As the stigma surrounding mental health decreases, demand for mental health care is on the rise. Carly McCord, PhD, licensed psychologist and director of Telebehavioral Health at Texas A&M, explains the role of technology in bringing quality mental health care professionals to all Texans.
Lindsey Hendrix: Hi everyone. Welcome to The Vantage Point. I’m Lindsey Hendrix. As the stigma surrounding mental health is starting to decrease, we’re recognizing more and more that access to mental health care is not where it needs to be. I’m sitting down with Dr. Carly McCord who’s a licensed psychologist and the director of the tele-behavioral health program here at Texas A&M. Welcome, Carly.
Carly McCord: Thank you so much for having me.
Lindsey Hendrix: We are facing a shortage of mental health care professionals, especially here in Texas. Can you set up what the problem is? How bad is it?
Carly McCord: Sure. Texas has the most number of people living in mental health professional shortage areas. We have over 10 million Texans living in these areas. Think about across the country—I think there’s only 10 states or so that even have 10 million people in them. It’s a lot of people that are going underserved. For psychology, two-thirds of our licensed psychologists operate in five of our largest counties. That leaves the remainder of the 254 counties clamoring for the last one-third of the psychologists, so there’s lots of counties that have zero psychologists and zero psychiatrists available to them.
Lindsey Hendrix: Is that an issue of there’s just not enough trained psychologists and mental health care professionals? Or is it that they’re just not going to the underserved areas to work?
Carly McCord: Probably a little bit of both, but a lot of them not going to those areas to work. A health professional wants to have a full caseload of people to help, and so when you’re in these low population areas, sometimes there’s not a huge business case for being in a rural area, and also, it sets up a scenario where you’re the only provider in that area. Burnout rates can be higher because you don’t have anybody to refer to. Everything that walks in the door, you have some sort of responsibility to figure out if you’re competent to help that person. If you’re going to send them to a specialist—and for us, this happens all the time at the clinic, that we have folks that come in with a concern and we know that they’re specialty care.
For example, a borderline personality disorder diagnosis. The evidence would say that the best treatment is dialectical behavior therapy and there’s very few places around Texas that provide that service. I could say, “Hey, we’ve done a full assessment, this is what’s going on. Your best case treatment option is this and this is where it is.” It’s probably, from here, it’s in Houston. It’s two hours away and so if I say, “I can’t help you and this is your referral source,” then really I’ve just turned that person away to no one. They’re going to continue to go without services and so we spend a lot of time talking about and consulting of what are the elements of that person in concern that we can help with? And there are often things like emotional regulation that we can help with. We present that to them. We say, “Here’s your best case scenario. This is where it is. Here’s what else we’re understanding is going on and this is what we can do, informed consent. What do you want to do?”
But yeah, it’s hard when there’s no referral sources. That increases your ethical risk. There’s just a lot of compounding reasons why I think providers are hesitant often to work in rural areas. It can be very hard.
Lindsey Hendrix: And if there’s 10 million people that are going without access to a mental health care professional, how many of those people will, in their lifetime, need access to a mental health care professional?
Carly McCord: One in four individuals in their lifetime will experience a mental illness. Some folks don’t even feel like you need to have a mental illness diagnosis, necessarily, to want to see or benefit from seeing a counselor. But certainly the one in four. The average, I think, is 10 years before people are able to obtain care when they need it.
Lindsey Hendrix: People will be living 10 years with some sort of mental illness and it’ll take that long to get the care that they need? Or it’ll take that long for them to recognize that they need the care?
Carly McCord: Probably a little bit of both.
Lindsey Hendrix: Right. And so that’s compounded when you’ve got time and distance. And do these illnesses start to exacerbate over time?
Carly McCord: Absolutely. They can.
Lindsey Hendrix: What are some examples of that?
Carly McCord: Some mental illness is episodic so it happens in cycles. And so, people experience depression for a period of time and then it may resolve over time with additional supports and resources or changes that they make, and so they think that all is well. And maybe it is well and then it’s not. For some of your more serious diagnoses, like bipolar disorder, untreated psychosis—hearing and seeing things that aren’t there—untreated mania—just that feeling like you have limitless energy—can have really poor effects when they’re left untreated.
Lindsey Hendrix: What are the societal impacts? What are the impacts on productivity, happiness, all of the things that go into a society if we have people who are not treated for their mental illness?
Carly McCord: Oh, that’s a good question. Poor mental health affects all facets of an individual’s life. It affects their work life and their work productivity and absenteeism. It affects the family life when those things aren’t treated. There’s a ripple effect out to all the areas of someone’s life. In areas where you lack access to mental health care, often people will wait until they’re in crisis. Until they’re having thoughts of taking their life and then they present to an emergency room. From a system’s perspective, when you would hope folks would route through their primary care provider, through their mental health professional and when those aren’t available, then they present to a level of care that, had they been seen sooner, would be unnecessary.
The ER visits are really costly. They’re about a $1,000 apiece. The literature would say that about 68 percent of ER visits for mental health, and then the psychiatric hospitalization, to the tune of about $23,000 apiece. Texas also has one of the highest uninsured populations and so when you think about the effects of where people are routing for care when they can’t access these lower levels of mental health care that they need, it puts a huge strain on the system.
Lindsey Hendrix: And I would imagine, too, that if people aren’t accessing the healthy care that they may be deferring to alcohol or drugs or some sort of self-medication. Do you see that?
Carly McCord: Yeah, I think that’s common. Everybody, we are created to cope and to try and thrive, and so sometimes things are negative coping that end up having negative effects. In the immediate term they make someone feel better and so if it wasn’t helpful they wouldn’t do it, right? Absolutely, people turn to less optimal choices when their right care isn’t available.
Lindsey Hendrix: What is Texas A&M doing to help address the mental health professional shortage here in this state?
Carly McCord: Sure. We see telehealth as a really great solution to bridge and bring access to care to places that don’t have it. Here in the Brazos Valley, all of the counties are designated as mental health professional shortage areas, and our School of Public Health has been doing community assessments of our region for a long time. And that data has shown us the lack of access to mental health, lack of access to transportation and through that we thought, well what other resources do we have here at the university?
The School of Public Health reached out to the College of Education to say, “What do you think about having doctoral students, doctoral psychology students, be able to provide mental health care out to these rural areas?” Eleven years ago now, no, 10 years ago now, we obtained our first HRSA grant that allowed us to pilot test telehealth out to Leon County with the support of local leaders and the local government, and the model was successful. And then the next county over said, “Can we do telehealth here?” And we wrote another grant and launched another access point, and then through the Texas Medicaid 1115 waiver, divided the state into regions and said, “Hey, come up with local solutions for your health problems.” It was a really great fit for us to say, point out again, we have these mental health access problems and we have a program that works and so we added three more sites through the Texas Medicaid waiver program. And then this last September I got another grant and am adding five more access points in three more counties.
And all that has been done with collaboration across a lot of colleges. All of the Health Science Center colleges have been a part of that. College of Education and the School of Public Health. And so it’s primarily been our doctoral students in psychology that are providing those services. But going forward, we really have a tried and true method, and so we will be creating a team of mental health professionals that we’d like to bring services across Texas to areas in need via telehealth.
Lindsey Hendrix: Describe the telehealth system. What does it look like? How does it work?
Carly McCord: Telehealth just means health at a distance. It usually implies the use of technology. It could be video conference, it could be audio only. Telehealth really also encompasses a lot of the remote patient monitoring. I think that that has a place in addressing mental health needs as well. For us, we use a video conferencing platform that’s HIPAA compliant and secure. It’s available from any mobile device and it’s pretty easy to use. So folks can enter their name and their password and log in, complete any paperwork and meet with their therapist and it’s all done virtually. We don’t have patients or clients that walk into the clinic. They’re all coming either to—we have both a hub and spoke model and an in home model.
For the hub and spoke model, we’ve partnered with community sites. Some are in primary care settings but some are not in health care settings. They’re in these resource centers. That’s another great program that the School of Public Health has started for our region. The client walks into that location and there’s a computer with a webcam and a microphone. They sit down in front of it and meet with their therapist. And we realized over time, the same reasons why people couldn’t get to Texas A&M Bryan-College Station, which is an hour, hour and a half, for all of these folks, is the same reason why they can’t get five or 10 minutes down the road. They don’t have a car. They don’t have money to put gas in their car. They don’t have child care. Their physical health is so poor they can’t leave the home. Their mental health condition is something that keeps them relatively home bound.
We started doing some phone therapy as well, audio only. The research supports that both video therapy and audio therapy are equally as effective as in-person therapy. We started doing audio only when it was clinically appropriate just to help keep continuity between appointment times. Over the last 10 years, as technology has picked up and more options are available, we were able to secure a platform where, in theory, folks can connect from their mobile devices from their homes for video sessions now.
Rural broadband is still a real issue, so we’ll begin pilot testing our in-home video, probably here in Brazos County where the internet connectivity is a little bit better.
Lindsey Hendrix: With your audio counseling, is that done through a landline? Can people call from their home?
Carly McCord: They can call from their home. They can call from their cellphone. We have folks that take their lunch break and sit in their car and meet with their therapist.
Lindsey Hendrix: Time, distance, money, these shouldn’t be issues that are preventing people from getting the therapy that they need.
Carly McCord: Absolutely, because the treatments that we give are all of the same evidence based treatments. It’s talk therapy and so it translates over whatever medium you’re using. There’s some special considerations to practice and to think about. That’s one of the things that I love about our training program and the psychologists that we’re equipping is they’re leaving thinking like tele-psychologists. They think about, for this particular person at this particular time, with these concerns, what types of services are appropriate and not appropriate and really keeping in mind access and continuity of care and pushing the envelope a little bit and just trying to get services to people.
Lindsey Hendrix: Is tele-behavioral health care appropriate for all cases? Most cases? How often does it work or is it appropriate?
Carly McCord: That’s a great question. I would say most cases. Most anything that’s appropriate for outpatient mental health care generally is appropriate for telehealth. Our number one exclusionary criteria would be people who self-select that that’s not really what they want. Some when we tell them it’s a telehealth clinic, then they don’t want to do it.
I think it dictates a little bit of the setting. There’s clinical reasons why in home telehealth might not be. Folks who have tendencies towards self-harm, they have access often to means to hurt themselves in the home that they could bring to a clinic but don’t typically bring with them to the clinic. And then there’s presenting concerns where we want them to get out of the house. We want them to come to a spoke. Someone with major depressive disorder, that behavioral activation is a key part of their treatment plan, then we want them to come to the clinic for their session.
We’ve had some really cool cases with agoraphobia, which is fear of open spaces or fear of leaving the house. A lot of times those individuals will go without treatment because they don’t want to get out and see their provider and so we typically, we can build a hierarchy of, okay, eventually obviously, part of the goal should be for you to leave your house but if you can’t leave now, then we build an exposure hierarchy for their anxiety so that the end result is that they are getting out weekly for their sessions.
Lindsey Hendrix: That’s fantastic. Do you have a specific case that you’d like to share a success story?
Carly McCord: Related to agoraphobia?
Lindsey Hendrix: Related to this program.
Carly McCord: Any case?
Lindsey Hendrix: Tele-behavioral health care.
Carly McCord: Oh it’s so hard to pick. I do this because of all the miracles that we get to see of people who were out of work and their relationships were falling apart and their mental health was poor and they felt like they had no reason to live. In fact, 42 percent of the people that seek our services have thoughts of suicide upon intake. And then I think part of the magic of working with people who haven’t had services before is all of a sudden they get in, they get the evidence based treatment, they get the help that they need and pretty rapidly you see these drastic changes. And their lives come back online and they find a reason to live again and they get plugged back in at work or volunteering in their community and their relationships get better. It’s just, it’s really amazing to see just how lives and families are changed when people have access to care.
Lindsey Hendrix: What are some of the signs that people should look for? When do you come to realize that you should seek help for a mental health issue?
Carly McCord: Yeah. I think functioning is probably one of the most critical things to think about. In our DSM, that’s our manual that describes all of the different diagnoses and what you need, every single one of them has the same criteria that has to significantly impair functioning. If you feel like you’re experiencing some anxiety or depression or some other symptom that is getting in your way of work or family or getting in the way of your functioning, then that’s a good time to seek treatment. And all too often people wait until they have thoughts of suicide as the alarm bell that says, “Hey, you should get some help.”
You started the show off by saying that stigma is decreasing for mental health and I think that it is, and I think that we have room to grow there, too, but I hope that people will start to not wait until they’re in crisis and realize that even as you notice impacts on your daily life that people know it’s okay to seek treatment.
Lindsey Hendrix: Relieve some of the fears that might be surrounding getting help. People fear judgment, perhaps from the people that are close to them, their family members, the people who see them getting treatment. Sometimes people are fearful that the provider themselves will cast judgment on them. Should they fear that?
Carly McCord: No. We spend a lot of time in our training to provide a nonjudgmental, accepting environment. Our field has moved a lot in the direction of multicultural competence and embracing and working well with diversity. Therapists, just like a doctor, just like a banker, we’re all people and so sometimes you don’t click with someone. I think if you do have a negative experience, to identify that that may be more about that person than it is about psychology or about therapy. That that should not be the norm and so if you do have a negative experience then it’s okay to not go back and it’s okay to look for someone else.
Lindsey Hendrix: That’s great. How much can clients expect to pay for the services that you provide?
Carly McCord: For the service that we’re providing in the Brazos Valley, we’ve been able to secure alternative funding sources that have provided the services for free to the individuals in the Brazos Valley. And then we have solutions to be able to partner with, again, wanting to go across Texas, we can partner with clinics. We can partner with schools and find ways that, generally, the idea would be that those entities are paying for the services to make it available. Folks may have to use their insurance or things like that as we grow and expand.
Lindsey Hendrix: Do a lot of insurance carriers pay for mental health services?
Carly McCord: It varies. It varies widely and there’s some different reimbursement policies for telehealth as well. In some cases you have to be in a designated rural area. You could be in an urban area and be underserved or need to meet with this specialty provider and if they’re seeing you via telehealth then it wouldn’t be reimbursed. There are, yes, it really varies. That’s something that we’ve dealt with at the clinic. We primarily set out to serve uninsured and then as people started telling their stories, as we did the phone intakes, we would hear a lot about underinsured, of, hey I did call and I only have four sessions. And I’ve used my four sessions. Or, my copay is more than I can afford and things like that.
Lindsey Hendrix: How long should people expect to continue their mental health care? Is it you go, you get the prescription, you leave? Or is it a drawn out process? How long does it take?
Carly McCord: It depends. We do have great medication options. Sometimes that’s all people need and that’s something that they can obtain from their primary care doctor often. When it comes to therapy, that depends on the presenting concern. Depends on the therapist’s orientation. Some therapists are very short term, solution-focused therapists, and that’s what they do and they want to do it quickly and give you tools and get you going. And then other therapies take longer. Those are good questions to ask of a therapist if you’re wanting to engage in mental health treatment, is to be an informed consumer about what do you think is going on? What’s the assessment? How long is this process going to take?
The average number of sessions at our clinic is nine. Some of our outcomes research has shown that the average time to clinically significant change was 12 sessions. I think on average, three to four months is a good expectation.
Lindsey Hendrix: Okay, great. You talked about different counseling styles, different approaches to mental health care. Should people shop around? Should they try different therapists? Should you—like getting a pair of shoes, is that how it works?
Carly McCord: Trying one that fits. That is totally an opinion question and so I’m sure that there will be folks out there that differ in opinion. I would give it at least two tries with any one person unless you have a really negative experience. Because counseling’s just hard in general. Trying to sort out for yourself. Sometimes it’s like an awkward dance with your therapist.
Lindsey Hendrix: The first date.
Carly McCord: The first session, first date, feels really awkward. You go back for a second time and you’re like, “Oh okay, actually, I’m kind of clicking with this person.” But I do recommend finding something that fits.
Lindsey Hendrix: You mentioned earlier that, obviously, our primary concern is providing care for people in rural and outlying areas, but that there are underserved people in urban areas as well.
Carly McCord: Absolutely.
Lindsey Hendrix: Can you get into that a little bit?
Carly McCord: Gosh, sometimes it’s just the traffic and the distance. You may have some kind of density of providers that they don’t reach that designation status and what an individual’s experience is living in that city, it may be impossible to get to the other side of town. Mental health shortage, anytime that I’ve talked with folks that are working in urban areas, they have those same kind of strains, they just look a little different.
Lindsey Hendrix: And then you mentioned even your mental health state could keep you home bound so you’re not even comfortable walking the five minutes down the road if you have a provider down the street.
What are some questions that you can ask your therapist about their style?
Carly McCord: Typically, that’s referred to as a theoretical orientation. You can really just probably ask them about, how does therapy work with you? What can I expect? Do we meet weekly? Just ask them directly, what’s your style and approach? A therapist should be able to tell you what their approach is. If someone asks me that question, I would say, “The core of my orientation is person centered, which believes that all people were created for growth and healing and change and that, given the right conditions, which is the unconditional, positive regard and acceptance, that often we can find our solutions. And so I like to partner with people to help remove obstacles in their way to change.” That’s kind of the foundation of what I do. And then there are—our science of psychology tell us a lot about specific treatments that are helpful for specific presenting concerns.
I might dive into, if they’re saying they came in for depression that we’ll probably use some kind of behavioral techniques and that looks like that your thoughts are connected to your feelings. And so we’ll dig in and start looking at your thoughts and what kind of “stinking thinking” you might have. How we can make some adjustments.
Lindsey Hendrix: And on the flip side of that, what are some questions that you can ask your primary care provider if you’re feeling like you ought to seek some mental health care?
Carly McCord: I think just bringing honesty and telling about your symptoms in the same way that if you thought you had strep throat, you would go in and you’d give all the details of, I think, being willing to be vulnerable about mental health. It just feels different, I think, disclosing that kind of information. But telling your provider if you’re, again, I go back to the functioning of, like, I’ve been experiencing anxiety and I just can’t get out and spend time with my friends like I used to. Or, I’m just having a really hard time getting out of bed. I feel like I’m crying all the time. Whatever those symptoms are, your primary care doctor should be trained to then dig in and start asking you more questions. Their primary role would be in medication management and so that would be a good question to ask. What are the medication options for this? And you can ask them if they’re aware of other options.
They may have, kind of, go-to referral sources for mental health as well, of providers that they recommend or that take similar insurance because they’re familiar with, they know if you’re being treated at their clinic that it might be likely that you are able to get in somewhere else.
Lindsey Hendrix: If people want to make an appointment at one of your locations, how do they do that?
Carly McCord: I’d recommend checking out our website. It’s telehealthcounseling.org. And even if you’re not interested in an appointment, there’s lots of information about our program and our training program and the research that we’ve done. But there’s a link there that shows where all of our access points are. It’s one phone number, though, so folks can call directly, 979-436-0700, and say that they’re interested in counseling services. We do a screening process to make sure they’re a good fit and then get them set up for an appointment with a counselor.
And at this time, our services aren’t available across Texas. I know we kind of talked about the vision is that, now I have this capability to log in from any mobile device, but we do have limitations on the services and the service region. Definitely check out the website to make sure you’re in the service region.
Lindsey Hendrix: Thank you so much, Dr. McCord, for coming out and talking about this issue. We are going to link to all of the resources that you mentioned in our show notes. Everybody, these services are available if you’re feeling like you need it, please seek help.
Carly McCord: Yeah, and even if not from us, there is—I don’t want to paint such a horrible picture of the shortage areas. The point in sharing that information, one, is so that we increase energy around this, but if you are someone that’s not feeling well and wants to see somebody, start now. The options may be limited but the state of Texas has divided the region and has local mental health authorities that cover the entire state. And there’s suicide crisis hotlines for our—we can put this information in the links too—one specific to veterans, Spanish speaking, there’s text only suicide lines. If you’re in crisis, please reach out.
Lindsey Hendrix: Absolutely. Well, thank you again so much for coming on the show.
Carly McCord: Thank you so much for covering this topic. It was great to spend time with you today.
Lindsey Hendrix: Thank you. Thank you, everybody, for tuning into The Vantage Point. We will talk to you next time.
The National Suicide Prevention Lifeline toll-free number, 1-800-273-TALK(8255) connects you to a certified crisis center near you.