Building a Mental Health System That Works with Sue Abderholden

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Welcome back everyone to the Mental Health Evolution podcast where we are talking about how the landscape of mental health is quickly evolving in our industry. Today we are joined by Sue Abderholden, the retired Executive Director of nami, which stands for the national alliance on Mental Illness in Minnesota. Sue spent more than two decades leading NAMI Minnesota and working at the intersection of mental health advocacy, policy and systems design. Over the course of her career, she witnessed enormous changes in how mental health is understood, funded and delivered from a time when systems were far more fragmented and underdeveloped to where we are today. We became interested in inviting sue on the podcast after reading an article she recently wrote for the Minnesota Reformer where where she laid out a set of extremely informed and specific recommendations for continuing to build a stronger, more functional mental health care system in the United States. And the tone of the piece was really helpful in terms of looking at the mental health system as what is still being built rather than broken. So we're going to dig into that and highlight some of those things as we talk to sue. But a couple of articles that we want to highlight. First, first is the article by our guest which is called here's how to Move Forward on a Stronger Functioning Mental Health Care System on the Minnesota Reformer. And we're going to dig into Sue's six points. Maybe not getting to all of them in this podcast, but we're going to cover what we can and then a few supporting articles that we have. The first is called the Landscape of School Based Mental Health Services and this KFF article examines how school based and school linked mental health programs reduce barriers to care. They highlight gaps in follow up and explain why early identification and treatment are critical, highlighting one of Sue's main points. Another article that highlights another point that sue is going to talk to us about is trends in State strategies to Improve the Behavioral Health Workforce. And this analysis reviews how states are addressing workforce shortages through loan forgiveness, supervision supports and diversity focused initiatives while expanding roles for peers and family peer specialists. So this article is helpful to kind of get a good look at that workforce and kind of where we are Currently with that, the next article I want to highlight is called Mental Health Parity and Medicaid Implementation for State Strat State Agencies. And Milliman explores how Medicaid payment rates and parity enforcement affects access to care, sustainability of providers, and the ability to expand services. Again, kind of highlighting parity is one of Sue's points. And then lastly, I want to highlight an article called National Guidelines for a Behavioral Health Coordinated Crisis System. And this is SAMHSA's 2025 guideline of how to lay out mobile crisis teams, 988 call centers, emergency departments, and community services, and how potentially those systems can work together, which was another good point from Sue's article. So hopefully that gives you kind of a bas about to talk today. All of those articles and links can be found in the show notes. If you're like, ooh, what was that? And I want to dive in a little bit deeper, we have got that for you. So turning to our guest now, welcome, Sue. Thank you so much for being here and for joining us today.

Thanks for inviting me, Rachel, of course.

Let's dig into your article. To start with, you said something in that article that really stood out to me. You said specifically that the mental health system system isn't broken, it's still being built. I would love to dig into that a little bit more. I know that personally, I have said those words about it being broken and I know many people that have and, and sometimes access to care is difficult or challenging in different settings and that sometimes leads to that statement. But I'd love to hear more about what you've seen and what you mean by that statement.

About a decade ago, because I used to call it broken all the time, too. I was really kind of thinking about it and I thought, well, what did we have that broke? And we had the state institutions, right? That is not a system. And let's be honest, in a lot of the institutions, they closed because of the poor care that was being provided. They closed because President Kennedy thought people belonged in their home communities with the correct supports and helping families and all of that. And so when I thought about it, I thought, well, that wasn't a system, so we don't have a system to break. And what we've been trying to do is, you know, develop, you know, frankly a, you know, robust, coordinated system. We have found out what works and doesn't work and, you know, we're not there yet. And so, and I also think in working with families, it also, I think, is more hopeful to say that we're Building something than we're fixing something.

Yeah. So if I can rewind a little bit. How did you get involved with mental health and with NAMI in particular?

Well, I've worked on disability issues my whole life. So I was at ARC Minnesota for a decade. I actually ran constituent co. Ran constituent services for Senator Bostone, worked at one of the parent training and information centers on special education, and then came to NAMI a little over 24 years ago. I have family members, but also during grad school, I worked at what was then a community facility of about 140 some beds for people who had a serious mental illness. And it was still than the institutions at the time, but I did that. And I had also worked in a group home for children with multiple disabilities. And at the time, the only alternative was the state institutions for those children. And I actually saw how hard it was for families not to be able to care for their children at home. Also, for over a decade, I did respite care for children with disabilities and mental illnesses, their families. And so I've kind of had my finger in it, if you will. And then I also have family members. So I've kind of seen it on both the macro and the micro level.

Yeah, yeah, that's a great perspective. So when you think back to what the mental health system looked like when you started this work 24 years ago, what are some of the most meaningful changes that you have seen?

So probably the biggest one was there had been a huge task force called the Mental Health Action Group, and they developed a list of model. We kind of called it the model benefit set. And we said, these are the things that Medicaid for sure should pay for and that health plans in the future should pay for. And up until that time, it was really based on grants or what money the counties were willing to put in. So if you needed an assertive community treatment team and there were no more spots open, that was it. If you needed in home supports and the county ran out of money, you didn't get it. And so all of those things were moved to Medicaid. A whole range of services. And, you know, there was some people who said, well, you're medicalizing mental health. And I'm like, well, we're assuring payment for treatment that people need and for community supports that people need. I think that was actually one of the biggest changes that has been made over the years. I think the other thing that I've seen is some really important programs developed. I would say when we think about children making sure that we were the first state in the country to make sure that teachers had continuing education on the early warning signs of mental illness in children. With half of all mental illnesses emerging by the age of 14, I'm like, we got to focus on kids if we want to really look at even secondary prevention. Right. Preventing these illnesses from becoming disabling, I think that is really. Or tertiary prevention, I think that's really important. So making sure the teachers understood what they were seeing were actually symptoms and not behaviors. And then creating our school linked mental health program, which I like more than schools actually delivering the services themselves. What we heard from families is they really wanted a firewall between the education records and the mental health records. And so the grant money actually went to community mental health providers who then located in the school so they could see the child in their own milieu. They could work with the teachers and things like that, but they could also bill both Medicaid and private insurance. And then the grant money was used for children who were uninsured or underinsured. So maybe the families had a large deductible and also to pay for things that you can't pay for under insurance. And it is extremely popular program in Minnesota. It grows nearly every year. It's in about 65% of actual school buildings and over 80% of school districts. And again, I think the difference from a school providing it is having again that firewall. But also when school is out, those providers are still there. If a child changes schools, that providers. And so that I think that continuity of care is important. And also it is not tied to special education. And so that is another important factor because a lot of kids with a mental illness are not in special education. They might need a 504 plan, but they're not necessarily in special ed. So I think those on the kids side, those were two important things. I think another thing was really looking at the first episode of psychosis programs. So we didn't just rely on the federal block Grant, you know, 10% of the federal mental health block grant going to that, but also put a lot of state money in and I would say not enough. And we aren't there yet. And especially with Minnesota legalizing cannabis, but again, it is such an effective program in preventing what is a very serious mental illness from becoming disabling. And the young people that I've met who have been through the program, I mean, it's just amazing, right? In terms of their recovery and their re involvement with their community. So I think those were some really important things. There was of course, work on workforce so that we had enough people to do the work that needed to be done. Housing, employment, all of those things. And of course, criminal justice things too. And I think an important thing in criminal justice is that every person coming into a jail gets screened for mental health so that they know up front whether someone is struggling or not.

Yeah, those are pretty significant things. So I want to dive into this early intervention piece. That's one of the. I think that's your first bullet point as far as what we need to continue to build. And I love this idea that if we are catching anything early, it's going to be that much better in terms of effectiveness of treatment. We're not letting symptoms get out of control. We're not having all of the additional things that fall apart in somebody's lives when symptoms get out of control. I love this idea of looking at you and also this idea about maybe even having a yearly type of screening, like a physical, like a mental health assessment for young people. So in an ideal world, what would you envision that this would look like?

What we've seen some clinics do is they routinely do the PHQ9, the depression screening, for any time, anytime any adult goes into the clinic. And I think that's great. But young people don't often go to clinics. And so I think we have to find other ways to do that. They're generally healthy. And so I think there's a couple things. I think some of the online screenings are helpful for teens and young adults. We've seen colleges certainly push for having mental health services on campus for raising awareness. And I would say that young people today under 40 really are much more aware about mental health than before. I think making sure that youth, as they go through, you know, they're doing a physical exam for sports or just the, well, child visits that were that, you know, pediatricians and others are really checking in on those kinds of issues. And we've seen some of that happen. What doesn't happen is when someone screens positive. And that's where I think some of the disconnect is like, are they getting referred to a mental health professional? Are they. Do they know how, frankly, to navigate their healthcare system to find out who's even in network? Do they know what to expect? How long do they have to wait? And we have seen some primary care clinics actually have a mental health professional on site, so that it makes it very easy to kind of make that first assessment. But that's where I see us kind of falling down people. Again, I think most People have said, yeah, in the last couple years, when I've gone to the doctor, they've asked me those questions about, have you been feeling sad? And things like that. But what happens when you say you are? And that, I think, is a huge problem. The other thing. And, you know, some schools were kind of doing it, and then that kind of fell off because some parents didn't want that to be done, and that became kind of a mess. But I do think that kids generally have to go see a pediatrician more frequently than, say, a young adult. And so that is another, I think, opportunity to really check in on how that child is doing.

Yeah, yeah, yeah. And it sounds like maybe even some education to help folks understand the purpose behind it.

It. Yes, right. And it doesn't necessarily mean everyone's going to be given a pill.

Right.

You know, as we all know, just having a pill does not, you know, necessarily alleviate symptoms. That's also some other work that has to go on, whether it's therapy, nutrition, I mean, you know, all those kinds of things. So people shouldn't be afraid, oh, they're just going to give me pills. They should really think more deeply, frankly, about that.

Yeah, yeah, I definitely agree. So let's transition to another point that you made, which is workforce development. And you've kind of even talked about this in. In where you' talked about some of the areas that we've already grown, but the importance of building a robust and diverse mental health workforce. Where are you seeing the biggest gaps right now? And what kind of investments do you think would make the biggest difference?

So we generally have a white workforce, and of course, our country is not made up of just white people. And I think it is important that we create a diverse workforce and diversity on all sorts of things. You know, I think you can talk to a lot of women and they want their ob GYN to be a woman. Right. Because they're going to feel more comfortable. And so I think the same is true if you're African American, if you're Somali, if you're Hmong, you might want to see someone who understands your culture, who understands racism. You don't have to explain it to them. And I think that's really important. Some of the things that we need to do, frankly, to make that happen is we know loan forgiveness programs are extremely effective, and that helps, especially if you're not coming into going into graduate school with much money. We also know that a lot of mental health professionals, particularly social workers, have to pay for their supervision. So on top of your Student loans. Now you have to pay for the supervision that's required in order to become licensed. We had a small program that actually paid for the supervision, including in culturally specific clinics, to make it easier, frankly, for people to be able to do their internships there. The other thing we know is that the tests are not necessarily culturally appropriate. And so we've seen the social work board actually, you know, on the national level testing board say, yeah, we looked at who doesn't pass and it's people of color and men. So the test is really kind of norm to white women. And so they said the test doesn't necessarily tell us whether that is going to be a good social worker or not. So I think finding some alternative pathways is also important. The other thing that we did, which I thought was frankly kind of novel, is we did, I would call it a non scientific survey. We found, our health department found that we literally had thousands of people who graduated and didn't go on and become licensed. So we sent out a survey, again non scientific, but people responded. And what we heard is that people said, well, especially people from communities of color. They said, I can't find a supervisor from my race or culture. And then I'm having a difficult time getting through that supervision period. So what we did is actually paid bipoc mental health professionals to become supervisors and just paid for them to do that. And it multiplied. I mean, we had over 200 people just in the first year actually go through that program. And so I think there are ways that are not necessarily complicated and not necessarily require a whole lot of money to create a more culturally diverse workforce. The last thing I would say is we got to start paying people. We know that a clinical social worker, I mean in terms of the, you know, the graduate school, the hours of supervision makes less than a dental assistant. Now I want my teeth cleaned well, and there's, you know, I don't want to put down that profession at all. But these social workers, right, they're required to have a lot more education and training and they should be paid for that.

Yeah. I think the question is, and then this leads into your next point though is where does that funding and parity come from? Right? That's the challenge. I know firsthand as an organization is that when I am limited in what I receive leave for a session, I can only pay people so much.

Right.

I joke all the time that I would love and it's, it's a joke, but not really. I would, I think $200 an hour would be a fair wage. For anyone doing intensive mental health treatment with clients. Right. That that would be a fair wage, but that's not anywhere near the realistic place that is even doable with insurance and certainly Medicaid and things like that. So. So I'm curious what some of your ideas are in regard to that. I love how you said that insurance or Medicaid should reimburse the true cost of mental health care. Yeah, that I think is the challenge everybody can see in the system as it exists right now.

I think there's a couple of things. One is, let's be somewhat honest, a lot of mental health professionals are women and when it's a women dominated profession, you generally get paid less. And so let's just put that out there. And I think also with the mental health system, because so much of it is reimbursed under Medicaid rather than private insurance, that you're already getting much lower rates because of that. And in some healthcare programs you can balance things out from something that isn't paid very much, but you're getting a lot of private insurance and so that you can balance it off. We can't do that in mental health because so many people have to rely on Medicaid and especially young adults who have, you know, emerging serious mental illnesses, they have to depend on Medicaid. And so I think, you know, one, obviously pushing for higher rates under Medicaid is important, but I also think pushing the, what I call kind of the third pillar of mental health parity, the non quantitative treatment limits, you know, in there is if you can't get enough people in your network, then you need to pay them more. And we know even psychiatrists often get paid a lot less than other types of physicians. And a lot of them are only taking private insurance now or I'm sorry, a lot of them are only taking cash only practices. And so really we should be frankly pushing back on those health plans, saying no, you have to raise the rates because you don't have enough people in network to meet the need. And that is the one part of parity that frankly does not get enforced and is much harder to enforce because it's not as clear, you know, saying that you can't have arbitrary treatment limits, you can't have different out of pocket costs. Those are pretty easy to measure. These non quantitative treatment limits are much harder. And that actually comes in, I would just add the non quantitative treatment limits also comes in when we talk about paying for first episode of psychosis programs. How do health plans pay for new cancer treatments? What's their decision making process. And here we have a program that clearly is effective not just in this country, but around the world. Right, we know it's effective. Then why isn't private insurance paying for it? What is their process for adding new treatments? And frankly, they just don't add new treatments for mental health. They just don't. We had a situation in Minnesota where we finally developed psychiatric residential treatment facilities, which of course for kids, are the only program that doesn't have to worry about the IMD or the Institute for Mental Disease exclusion. So they can be more than 16 beds and still get Medicaid. So we added them to our system in Minnesota and the private health plans refused to pay, even though under state law they're required to pay for hospitalization and residential treatment. They said this isn't any of those. And we're like, well, it's one of the two. And we had to actually pass a lot to require them to cover it, which is absurd.

Wow.

Yeah.

Yeah. And that, that kind of leads into the last topic I wanted to jump in with you, which was about the crisis, mental health crisis. And you talked about how people can end up in jails or emergency rooms and looking at what brought them there, but even more specifically how to build a mental health crisis system. So I would love to hear some of your ideas on that.

You know, often I get, you know, sheriffs and others, you know, saying, why are all these people with mental illness in the jails? And I just say, well, who brought them there? You know, did police actually have to bring them to the jail? And I think that's a huge thing when we think about crisis services. You know, I mean, the feds say you gotta have someone, you know, someone to contact, someone to respond in, a place to bring people. Great. But I think we've made it complicated. And in Minnesota we've made it even more complicated. So. So certainly 988 is wonderful. And we have to keep getting the word out about 988 and how effective it can be. But second of all, we have a law in Minnesota that says if you call 911 and you need a crisis team, you're supposed to get referred to them. It's called Travis's Law. It was a young man who was killed by police in a mental health crisis. So you're automatically supposed to happen. But what we've seen is despite the fact that we have had a statewide mobile mental health crisis system for almost 20 years, maybe even a little bit more than 20 years, covering every Single area of Minnesota. What we've seen is police departments deciding that they want to do their own. So instead of collaborating with that county crisis team, they want to create their own team. And we actually have state standards for our crisis teams. So now I think we've made it like, so who goes out? What is their role versus the county team? And so I think we're making it really confusing for people. And we have to remember if you're an of a police department, you don't have to follow hipaa, but our mobile crisis teams do. And so, you know, again, that adds a whole lot of things. But what, what really bugged me, I'm going to be honest, you know, I take. Well, when I worked for nami, I took a lot of calls from families because I was usually there on the weekend and late and so calls came into my office and I took them and you know, they're sitting there saying, I can see my loved one decompensating. I can see the symptoms coming back. I don't know if they stopped taking their medicine or the meds not working or there was some kind of trigger, I don't know. But when I call the county and I ask for help, they say if they're not willing to go to treatment voluntarily, you have to wait until they're a danger to themselves or others. And we just wouldn't do that for any other healthcare condition. And so the idea I came up with is called voluntary engagement. It's in our commitment law. And we finally got money two years ago and the pilots started in September. And the idea behind it is if you see someone struggling, why can't you send someone out then? Why can't you send out a peer specialist to talk to that person, to engage that person into treatment voluntarily? Because we all know getting someone in treatment voluntarily usually is better than having them committed. And I understand sometimes we do have to have people committed. I'm not against the commitment laws, but what I am against is waiting until someone hits a full blown crisis where you need to call the crisis team or you need to call the police or they need to be brought to the er. Why aren't we going upstream? And so these pilots are supposed to track data to see if we can prevent a full blown crisis from appearing. And we did it in a very holistic way. So not only do they go out and talk to the person, but do they have health insurance, do they have a prescriber, do they have housing? Right. What's going on in their life? They can go to the families and talk about suicide. Prevention means restriction, help them understand how to talk to someone who's hearing voices. So we tried to kind of create kind of a holistic way, not just a police officer going out and driving someone somewhere. And so I think that's important. The other thing that we've seen in Minnesota because of George Floyd's murder is that the legislature changed the use of force laws, deadly use of force laws. So once that changed, when police come out to actually transport someone to an emergency, to a hospital, if that's what they need, what happens is that if the person's not willing to get into the car voluntarily, they won't transport them. And I keep saying there's something between killing someone and getting them into the car voluntarily. I think there's something in between there. And so the other thing that we tried to do is for quite a few years, as part of our Medicaid system under non emergency medical transportation, we created another type of vehicle called protected transport so that you could actually transport someone in crisis and dignity. So it's an unmarked car, basically it can be Dr. By someone who's taken mental health first aid, so understands de escalation. And if the crisis team says yes, they're safe to be transported that way, they can be transported that way. Not in handcuffs, not on a stretcher. Unfortunately, we only have about three vehicles in the state of Minnesota, but we did last session allow our crisis teams to use their grant money to buy a vehicle so that they can actually be transporting people and not relying on police. The last thing I'll say in terms of where to go, which I think is always what people struggle with, with. We have not built central receiving centers or those 23 hour centers in Minnesota. Part of the reasoning behind that, and for those states that have done that, I understand you think it's great, that's great. But here, what we said is when someone is in crisis, healthcare, mental health care, whatever it is, right, we just go to the emergency room. We go there. We don't know usually about some other place that only takes people with mental illnesses. And if you're building it so that only police can take them there, then we've created a weird disincentive as well. We want to avoid, frankly contact with police whenever we can. And so we've pushed and said for psychiatric emergency rooms within the emergency department so that they aren't, you know, in a room that's loud and you know, all of that kind of stuff, but they can be at a quieter part that's actually staffed with mental health practitioners and professionals. And then attached to that would be crisis homes. So we have a lot of crisis beds in our residential facilities. Our residential facilities are generally 16 beds so that they can get Medicaid. We have about 60 of them across the state of Minnesota. So they're small. And in rural Minnesota, they're often even smaller than 16 beds because they can't fill 16 beds in Northwestern Minnesota. And so those crisis beds are helpful because these places look like homes. They don't look like a hospital or anything like that. And so people can go there and frankly sl. Recharge their batteries, kind of address what's going on and be well enough to leave within a few days. And I think that's important too. Not everyone needs long term hospitalization, long term residential treatment. For a lot of people, they just need that kind of break. But it's actually staffed by mental health professionals and peers and practitioners to really help that person through. Get through their crisis.

Yeah, yeah, yeah, that's a lot to take in. But yeah, no, you've done a lot of. That's a lot of great information to kind of synthesize about ideas of where to go. And I do think as our industry is changing a lot right now, there is an opportunity to think about what else is needed, how do we creatively address some of these issues that we're seeing. And so I love how clearly your perspective kind of puts everything together. I want to just ask you one last question. And if listeners could take one message away from this conversation, whether it be someone seeking care or a provider or an organization, what would you hope to have people take away from this?

That you can create change? I think too often people are like, wow, there's nothing I can do. And I teach a class for social workers on health and mental health policy at the University of Minnesota. And what I want them to take away from that is when they're providing treatment or supporting someone, when they're hearing from a family member who said this doesn't exist, what can I do? Not to just say, I don't know, but to say, let's look at changing that. Let's look into it. Is it a simple law that can change? Is that somebody's just not doing their job? Is it a misinterpretation? But too often I just see people say, well, there's nothing I can do. And after being in advocacy for over 40 years, I just want to say that it does work. You can create change. And your stories, whether it's yours as a professional or as a parent or as someone living with a mental illness. Your story is so impactful and I just want you to hang on to that hope to know that change is possible.

I love that. Thank you so much and thank you for being here Sue. We appreciate your leadership, your long term perspective, what you've learned and kind of future casting, some of what we can build. So thank you for that to our listeners. All of the articles we mentioned will be in the show notes as well as Sue's article and we will have ways that you can reach out and connect to her if you would like to explore that connection further. And we will be back next week to discuss more issues relevant in the mental health care community. Thanks for listening and we'll talk to you later.