#10 Best Medical Care for Emerging Adults w Mental Illness

Proem

Continuing the series spiral with emerging adults with mental illness at the center, along the outbound curve, we experienced a parent, a high school teacher, primary care and emergency doctors, and community services. Now we arrive at mental health providers in the person of Michael Macht Greenberg, who administers an integrated system of mental health medical services, McLean Hospital, of the preeminent healthcare system, Mass General Brigham’s Hospital. I met Michael working together at Boston Children’s Hospital. Michael was the administrative director of the Department of Medicine, and I led the patient/family experience initiative. We both left Boston Children’s more than ten years ago. As circumstances allow, we still meet for coffee at least quarterly, in person or virtually. Michael’s low-key presentation belies his passion and compassion for emerging adults and people with mental illness.

Podcast intro

Welcome to Health Hats, the Podcast. I’m Danny van Leeuwen, a two-legged cisgender old white man of privilege who knows a little bit about a lot of healthcare and a lot about very little. We will listen and learn about what it takes to adjust to life’s realities in the awesome circus of healthcare. Let’s make some sense of all of this.

Like what you’re reading, hearing, or watching? Go to my web page?https://health-hats.com/support?to choose a method of support that suits you. Thank you.

Health is fragile

Health Hats:?Michael, thank you so much for joining us. I appreciate it. I love seeing you. This is different from our usual coffee at Pete’s.

Michael Macht Greenberg:?Always good to be with you. Thanks for asking to chat.

Health Hats:?Yeah. When did you first realize health was fragile?

Michael Macht Greenberg:?Wow. As a kid growing up, when you start losing people, grandparents, and great-grandparents, you start realizing you can lose people. Those people who have been important in your life aren’t around anymore. Fortunately, I am a healthy guy, and my experience with fragile health is limited. I’m fortunate that, with limited exception, that hasn’t been too dramatic or traumatic. But while growing up and realizing the people you love aren’t around forever, that gives you a thought about how important life is.

Leadership at McLean’s Hospital

Health Hats:?Thank you. The reason that we’re talking is that you’re a director of an adolescent mental health system. Could you tell us about what you do?

Michael Macht Greenberg:?Sure. I work at McLean Hospital, a private psychiatric hospital, part of the Mass General Brigham system. My roles at McLean include Senior Director for Child and Adolescent Psychiatry. I’m also one of the Interim Associate Chief Operating Officers at McLean. So, I have a role specifically related to children, youth, and families and a position regarding the hospital’s executive leadership.

Levels of care

Health Hats:?Are the services you provide inpatient? Are they inpatient and outpatient? What’s the array?

Michael Macht Greenberg:?McLean has an?extensive range within the child and adolescent division. We have two inpatient units, probably six or eight residential treatment units of various types, and four or five partial hospital day programs. Our outpatient clinic provides what you might think of as typical outpatient care, but there are also subspecialty components, including neuropsychological testing. We have two licensed special education schools. One is a regular high school for kids with emotional problems that impair their ability to participate in education in a typical school setting effectively. We also have a licensed school for kids who are on the autism spectrum. Our school consultation service provides education and outreach to several school districts across Massachusetts. I have to think if I’ve left anything out. We’re trying to meet folks where they are and provide services at the level that people need. So, we have a wide array of care.

Massachusetts Child Psychiatry Access Project (MCPAP)

Health Hats:?How do people find you? Do they get referred by primary care physicians? Do they get referred by community counselors or psychiatrists? Is there an emergency room that you have or have access to?

Michael Macht Greenberg:?Folks get to us from various avenues. It can be everything from Google and people searching the internet to see our services. We have an extensive network of coordinated care with primary care doctors. You reminded me. In addition to all those other services we mentioned, McLean Hospital is part of the?Massachusetts Child Psychiatry Access Project?or MCPAP. That’s a consortium of hospitals across Massachusetts that provide consultation and referral to many primary care doctors across Massachusetts. So, you can get to us from the internet.

Health Hats:?Wait a minute. Is that referral meaning that people are patients at McClean, and then there’s a referral to primary care that’s comfortable managing?

Michael Macht Greenberg:?Typically, the other way, if I’m a primary care doctor and I have a youngster with a psychiatric issue, and I want to consult with the child psychiatrist about what medication might be appropriate, what clinical services might be indicated, and if I sign up to be part of the MCPAP network, I can reach out according to the protocol we have. And within about 30 minutes or an hour, I’ll be on the phone with a child psychiatrist, at least having an initial chat about what it is that’s on my mind. Then we can schedule face-to-face consultations with kids. Still, we support that primary care practice in understanding what resources, not exclusively within McLean but across the whole community, you might refer to if you’re looking for a therapist.

Supporting Primary Care

Health Hats:?I told you before we started recording that I had interviewed somebody who was the Chief Medical Officer of a state Medicaid program. He was a primary care physician interested in behavioral health and young people. One of the things that he talked about was that these are my words, not his. There’s a cohort of primary care physicians comfortable with behavioral health issues and then seeking advice. Then some are at sea. It’s not their wheelhouse. So, he spent time in his role trying to increase the proportion of primary care physicians that were comfortable keeping young people and treating them with advice. His challenge was finding advice. He didn’t talk about a network as you just spoke about.

Michael Macht Greenberg:??It would be interesting for this individual to become more familiar with something like MCAP. The other exciting news is that other States have implemented the model of MCAP. I don’t know which state this individual represented, but it is a transferrable model to other areas. The MCAP design is to avoid taking over care right from the primary care doctor, the pediatrician. For that purpose, we want to help primary care doctors retain patients in their practice with confidence that they can take care of them appropriately and a sense of not being alone, that they can reach out and talk with somebody and get advice. It is purely for consultation.

Mental Illness and Covid

Health Hats:?You and I have talked before, and it comes up with almost everybody I speak with, either the reality or the perception of an explosion in young adults, emerging adults, whatever we want to call them. An increasing need that was already pressing. But then covid came. The challenges of Covid made it much worse. Is that something you guys are dealing with?

Michael Macht Greenberg:?Oh, absolutely. I know we will talk more specifically about kids and young adults. There was a strong need for mental health services before the pandemic, and indeed, as the pandemic has continued, we think we’re getting the better of it. We are seeing absolutely an uptick in needs and referrals. We see it at McLean Hospital across all age groups. These have been tough years for folks of all ages. So, the factors that have made it difficult have had a meaningful impact on children and families.

Capacity – space, and staff

Health Hats:?So, regarding capacity, there’s space and staff. I’m sure you know of more critical factors than space and staff, but those are the ones that I’m aware of. I remember that at one point, you and I talked about how you had added beds or were adding beds. Then you still had an imposing waiting list. Is that something you’re in the middle of?

Michael Macht Greenberg:?Sure. So, a couple of things we had throughout the pandemic at McLean Hospital have an additional 100 inpatient beds. First, an additional adult inpatient opened on the Belmont campus, and then three inpatient units opened at a new site in Middleborough, Massachusetts. We already had a presence in Middleborough. But then we took on another building and opened three more units, two for adults and one for teenagers and kids aged 13 to 18. So, over the last couple of years, the aggregate of that has been 100 beds. And yes, it has the space. It has the staff. And it’s being able to have the money to pay staff, the increasing wages that are necessary and appropriate, but also a result of a very tight labor market. So, there’s a lot of competition for recruiting, and having the right staff is expensive. It becomes a challenge. A challenge to make sure that you are running those beds in the safest, most thoughtful way to have the staff do that. Sometimes we have beds that we’re unable to open because we don’t have enough nurses or doctors to take care of all those patients. It’s a lot of effort. It’s a constant, constant challenge we’re working on.

Using Peer Experts – lived experience

Health Hats:?Do you have peer support as staff, people with training, or people with lived experience? Is that part of your staffing, or is that more of a community-based thing?

Michael Macht Greenberg:?All of us share the need for mental healthcare. All of us in the community must be attentive to our emotional well-being and take good care of ourselves and each other. Many of us have some lived experience of being in therapy or needing treatment or whatnot. As a formal part of our recruitment process, we don’t have the notion that we are recruiting people who have lived experience in that way. We’re looking for people who are trained, empathic and committed to doing an excellent job. Several folks within our staff population have some lived experience. But we typically do not recruit people because we’re looking for folks with mental health histories. There are resources available for folks. And we can help them find those peer support groups, which can be very important. But we find that a valuable addition to the staff we hire and the qualities we look for in the people we recruit.

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Coalitions and partnerships

Health Hats:?You’re talking about the collaboration of this network with primary care. Is there a similar network integrating all the different needs that people and families have? Collaboration is the key to success, like the public health of mental illness. You and I met at Boston Children’s Hospital, where you were the administrative lead for the Department of Medicine. Both of us were active in building internal or external coalitions to accomplish the mission we were charged with or brought into. How about those coalitions with the community? It seems like it’s tough because while you are local, in that you’re in Massachusetts, and with a particular health system, you’re also well known. People come from and go to a widespread area geographically; building coalitions that widely can be a lot more challenging.

Michael Macht Greenberg:?McLean Hospital is a well-known institution with many folks from Massachusetts. We are based in Massachusetts, although not exclusively in Massachusetts. We have a site in Maine and a site in Texas.

Health Hats:?I didn’t know that.

Michael Macht Greenberg:?Yeah. Folks from all over the country come to some of our programs; frankly, we have people from all over the world for some of the programs.

I agree with you, Danny, that coalitions and partnerships are crucial to success and thoughtful advancement, and effective care. I’ll give you a few examples of how we try to make partnerships in the best interest of good healthcare for our patients. The first is along the continuum of all the programs that I described. One of the things that I have worked very hard on as the senior director of the division is to have those programs know each other, cooperate and work together, either on the individual level when patients are referred from one program to another or on a broader programmatic level, where we get leaders from different programs together to talk about the services they provide, the needs of the kids that they’re meeting, the needs of the kids, they feel frustrated and yet unable to meet, and how the different programs can work together. Either again to benefit a particular child or to develop a new program or intervention that could be more broadly administered. I mentioned the MCPAP program, which is an effort for us to partner with primary care doctors and pediatricians across Massachusetts. I mentioned the school consultation program, which is our partnership with school districts across Massachusetts, where we’re not only providing education about clinical intervention and understanding mental health topics. But we’re providing support to school staff dealing with many challenges.

Academics, research, advisory panels

Finally, one of the critical pillars of McLean Hospital is academics and research. We have a lot of exciting research happening. We have colleagues around the hospital participating in national meetings, presenting talks and papers, and being part of leadership work groups. We plug into the available networks in ways that enrich the staff at McLean and hopefully benefit the patients we’re trying to serve. But I agree with you. Partnership engagement is very enriching and essential.

Health Hats:?I have two more things I want to ask you. First, is it part of your work? Do you have advisory panels of community members, parents, and primary care clinicians that help evaluate your work and make recommendations or talk about what’s happening outside of your facility facilities?

Michael Macht Greenberg:?We have parent and family advisory groups that are part of the fabric of the hospital that we design for listening and learning so that we can hear from families what their experience has been and what their recommendations are. Thoughtfulness and humility would be necessary for any institution to remain strong. And I agree, that’s very important. We want to be available to share the knowledge that we have to the benefit of the folks who are coming to us for help and advice. We also want to ensure we always remember the importance of listening and paying attention because you can learn something from the person you’re talking with.

Stigma

Health Hats:?All right, so my last thought is, if you were queen for a day and you could wave your magic wand and change something that would either make your staff’s life or your patient and family’s life easier, what would it be?

Michael Macht Greenberg:?Hard to pick. Just one?

Health Hats:?Okay, so pick two.

Michael Macht Greenberg:?So many wishes. One thing we continue to pay attention to is what has traditionally been the stigma of mental health. It has been for many years that if one were to share a mental health problem, you could risk folks perceiving that there’s some weakness or inferiority or encounter judgment or this kind of thing. We don’t judge people’s character because they have cancer or diabetes. But there has been that unfortunate potential to look with some amount of judgment when folks talk about depression or anxiety. I think this is the beginning of change, and I’m grateful for that, but I feel we still can continue improving.

Health Hats:?It’s hard to get if you feel that getting care and help early is hard.

Michael Macht Greenberg:?Yes. Absolutely. That is such an important point to make. We are available for people who want and are willing to come and work with us, and folks feel that it’s okay. Now, we see many more prominent public figures making public statements about the appropriateness and the necessity of good mental healthcare. I also want to celebrate a significant, nationally recognized de-stigmatizing healthcare campaign run through McLean Hospital. We have various patients, public figures, and celebrities that give testimonials, often arranged in a visual display. It’s been at Logan Airport. It’s been at many other public venues.

Level the playing field between physical and mental health

But to answer your question, if I were king of the world and could wave the wand, I think minimally, I would want to level the landscape between physical and mental health. We need to help people realize that we’re all human. We all have our vulnerabilities. We all deserve to have care and understanding without judgment and self-recrimination. I will go with that one because if I could pull that off, that would be enough accomplishment.

Health Hats:?All right. Thank you.

Michael Macht Greenberg:?Sure, thank you so much. This has been rich.

Health Hats:?Oh, thanks for all you do.

Michael Macht Greenberg:?Yeah, always good to chat with you.

Reflection

?My first job in healthcare was as an aide at the Detroit Psychiatric Institute (DPI). I got the job because I didn’t want to cut my hair.?I had a choice between reading water meters or as an aide at the DPI. The water meter gig paid more. I was a privileged white boy from the suburbs and couldn’t bring myself to cut my hair.?The Psychiatric Institute was an inner-city monstrosity with very sick people, very sick poor people, mostly of color. One supervisor resented me and set me up in dangerous situations, leaving me alone with delusional, angry people. I got hurt several times. Another supervisor was impressed with my courage and naivety.?He taught me and protected me. My nursing supervisor introduced me to the idea of nursing school and convinced me to apply. The rest is history.

I tell that story to reflect on how different the DPI was from McLean. McLean is more for privilege and DPI for people experiencing poverty and down and out. The institutional practice of mental health care changed a lot over 55 years. As near as I can tell, the Detroit Psychiatric Institute closed in the late 1990s. While inpatient treatment of emerging adults with severe mental illness is, on average, considerably more humane than my experience at the DPI, we have a long way to go. Michael Macht-Greenberg confirms that we lack sufficient beds and licensed professionals to staff those beds. Mental illness continues to be a stepchild to physical health as if they can be separated. I’m not sure why producing this episode so depresses me. Michael is a compassionate, passionate, tireless leader of the best this country has to offer.?I should feel positive and hopeful. We’ve come a long way, my friends. And yet…

Podcast Outro

I host, write, edit, engineer, and produce Health Hats, the Podcast. Kayla Nelson provides website and social media consultation and manages dissemination. Leon van Leeuwen edits the article-grade transcript. Joey van Leeuwen supplies musical support, especially for the podcast intro and outro. I play bari sax on some episodes alone or with the Lechuga Fresca Latin Band. I’m grateful to you, who have the most critical roles as listeners, readers, and watchers. See the show notes, previous podcasts, and other resources through my website,?www.health-hats.com,?and?YouTube channel. Please subscribe and contribute. If you like it, share it. See you around the block!