling apart, and civil liberties is just another word for nothing left to lose, right right, um, and you know the, the definition of, the definition of well as the state is concerned and, and to that extent, mental, you know, community mental health care can be for an individual who's not part of the system, it's not connected to a system or a community that provides care is well if you're not out hurting anybody else or yourself. You're good, um, and I I tend to think that there's a, there's a better, better model than that. Um, I definitely like your answer. The one protest I've had to, you know, should we change this? You know, should we come away from deinstitutionalization, maybe dial it back a slight bit, you know, is the staffing. It's like how do you design?
Speaker 1:Ross Ellenhor was talking. Dr Ross Ellenhor was talking about this. Like you know, the family was not designed to exist alone the way that it does. It was designed, you know, families are supposed to live in community. We're not supposed to be every man for himself, and this is mine and that's yours and it's very much the American way. But what it's done as a result is is provided these deep channels for isolation within the context of our social makeup and that, you know, as we know, especially for anybody who's who might be vulnerable to it is going to cause us to see mental illness at some of its deepest levels. Isolation is one of the worst things a person can do. So I don't.
Speaker 1:I think that we've got a few solutions here. How do we, how do we cobble them together? Like you know, I'm just ready for you to go ahead and deliver this brilliant model that will change the world. You know I'll be, I'll be glad to stand at your side and help you deliver it. So I think you're doing a piece of it there at Monarch. I'm really appreciative of the of the work that you're doing there. Tell me and just before we go, if you would tell me about the levels of care. Again, you know, for the people who are listening, tell us about how the model at Monarch is designed and some of the successes that are part of that model.
Speaker 2:Oh, sure thing. So at the entry, at admission, people are admitted to the residential treatment program, which is a fully staffed, 24-hour staffed unit that's on campus, and so this is a higher acuity getting to know the individual, forming attachments, helping them get to the activities that will help them ultimately to get on to the next level of care, and so that one really is focused on improving affect regulation, improving social cognition, so that people start to understand other people and their intentions a bit better and very very important, my favorite treatment plan.
Speaker 2:The goal for every patient is turning to others when you're in distress, right, and just being able to say, hey, I need 10 minutes, that kind of thing, because that helps with the co-regulation of affect but also starts to build trust in times of distress. And that's when people have the hardest time reaching out to others is when they're very upset and overwhelmed.
Speaker 1:In a receivable way address their need. You know, it's like I get to say something, I have a need, and then people are going to respond to it.
Speaker 2:I mean, it sounds simple but it's brilliant, you know in my view it is simple and sometimes it takes a year or more for a person to get to where they're actually able to do that consistently across time. Once we're there, we're in a great shape, consistently across time. Once we're there, we're in a great shape. The next level of care is called the therapeutic community program and individuals don't have to be asymptomatic or massively improved. They just have to be functioning a bit better, managing their day-to-day and are interested in doing things like the work programs.
Speaker 2:We have an on-campus work program with a transitional work program to work in the community If they want to go to school, be engaged in some kind of activity. You know this is very much borrowing from Ellenhorn, but also Cooper Reese's Having a Dream. And if you have a dream and there's something you really would like to get after, then we help them sustain that and develop that and so they can step down. They're still on campus, they still have the groups and their same level individual psychotherapy, med management et cetera. But they really are at that point beginning to look out into the broader community of Montrose and think what do I want to do next?
Speaker 1:And that's the house across the street, right, it's still connected, still close, but a little slice of independence, a little slice of separation, that's right and less checks with.
Speaker 2:You know it's now two-hour checks, every two hours they're checked on, kept up with.
Speaker 2:Once they are ready to start thinking about, you know, moving out into an apartment in the community, then we start thinking about the enduring care group and there they begin to think about things like greater autonomy and independence, maybe managing their own meds, if they have that capacity, and finding an apartment nearby.
Speaker 2:And that's when the PAC model comes into play. That's when you know our PAC model team is already, knows them, is very familiar with them, has connections with them, has a therapeutic relationship with them, and then they kind of take over that part of the treatment and that can last, for you know, a year, two years, whatever the length of time that that person needs and facility can manage, et cetera. The last thing we have is just it's not so much a program but rather an offering and a kind of a buffer, which is the respite care program, and that's simply people, when they get in crisis, they don't have to go to a hospital, they can go, stay in a respite bed, have 24-hour supervision, have a few more contacts with staff and help to deescalate and palm, maybe take an adjustment to medications, and that oftentimes really stops a slide into greater deterioration and also prevents another hospitalization, which we all know if they have to do it absolutely, but if we can avoid it it helps with continuity of care and disruption.
Speaker 1:The stumble, not a fall, for sure, yeah.
Speaker 2:Yeah, absolutely. And then our last program is just called graduation and that's when they say you know you're fired. We celebrate them and we're very happy for them and they can stay connected to us through an alumni association. Some of them can stay on with their therapists, do an outpatient therapy, etc.
Speaker 1:But it's really a great day when people graduate. That's really great. You've had members or residents who have stayed at, let's say, the third level of care in with support of the PAC team for years five, 10, even 15 years. Is that accurate?
Speaker 2:That's accurate.
Speaker 1:Yeah, and I, you know that's just. I mean, and I think what you've, just, what you just talked about, is not necessarily even it's. It's a model that could be laid over the care for anyone who's experienced something that I would call a serious you know serious mental illness or an addictions issue or co-occurring conditions. If you've been hospitalized for something I you know, come out and take some time, some, you know, some pretty concerted time, to take care of your condition, learn about it, know about it, receive support around it, take another step down, take another step down and then, when you're ready to stop taking steps and those steps may have different lengths for different kinds of people and their various conditions, but that's our, that's our model, you know that's.
Speaker 1:If we could, if we could get the insurance companies and the hospitals and the community mental health programs to kind of sign on for some version of this model, I think we could start to have a handle on real mental health care in our, in our, in our country, honestly. So we're getting closer. I think that the private pay industry is helping us. We're getting closer. I think that the private pay industry is helping us.
Speaker 2:But one thing I'll point out about Monarch is that they are owned by a nonprofit that's trying to promote that model and take it other places, which I'm incredibly excited about.
Speaker 2:So we're looking forward to the further development of the Monarch community model and other places around the country. I know you're excited about it. You've got nothing else better to do, Is that right? Well, yeah, you know. I mean it was one of the many things that excited me about this project when we began talking about it about four years ago. So, you know, because the need is so great. Right, we know this across the country may not have the perfect solution, but if we have a viable model that can be done at a lower cost, that will be funded by insurance and third party, then we begin to tackle it.
Speaker 1:Yeah, I think, with viable models. Tell me if you think this is accurate. If we have a viable model that's starting to have a place to live in all kinds of places around the country and we start to embrace something like that, do you think that the level of acuity would begin to decrease?
Speaker 2:You know, I would hope so. I don't think the number of individuals that are going to be affected by mental illness are going to decrease, you know, because there are so many systems issues and so many social issues. You've seen the rise of mental illness and unwell mental health, but, yeah, I think the acuity and the severity of the long-term impacts could in fact begin to drop a bit. So, yes, we're always going to be, you know, suffering as humans and we're all going to have difficulties, but maybe not to the degree that we have so many people that end up in a homeless state because of their illness.
Speaker 1:Yeah, and maybe they don't have to repeat a cycle three and four and five times just to end up landing in the kind of care that they need or become homeless or any of these other things. So well, Dr Fowler, it is always a pleasure to speak to you and see you and learn about what's going on for you and hear your wisdom. I really appreciate you taking time to be on the show. This has been Mental Health Matters on WPBM 1037, the Voice of Asheville. I'm Todd Weatherly, your host here with Dr Chris Fowler. Dr Fowler, thank you so much, thank you, thank you.