HELP and It’s Commitment to Removing Barriers to Mental Health Services
HELP Behavioral Health and Counseling Services is a recognized provider of mental health services throughout the County of San Diego since 1993. More recently HELP has expanded to services into Orange County, the Inland Empire, Imperial Valley, Santa Barbara, and the Bay Area. HELP currently employs 68 mental health providers, including licensed Psychologists, licensed Social Workers, MFT’s, and Neuropsychologists, all providing their assistance in various treatment venues. Each clinician has his or her own specialty, and is referred clients according to the provider’s expertise and geographical location.
A unique dimension of HELP is that it is an all-service organization. HELP accepts Medicare, Medi-Cal, all PPO insurances, some HMO’s, contracts through businesses tied to HELP, private pay, and sliding scale fees. Many of HELP’s referrals come from home health agencies, social service agencies, the Veteran’s Administration, physicians, hospitals, and mental health professionals. HELP is able to provide continuation of care for the client who is hospitalized or admitted to a care facility for short- or long-term care. For example, the clinician is able to consult with the client at the hospital or care facility, then follow him or her upon discharge for psychological treatment in the home or office environment. The client referrals, insurance verification, billing of insurance, and the reimbursement to providers are handled entirely by HELP Staff. As a result, HELP clinicians have more time to spend with their clients, allowing for better quality care.
For the past 23 years HELP has been able to assist a large number of individuals, couples, and families who would otherwise have been unable to obtain treatment. Historically, I found that treating clients in their own homes, in their comfort zone, was highly effective in understanding the context as well as the individual, and in helping clients make changes and reap the benefits of therapy. In particular, many older adults were more open to expressing their feelings, which often extended to teaching assertiveness skills for those who were never able to speak up for themselves. In-home therapy was not only intrinsically rewarding in helping clients bring back purpose in their lives, but I also envisioned its value in helping improve the quality of mental healthcare in San Diego.
Upon becoming CEO of HELP Mental Health Services, I became aware of the fast-growing percentage of older adults in need of mental health services who were unable to access effective treatment. It was surprising to find that fifty percent of HELP clients were home-bound older adults and similarly disposed individuals. Regular meetings with home-bound clients became increasingly frequent during that time, with HELP increasing services in 2005 to younger adults who were physically home-bound or unable to access transportation for other reasons. This kind of expanded effort became so successful that I was able to generate a business model around these services known today as HELP.
Circumstances Limiting Access
Although lack of funding can be a major limitation in accessing services, the issue of actually getting to an office is also a primary hindrance to treatment. Typically, such individuals include those who are home-bound for reasons ranging from serious illnesses and physical disabilities, to a lack of adequate transportation, and from agoraphobia to social anxiety disorders. Other complex situations such as having young children, residence in a more rural area, or even circumstances relating to protective services all demonstrate challenges to keeping a regular schedule of in-office appointments. A typical visit to a therapist often demands difficult scheduling adjustments, and always requires finding a way to get to and from a therapist’s office. While this is a simple routine for some people, there are many others who are burdened by these requirements, making it difficult and at times impossible for them to access these vital services.
Extensive research on home-based therapy documents a number of other unique factors and instances that make a typical office appointment impractical for many individuals. In one example, for certain Indian tribes the home is a much more acceptable venue for mental health interventions than the office setting (Schacht, Tafoya & Marabla, 1989). Furthermore, ethnic minority clients often do not trust mainstream mental health professionals; therefore, making a home visit is often the only alternative, as it “breaks the ice, reducing suspiciousness, thus increasing trust” (Morris, 2003).
The fear of being categorized as insane or mentally ill can be overwhelming enough to make individuals avoid mental health services altogether. Moreover, this issue of stigma extends far beyond one’s personal concerns. The anxiety of possibly facing stigmatization quite often revolves around common false assumptions such as the idea that the client’s employer will find out and it will affect their position at work. The client may fear losing their insurance benefits due to a mental illness diagnosis. Research conducted by Amy Watson and Patrick Corrigan from the Department of Psychiatry at the University of Chicago shows that stigma plays a large role in deterring people from pursuing mental health services “namely to avoid the label of mental illness and the harm it brings”(Watson & Corrigan, 2004). Watson and Corrigan’s research concludes that “in particular, the threat of social disapproval and diminished self-esteem that accompanies the label may account for underused services”.
Validity of Home Visits
When most people think about home visits, they view them as simply a necessary and perhaps even popular practice from the past. Most literature on home-based therapy (aka “home visits” and “in-home therapy”) “focuses on some type of case management regarding child abuse or neglect, or foster child concerns” (Zur, 2010). Other home-based treatments have been reported with delinquent teens and their families (Intervention therapy), with chronic mentally ill, and projects with disadvantaged families (Heath, 2005; Volker, 1999).
Historically, “home visits were not considered a valid clinical option for clinical transference reasons” (Zur, 2010). Psychoanalytic-oriented practitioners and risk management experts were, and many still are, likely to frown upon treatment that departs from the office setting. With the Civil Rights movement of the 60’s and the rise of psychotherapy in the 60’s and 70’s, and the passage of Public Law 96-272, also known as the Adoption and Child Welfare Act, home-based family therapy became more common (Morris, 2003). The law was enacted to increase the safety of foster children and avoid their out-of-home placement. Thus social workers routinely assessed child abuse and neglect, and domestic abuse in the home.
A Special Case: Elderly
Today’s elderly population grew up in an era when psychological help was not only uncommon, but was actually looked down upon. Needing mental help meant needing a locked room with padded walls. Therefore the elderly tend to hold a more skeptical, stigmatized view of psychological services.
The aging process often drives individuals to become home-bound or at least creates difficulties associated with leaving the house. Diagnoses as common as arthritis or impaired vision can create difficulties in committing to regularly scheduled appointments. Ironically however, the elderly population also happens to be those most affected by depression, and therefore more often in need of mental health services.
Untreated depression has severe implications for the elderly. It doubles the risk of developing cardiac disease, reduces the ability to rehabilitate, and increases the chances of dying from illnesses. Furthermore, it is more likely to lead to suicide than in any other age group. In fact, suicide rates for individuals over the age of 85 are almost twice as high as the overall national rate (Centers for Disease Control and Prevention, 2008), (San Diego County Health and Human Services Agency, 1998-2007).
The high depression rate can be easily understood. Older adults are more vulnerable because they have experienced multiple losses such as the ending of careers, loss of independence, deaths of family and friends, and loss of senses and certain body functions.
Studies of older persons who have committed suicide indicate that few were receiving mental health treatment or treatment that was deemed adequate. Overall, depression affects nearly 6 million Americans over the age of 65, but only ten percent receive treatment. Information from the Cleveland Clinic Foundation cited both stigma and the belief that there is no help as a reason for why many elderly do not seek treatment for depression. Dr. Zur’s research also points out that too often senior adults have other physical disabilities that distract them from addressing psychiatric needs (Zur, 2006).
The range of patient needs and subsequent delivery of unique services is not always possible in an office setting. It remains that creative intervention is often made more effective outside of the office setting. In-vivo interventions are a necessary component in the provision of expanded mental health services, especially for the elderly of our society.
More than working with the elderly, the evidenced-based platform from which HELP delivers services has continued to influence its choices of treatment modalities. Approaches as pain management therapies, family therapy, daily caregiving counseling, and behavioral methods for child management are given emphasis. Various types of psychological assessments performed by HELP clinicians, including evaluations for pain pumps, spinal cord stimulators, and gastric bypass surgery are also available. In-home legal capacity exams, dementia evaluations, and competency evaluation services are also available. While therapists from differing backgrounds and theoretical orientations may disagree as to the primary causes for dysfunctional behavior, they do agree upon where the dysfunction is most frequently being manifested. That is, outside of the home a person may be quite functional in their employment or social settings, while they are less than successful in family relations within the threshold.
In-vivo treatment methods utilized at home capture the environment and the dynamics of the family first-hand. A home visit serves to support or question the hygiene, organizational abilities, cultural and religious customs and daily rituals of the client. The home visit can help to establish treatment goals and management skills while utilizing client strengths and validating a client’s reports about their perceptions and coping abilities.
As the therapist crosses the threshold of the client’s home, it is important to realize the subtle and yet ever present impact of the threshold as a therapeutic factor in the treatment process. The home environment may be reconstructed to a degree in the therapist’s office; however, upon entering the home, the therapist becomes a part of the family with boundaries and many other issues arising as a result. It is this arrangement that increases the likelihood for successful therapeutic contact with home bound individuals, and HELP clinicians are experienced leaders in this type of intervention.
For more information on HELP Behavioral Health and Counseling Services, or for those interested in becoming a HELP Clinician, please visits our website at www.helptherapist.com , or call us directly at 858-481-8827.
Centers for Disease Control and Prevention (2008). Retrieved 2/3/2013 from the National Center for Injury Prevention and Control (NCIPC) website .
Heath, D.S. (2005). Home treatments for acute mental disorders: An alternative to hospitalization. New York: Routledge.
Morris, J. (2003). The home visit in family therapy. Journal of Family Psychotherapy, 14 (3), 95-99.
San Diego County Health and Human Services Agency. Emergency Medical Services, Medical Examiner Database 1998-2007.
Schacht, A. J. & Skovholt, T. M. (1989). Home-based therapy with American Indian families. American Indian and Alaska Native Mental Health Research 3(2), 27-42.
Volker, T. (1999). Beyond the clinic: In-home therapy with Head Start families. Journal of Marital and Family Therapy, 25 (2), 177-189.
Watson, A. & Corrigan, P. (2004). The Impact of Stigma on Service Access and Participation. The Behavioral Health Management Recovery project. University of Chicago Center for Psychiatric Rehabilitation.
Zur, O. (2010). Beyond the office Walls: Home visits, celebrations, adventure therapy, incidental encounters and other encounters outside the office walls. Retrieved 10/17/2010 from http://zurinstitute.com/outofofficeexperiences.html.
Zur, O. (2006). Therapeutic Boundaries and Dual Relationships in Rural Practice: Ethical, Clinical and Standard of Care Considerations. Journal of Rural Community Psychology, V. E9/1.