By Gaan Akers, LPC, NCC | November 14, 2024
This interview between Titiana Jordan and Gaan Akers focuses on the complexities of accessing mental health care in today’s digital landscape. It offers guidance on how to navigate mental health resources, including teletherapy, online support groups, and digital tools for managing mental health. The importance of finding the right support and understanding available options is highlighted.
Video Transcript:
Welcome to our Mental Health in a Digital Age series. I’m Titania Jordan, Chief Parenting Officer at Bark Technologies, and I’m here on location at Hillside with Gaan. I’m so excited this has finally come to fruition. Thank you so much for being here.
Gaan, first tell us what you do here at Hillside. I’m the Director of Clinical Education and Outreach. A lot of what I do is educating parents, the community, and clinicians on mental health and on levels of care and treatment, especially for children and adolescents who need higher levels of care. This is going to be so impactful. I am so honored to talk to you today, not only in this professional realm but also as a parent. As the parent of a high schooler now, I’m in this space, and I didn’t know about the levels of care. So if I don’t know about the levels of care, how many more parents out there don’t understand what comes next? So, if we could start with just education on the levels of behavioral health… Obviously, if your child has a fever for a long time or breaks a bone, you go to the pediatrician or you go to the ER. But when your child is struggling with their mental health, with their emotions, what are the levels of behavioral healthcare that exist?
That’s a great question, and I think it’s one of those things that you don’t think about until you’re in it, right? And then when you’re in it, you’re in crisis, and it’s really hard to figure out what levels of care exist in mental health. Most people think of regular outpatient care; most people are familiar with that – going to see a psychiatrist or going to see a therapist on just a regular, once-a-week or once-every-few-weeks basis. Then, a lot of times, when things are a little bit more serious, people just think, just like a physical health thing, “Well, we go to the hospital, right? Like we go into the ER or we go into a psychiatric hospital.”
In reality, there are levels of care that are in between that. We don’t need to always default to going into a hospital because sometimes that is just kind of overkill; that’s more than what we need. There are intensive outpatient programs. There are things that are like a hospital, called partial hospitalization programs, where your child still stays at home with you but they are in treatment Monday through Friday or throughout the week as a full day, instead of school, for a period of time in order to really stabilize the crisis, address some of the symptoms, and really learn skills in order to get back to their life.
So I would start with maybe the lowest level of care first, right? We always want to default to the least restrictive, lowest level of care. So you have regular outpatient therapy; so this would be, you know, talk therapy once a week, maybe with a therapist. Then, if talk therapy is not working and a client could really benefit from some medication, then that’s where a psychiatrist could come in, right? And so it might be a combination of talk therapy and some medication.
Then we might need to look at a program that is more intense than just once a week. Sometimes you have programs that are intensive outpatient, or IOP is the acronym (you’ll see a lot of acronyms in mental health). IOPs range from, you know, a few times a week to maybe five days a week at, you know, two hours a day. Most IOPs kind of range from anywhere around nine hours to maybe 18 hours a week. And so it just depends on the program, it depends on the need, and on how the treatment is planned. IOP is really helpful for, you know, teens and clients who are starting to have symptoms disrupt their day-to-day functioning. You know, they’re really kind of…you’re noticing the difference. They’re having a hard time making it through the regular day, following their routine.
A higher level of care than IOP would be a PHP, or a partial hospitalization program. Some people call it a day program where you just go to treatment for the day, right? They still stay at home, they still function as part of the family. However, you know, during the day, they would go…they would be in therapy groups, they would do individual therapy, they would see psychiatrists about medication, they would get a lot of support. And so partial hospitalization program, or PHP, is also different, you know, in different settings. Some people meet Monday through Friday; some programs will meet seven days a week, based on the clinical need. Most PHP, or day programs, will be time-limited. Same with IOPs, you know, you’re not going to go to these programs forever. You go for an amount of time that will help stabilize the high acuity symptoms, and then you might step down to a lower level of care or back to outpatient. It’s just one of the ways in which we can help come alongside your child, help come alongside the family, and give a lot more support in order to get back to their day-to-day functioning.
So if I’m going to recap the levels of care, it’s…I’d say maybe school counselor, pediatrician for that initial assessment if you’re worried. Then, perhaps a therapist, a licensed professional counselor. Then, perhaps a psychiatrist if there’s medication that might need to be prescribed. And then you don’t need to jump right to full hospitalization. What we’re talking about now are those levels of care in between that a lot of people might not realize exist. And so that’s IOP, intensive outpatient, and then PHP, partial hospitalization.
Okay, and then is there anything between PHP and full hospitalization? So in terms of the next step, usually hospitalization, the inpatient short-term acute hospitalization, would be used when a person is at imminent threat. They have suicidal ideation and a plan or means to carry it out, ways of harming themselves or harming someone else, or they’re having active psychosis, symptoms of having delusions or hallucinations. That’s when hospitalization is needed because they need round-the-clock care.
It is surprising, I think, a lot of times for parents to know that just having suicidal ideation doesn’t mean that your kid has to be in a hospital. Having suicidal ideation without a plan or intent, or what we would call passive suicidal ideation, can be treated at an outpatient level, and treated effectively as well. One of the things that happens when kids go into the hospital is that it could be really traumatizing because they’re away from their family. It is a very intense level of care where people are checking on you every 15 minutes to make sure that you’re okay. When you really think about it, some kids need that if they’re at the place where they’re at imminent risk. A lot of kids don’t need that, and we can address a lot of the safety concerns and step up the safety in the home. We can work with a clinician who is skilled at working with kids who are having suicidal ideation or self-harming behaviors in order to stabilize these symptoms effectively while they’re still living at home with you.
A lot of times people think therapy is nice if you can afford it. Thankfully, Hillside actually works with certain insurance providers, correct?
That’s correct. As one of the oldest nonprofits in Atlanta, we’ve been working with children and families for a really long time. It is part of our mission to provide quality care that is accessible to most people. So we try to work with all insurance. We have people from all socioeconomic backgrounds accessing treatment. They can use their health insurance, anywhere from private commercial insurance to Tricare, or Medicaid. We’re able to help support a lot of families from all walks of life. Hillside is proud that we’re able to do that.
That’s critical: that this level of quality healthcare is available to all who need it, and not just those who can afford it. And it is hard to navigate healthcare, even with access to funding. There are still other barriers for different families. When we talk about IOPs and PHPs, you’re also looking at whether the family has the ability to transport their children to treatment. For some families, the barrier to treatment is not just being able to afford the treatment, but also being able to take time off from work or afford the gas to get there every day. These are issues that we as a society have to think about. There are things that we can do in order to advocate for more access, not just funding treatment, but coming around people and helping them access treatment.
Problem-solving sometimes creatively. Hillside also offers in-home care too, can we talk about that?
Yes. I didn’t talk about it at first because it’s a unique program. Not a lot of people offer in-home care. Hillside has an intensive in-home therapy program that is in-network with a few insurance companies. The reason it is not in-network with all insurance companies is that a lot of them don’t recognize in-home care as a benefit for mental health.
With Hillside’s in-home intensive therapy program, it is typically about 4 hours a week in the home or in the community. Even though we say it’s in-home, it’s not always just in the home. We come alongside the therapist or the psychiatrist that the family is already seeing to help give additional touch points through the week, to be accessible for the family 24/7 for whatever they need. Oftentimes, what we see is that even in treatment, especially with kiddos, you can go into a therapy room and then you talk about the things or you learn about a skill, but they’re having a really hard time translating that into real life. The same is true for parents. Sometimes we talk about behavior management plans, and you know, you spent a lot of time and effort coming up with something that would be really effective. Then, when it comes down to the time to implement, you’re just like, “I’m not sure how to do this.”
So our intensive in-home team is that team of clinicians who will come to you, who will help with implementation in the home or in the community. For example, we’ve seen a good bit of kids in the past few years because of COVID who really struggle with returning back to school due to anxiety, due to just a lot of mental health symptoms. And so one of the things that the kiddo might be working on in their typical therapy is talking about their anxiety and some skills that they can use in order to manage that anxiety. But the intensive in-home therapist would say, “You know what, before school starts, let’s go up to the school. Let’s get your schedule, let’s walk through the school building and find your locker and find all your classrooms, and let’s breathe through this. Let’s make an appointment with your school counselor before the semester starts and talk about our co-ahead plan for when things are starting to get a little bit hairy, so that you can go to your counselor and they know what the plan is. So you have something already in place in order to be successful if the treatment goal is to be able to make it through the school day successfully.”
So it’s coming alongside the kids, coming alongside the families in just whatever capacity that they need. That’s awesome, Gaan. There are times when, as a parent, you feel like you don’t know what to do; you’re not quite sure about the next step. Can you talk to us about the warning signs that you do need to seek out a higher level of care?
Yeah, so one of the things that, you know, if you’re already in regular outpatient services, right, and it just doesn’t seem to work, you know, if symptoms are not getting better, if symptoms are starting to get worse, that’s the number one sign, right? Okay, maybe we need to do a little bit more. And sometimes, you know, we think our kiddos are fine, and then all of the sudden we find out about something like, “Oh, self-harming behavior,” or we find out about suicidal ideation. Anytime self-harm and suicidal ideation comes into play, those are the things that I generally would say let’s get an assessment to see if we need a higher level of care because those are the things that you just don’t want to take any chances on. Even though self-harming behavior does not always mean that a client, a child, is suicidal, however, self-harming behavior is still the number one predictor of a completed suicide. So we take that very seriously in order to make sure, right, that they are going to get the treatment that they need.
So anytime, you know, self-harming behaviors, suicidal ideation, as mentioned, higher levels of care is something we want to look at in order to stabilize those high-risk behaviors. Other things that we can look at, you know, would be maybe substance use. And it’s so hard because teenagers, right, part of their developmental kind of life stage is kind of exploring a little bit, and maybe there’s some dabbling and there’s some experimentation, and not all of that means that they immediately need to go to rehab, right? However, if we’re looking and seeing, you know, there’s actually a habit, you know they’re using all the time, they are hanging out with friends and peer groups who are heavy users, that’s really a big red flag that we really need to seek support. Same thing with disordered eating. There are all these kind of presentations: are they losing weight, are they engaging in behaviors like purging? That’s something we need to be concerned about. To be safe, you know, at worst you get the assessment and they say, “You don’t need a high level of care; you just need to see an outpatient therapist.” And that’s great, but we don’t want to take any chances when there’s any kind of more severe psychiatric symptom.
One of the other things that a lot of times people don’t think about as a severe psychiatric symptom is that if there’s drastic changes in sleep patterns, if there’s drastic changes in their eating behavior (and not just like with eating disorders, but even with depression and anxiety, sometimes we’ll see a big change), and then big changes in their social engagement. You know, if they’re all of a sudden isolating a lot, and if they just stop doing the things that they used to care about, those are really big red flags where we want to just say, “Let’s let’s get this checked out.” But anytime that, you know, as parents we kind of have that little spidey sense, and something in our gut is saying, “Something’s not right here,” trust that. Go and get an assessment. It does not mean that they need a higher level of care; it just means that we are not going to ignore symptoms, just in the same way with our physical health, right? If our kids are just having a little bit of, like, a stomach ache, but it’s persistent, that’s when we’re like, “Maybe we should call the doctor.” So that kind of persistence, the intensity, and the frequency is what we want to look at, and that’s going to be the key determination in terms of symptoms of what level of care is going to be needed.
Awesome, Gaan. What should parents ask when they’re looking for the right program for their child? Yeah, because there’s so many programs, right? Not only were we navigating levels of care, now let’s say, “Okay, we’re looking at intensive outpatient.” Well, there’s eight different intensive outpatients in metro Atlanta; which one should I choose, right? So, first thing, you know, when we talk about any program, intensive outpatient, partial hospitalization, most of the time, you know, the first factors you talk about is kind of, you know, what time do they need to be there, what time do they need to get picked up, how much is this going to cost. Those are kind of, you know, your standard givens. But what you want to do is dig a little bit deeper because if you’re going to spend, you know, you’re going to invest this time and the financial resources to get treatment, you want to make sure it’s the right treatment, right, for your family.
So when you ask about their schedule, right, what is the time commitment? Some programs say, “Oh, we only meet for two weeks.” Some programs say, “No, we need you to commit to six weeks.” Some programs say, “No, we need you to commit to 12 weeks.” Well, why is that? Tell me more, you know, because different presentations might require different things, right? Right. So not only do you want to know what the time commitment is, but why is that the reason? What does the schedule look like? What will my kid be doing? Because what you don’t want, right, is your kids there; you think in treatment, and they’re just kind of sitting around watching videos. They can do that at home, right? Exactly. And so you want to see, “What will my kid be doing in this treatment program?”
And then, other than, you know, what’s part of their schedule, who will be seeing them, right? Some programs, it’s only group therapy. Who’s leading these groups? Are they therapists? Are they paraprofessionals? Are they led by nurses or, you know, psychologists, or what does that look like? What is the purpose of these groups? Would it include individual therapy? Would it include family therapy? And then, you know, would it include psychiatric medication management, right? So if they say, “Oh yeah, they’ll, you know, work with a licensed therapist, but they won’t see a psychiatrist or a nurse practitioner,” then they’re probably not going to address it from the pH of…they’re not going to address it from the medication standpoint, right? And so you want to see who will be treating my kids, right?
The other question that we want to consider is then, “So who are these other kids in their group milieu?” Yeah. Because, you know, some programs have a wide range of ages; some are single-gender, some are co-ed, some have really specific treatment goals. So, like, are you…you know, if you have a kid who is using substances, are they going to be in a group with other kids who are struggling with substance use, or are they going to be in a group with a bunch of kids who are struggling with suicidal ideation? What does that look like? You don’t have to know the super specific part, but you want to kind of know the broad brush stroke. Group work can be so powerful for teenagers; that’s part of their life stage, that whole peer thing, and it could kind of be detrimental too if it’s not the right clinical fit. So you want to know, “Okay, so who would my kid’s peer group look like in this treatment program?” And not only what the peer group looks like, but how does staff handle that kind of peer-to-peer relationship? Are the kids allowed to talk to each other outside of treatment? Are the kids encouraged to make friends with each other? Because different treatment programs are going to have different goals. If you have a group of kids who are learning social skills, they’re going to encourage friendship. If you have a bunch of kids who are struggling with substance abuse, you’re not going to want to encourage those friendships. So those are the kinds of things that you also want to ask in terms of, “Who’s treating my kids? Who will my kids be around?”
One of the things that I think, personally, is really important when you’re looking for programs for children and adolescents is, “What would my involvement be as a parent or as a caregiver?” Because even though our child seems to be the one struggling with the mental health or the behavioral health issues, children don’t exist in a vacuum. They exist in a family system. So how can I be part of coming up with a treatment plan? Because even though the professionals are the experts at maybe the treatment modality, you, as a parent, are the expert on your child. You know their routine, you know their temperament, you know their ins and outs, and how things have changed. So a program that is going to involve you and use your expertise on your child, and really incorporate goals that are going to be appropriate treatment goals for your whole family, is going to be really important. You want to also choose a program that you’re going to feel comfortable with, that you’re not going to feel judged, that you’re not going to feel left in the dark, and that they’re going to have good communication.
Personally, I feel like family therapy is always a big thing anytime you look for treatment for children and adolescents. It does not necessarily mean that something’s wrong in the family system, in the sense that it’s dysfunctional. It just means that we need a little bit of support to empower, because most of the time, as parents, we are doing the best that we can to help our kids, and it’s not enough. So this is the part where the professionals can come and empower you and give you some extra tools in your toolkit in order to help manage some of the symptoms and alleviate some of the symptoms for your kiddos. So, the family involvement and engagement is another big piece of it that we want to look at.
Wow, you have given us so much more to consider when you are looking for the appropriate level of care for your child. This is so helpful. Thank you so much. I’d love to talk now about how the integration of telehealth and virtual therapy has changed the landscape of behavioral healthcare for children, and what benefits and/or challenges this presents for parents.
So, one of the few good things during the pandemic years is that people got really comfortable with virtual meetings and appointments. Especially in Atlanta, where the traffic is just a beast, not having to get in the car or commute is a huge bonus. What we know from studies is that for people who are appropriate for telehealth, treatment outcomes are generally about the same from virtual treatment and in-person treatment.
However, my qualifier is that this is for people who are appropriate for this type of treatment. Hillside has a virtual IOP program that serves children and adolescents ages 12 to 17. One of the things that we want to see is if this kid is going to thrive and be able to stay engaged in this virtual programming. Sometimes, parents off the bat just say, “Oh no, no, no, we just can’t do virtual.” Because we kind of all have a little bit of a bad taste from when the pandemic started, and everybody’s trying to homeschool that first two weeks, and they’re just like, “This is such a nightmare.”
However, what we want to look at is that some programs do a really good job. I feel like Hillside therapists do a really good job keeping the kids engaged in the virtual programming. So one of the things that they generally look at then is what kind of kid would not be appropriate for virtual care.
So, first things first, kids who struggle with psychosis or psychotic symptoms. If they’re having active hallucinations or delusions, that’s really difficult to assess when you’re not face-to-face and in person. So those kiddos are not generally a good fit for virtual treatment. Or really anyone with those types of symptoms because the clinician can’t really get a full picture of what’s going on. The other thing would be people who are really struggling with substance use, especially if there’s no way to keep accountable, right? You know, it’s really hard to say if a person is high or drunk, you know, on a screen. And that’s definitely going to be unhelpful, right, if they’re going to treatment without really showing up, showing up in all those ways. You know, a lot of those things like substance use, active substance use, active psychosis, those are the things that you can’t miss when they show up in person, right? Like their body language, the way that they walk, the way that they move, even the way that they smell, right? Is a big clinical clue for their eyes, yeah. And you don’t miss that in person; you miss that on a screen.
The other thing, you know, with teenagers especially is that if they have a history of problematic internet use, treatment online might not be the best thing, right? Because we really can’t guarantee, you know, that they are going to stay engaged online. They might have the screen open, but they could have another window open doing things they’re not supposed to. And so there’s a little bit of assessment that needs to happen. However, for those on the plus side of it, you know, if the kid could be a good fit for virtual programming, or anyone for that matter, the plus side of it is that it becomes so much more accessible, right? You know, a lot of specialized treatment is not offered in areas that are not just big cities, right? Specialized treatment protocols and things like that are generally not offered in smaller towns or rural areas. All of a sudden, the use of virtual programming opens this whole possibility up for access for folks in order to be able to really access specialized, life-saving protocols. And so there’s definitely a benefit there. Of course, there’s the practical benefit of not having to commute, you know, and just making it easier for treatment to happen and just taking away a few more obstacles for consumers in general.
Yeah. So, Gaan, we would love to hear some success stories or just positive outcomes for children who have received care at all the different levels of the behavioral health continuum. Because, as you mentioned, when you’re in that mode deciding what kind of care you need, you’re in crisis mode. So hopefully you can share some stories that you know of parents and kids who have come on the other side of it and have been helped and are now in a better place.
Yeah. Several stories come to mind. You know, most of my career, I have worked with kids who are in higher levels of care with high acuity. And you know, in the family session, I see it in all parents, right? That worry that, “Oh no, like this is going to ruin their lives,” right? Like we think in that moment that something so big is going to make an impact for the rest of their lives. And in a sense, it does make an impact for the rest of their lives, and treatment can be really helpful. Part of that lesson they might learn is how resilient they are, right? That they can go through something so hard and come out on the other end stronger as a person and as a family.
So we have had kids in our residential program who have multiple suicide attempts, and really by sheer luck, the kid did not die by suicide. You know, the attempt was interrupted, is what happened. We’ve had kids who, when they came to us, looked like a butcher’s block because they self-harmed so badly. You look at these kids, and as parents, when you’re in that moment, it is hard to imagine how things could be better. I’m so happy to say that these are the kids that we’ve seen in our residential program that actually went through the treatment and came out on the other side. They are the families that email us two years after they left our program and say, “Hey, kiddo’s doing so well. They just got accepted to school; they’re going to actually go out of state to college, and this is what they’re going to do.”
It is actually one of the reasons I keep doing what I do, right? Because it makes such an impact. We are literally saving lives, and we’re changing the course of their life. At the end of the day, treatment can really help a kid figure out and build the kind of life that’s worth living. When things are really dark, when they just don’t feel like life is worth living anymore, that’s where treatment comes in.
A lot of it is not going to be linear. It is not going to be, you know, we come and we do this one thing and then everything is magically better. Realistically, I do want parents and families to know that sometimes it took years in order to get to this really dark space, and it might take years in order to get out of it. And when I talk about years, it’s not that it has to be a really high level of care always. It might be a combination thereof, and treatment, even though they’re different levels of intensity, it’s also not linear, right? We might have a kid who does regular outpatient, and then their symptoms have exacerbated, and then they go into a PHP or a day program, and then they do better and they come back out to regular outpatient for a while. You might have a kid who does the whole continuum of… They have had some really, really scary close calls, and they’ve been hospitalized, and they need a residential treatment program where it’s a little bit more long-term and really helps build some skills in a really safe environment, and then stepping them down into an outpatient program and then going to regular, you know, once-a-week therapy. So the treatment process could be kind of anywhere in between and whatever’s needed. It doesn’t mean that they’re always going to be at super high levels of care, and it doesn’t mean that things are always going to be smooth sailing, right? Sometimes we do hear, you know, from a client and family that, you know, they did wonderfully at high levels of care, and they are, you know, so positive, and everything is going really well. Then something happens outside of their control with their family, something tragic happens, and then all of a sudden, it’s like, “Oh, we might need a little bit of extra support right now.” And so they might come back into an intensive outpatient program in order to just get, you know, maybe a little bit of a tune-up or just a little bit more support in that moment.And so those are the things that we think about when we’re talking about treatment, the course of treatment in general. When we fully engage in treatment and we actually put forth the effort to do it and follow through with the recommendations, we see positive outcomes. Families continue to thrive, and they come out so much stronger on the other side. Not only did they overcome such a big obstacle together, they also come out with the tools and the ability to communicate and talk about hard things, and these are the things that carry on into adulthood for these kids, and they pass down to future generations.
Can you speak to, and no pressure if you can’t, the nuance of parents feeling like a failure? Like if their child does end up needing this level of care, I feel like there are parents who are like, “What did I do wrong? How come I wasn’t able to help my kid fully? How come I’m not able to help my kid be okay?” Can you speak to that at all?
Definitely. I think there is so much, there’s the stigma, but there’s also a lot of shame and blame. I said it already; I’m going to say it again: Most parents who have kids in our higher levels of care are really doing the best that they can. I say that wholeheartedly because I know that it is really hard to be a parent, and being a parent in this day and age, where we’re navigating so many other things that we didn’t have to deal with when we were children. There are things about mental health that are way outside of our control. There is definitely the genetic factor that we just don’t have any influence over, right? Like, they unfortunately sometimes draw the short stick, and depression or anxiety runs in the family.
There’s also just a lot of isolation that happens with parents when you’re parenting a child who is struggling with mental health issues because you get people who are well-meaning but really don’t understand, that are just giving suggestions or having critiques that you’re just thinking, “Well, if it was that easy, don’t you think I would have done it already?”
So, first off, I want parents to stop for a second and validate themselves to say, “Hey, I’ve done the best that I can in order to keep my kids alive so far and still keep the family functioning,” because you still have to pay bills; you still have to take the other kids to school. Life doesn’t just stop when one of your kids has mental health issues. So, first off, I want parents to stop and just say, “Hey, I need to say I’ve done the best that I can, and there’s absolutely no shame in asking for help.”
I think part of it is thinking in the same way: Our mental health and our physical health are really not that different. If your kids are having some physical issues, and you’re not a doctor (and even when you’re a doctor, and it’s like a specialized issue), you would want to take them to someone who is trained to really work with that particular issue. So, with mental health, it’s the same thing. It is what their brains are doing; there’s so many different components that are involved. You want to be able to engage with the professionals who are trained to work with these issues so that you can get the support that you need to help your kids get better.
And there are so many great professionals out there. I think that’s the other piece of it. Sometimes it’s just finding the right fit. You know, the first therapist that you see might not be the best fit. The first psychiatrist that you see might not be the best fit. You know, maybe the first medication that you’re prescribed might not be the best medication. It might take a little bit of trial and error, and that’s okay because we want to find the right fit so that your kid feels comfortable, that they feel safe, so that they can actually engage in the treatment process. Otherwise, it’s not going to be effective.
Absolutely. Gaan, thank you so much. This has been so impactful. I learned so much. I know this is going to help a lot of parents out there.
Thank you so much for your time.
