Healing A Broken Mental Health System: Mitchell Clionsky Of Clionsky Neuro Systems On 5 Things That Can Be Done To Fix Our Broken Mental Health System
An Interview With Stephanie Greer
We need to promote mental health at a larger scale. Rather than waiting for mental illness to treat, proactive models emphasizing social engagement, regular exercise, and avoidance of alcohol and other drugs needs more attention.
The current state of the mental health system is a conversation that echoes in the halls of policymaking, the corners of social advocacy, and within the private struggles of individuals and families. As we continue to witness an unprecedented need for robust mental health support, the shortcomings of the existing system become more glaring. It is within this backdrop that we seek the insight of those who are at the forefront of behavioral health. In this interview series, we are talking to behavioral health leaders, policymakers, mental health practitioners, advocates, and reformers to share their perspectives on healing our broken mental health system. As a part of this interview series, we had the pleasure of interviewing Mitchell Clionsky, Ph.D.
Dr. Mitchell Clionsky is a board certified clinical neuropsychologist with 45 years evaluating and treating patients with a wide variety of emotional and neurologically based conditions. His practice specializes in people with mild cognitive impairment and dementias, such as Alzheimer’s disease; concussions with persistent impairments in thinking and emotional regulation; and Attention Deficit Hyperactivity Disorder. Along with his physician wife, Emily Clionsky, MD, he has developed a 5-minute test of cognition for health care providers to use as part of their regular office visits and has published Dementia Prevention: Using Your Head to Save Your Brain (Johns Hopkins Press), a scientifically based, how-to approach for reducing the risk of developing dementia as you age.
Thank you so much for joining us in this interview series. Before we start, our readers would love to “get to know you” a bit better. Can you tell us a bit about your background and your childhood backstory?
I have the dubious distinction of being both a psychologist who provides professional care for those with memory disorders and my personal experience as the son of a wonderful woman who developed dementia in the later years of her life. I have seen the effects of mental disease from both sides of the clinical setting. Additionally, my later-life marriage to my high school sweetheart who earned a medical degree and became a psychiatrist, has created a personal and professional “marriage” of psychology and psychiatry, allowing us to treat patients from the combined perspective of thinking, emotion, and physical health.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My mother had a saying, which she roughly translated from a Yiddish axiom, “If you can’t get on the table, get under it.” Throughout the years I have never actually found anyone else who knew this saying, but nonetheless, to my mom it meant that you should find a different way to solve a problem if the first way doesn’t work. This has become a guiding philosophy to me as I have looked for unique approaches to help people create new approaches to problems that they had been unable to solve. It also embodies my belief that giving up is not an option and that you need to examine situations from every perspective.
Let’s now shift to the main part of our discussion. It is often said that “the mental health system in America is broken”. What does that statement mean to you? From your perspective what is “broken” today?
With the increasing stress and complexity of life, the breakdown of social support, the isolation that has increased for many of us, there is an increasingly greater need for a listening ear, a coach, a professional mentor, someone who can help us to find ways out of our emotional ruts in the road. Along with this, the stigma of having emotional problems has lessened and has made for an increasing willingness to obtain mental health services. Unfortunately, this demand has outstripped supply. It has led to much longer wait times for mental health services and often a reliance on less well-trained providers of service. I dread the question, “Can you recommend someone I can see for ongoing counseling or medication supervision?” I know that there are simply not enough experienced and well-trained therapists and psychopharmacology specialists to meet the need and that many therapists are placed in a situation of rationing their services to less frequent meetings than should be occurring because they are trying to fit so many patients into so few appointment slots. Even with the pandemic-era availability of virtual therapy through audiovisual modalities, which should make it easier to find a care provider who might be at a greater geographical distance, insurance policy limitations, financial restrictions, and technological limitations will often get in the way of good care.
What about any bright spots? Do you think there are any elements that we get right in today’s world that we wouldn’t want to reverse unintentionally?
I believe that virtual or online psychotherapy offers tremendous opportunities if we can improve access to broadband internet and technological limitations of patients, especially in minority populations and underserved areas. I also think that much can be gained by using apps, computer programs, on-demand webinars, and other digital technologies to extend what therapists can do in their interactive sessions.
In your opinion, what are the 5 most impactful things that could help heal the broken mental health system? These could be on any level including training, workforce, policy, culture, equity etc.
1 . Embracing group therapy modalities. We are still stuck in a one-to-one model of therapy delivery. This model is reinforced by the reimbursement models in which group therapy pays the provider at one-fourth the rate of an individual session. From the therapist’s perspective, it makes no sense to try to manage the care of four different patients with four different schedules, in order to receive the same payment as when seeing only one patient at a time. I have had a lot of experience in providing group therapy, either for patients with the same diagnosis or a similar presenting problem (dealing with parenting, stress management, learning assertive communication, adapting to the changes brought about by an illness or injury). The group setting, supplemented by some individual sessions, extends the therapist’s time to reach many more people and can improve each patient’s sense that they are not alone. They can often learn new approaches from the experiences of others in the group and can share in helping others manage their problems. In this way they also feel that they are part of a much larger therapy “family” where support comes from others and not just the therapist. In a pure individual therapy model, a busy therapist might help 30 patients every week. In a combined group and individual model (2/3 group and 1/3 individual sessions), each therapist can now impact two to three times as many individuals and the effects of interventions can be multiplied.
2 . We need to support the training of therapists. When I received my Ph.D. in 1977, there was substantial financial support from NIMH and other government programs. Not only did I receive my education for free, but I also actually earned a stipend while in school. Over the years this level of support has dwindled and is almost nonexistent. The psychologist training programs that have arisen since then require the student to take out large loans to achieve their degrees and places them in debt for years into their professional lives. It has also limited the socioeconomic range of incoming students and has deprived the mental health field of practitioners from low SES backgrounds and underserved populations. In medicine, the same problem has resulted in many psychiatric residents being recruited from foreign countries where there are cultural if not linguistic limitations. Many physicians leave medical school with $300,000 in debt and pushes the brightest to pursue careers in more lucrative technological or financial fields rather than in health and mental health care.
3 . We can support the development of technology based interventions. One example of this is online treatment for insomnia, a major problem that impacts emotional wellbeing. A cognitive behavioral program called Cognitive Behavioral Therapy for Insomnia (CBTi) can be a very effective mechanism for treating sleep disorders either alone or, much more often, as an adjunct to interpersonal psychotherapy. I believe that support for similar approaches, perhaps incorporating artificial intelligence as a therapist assistant could extend the reach of every therapist to reach many more patients.
4 . We need to help mental health providers understand that physical health and habits are often involved in the mental health problems they face. Obstructive sleep apnea, or sleep-disordered breathing, is one such example. Very recently published data informs us that 50% of people over age 58 suffer from undiagnosed sleep apnea! When people have this condition, they have disrupted sleep, are fatigued, anxious and depressed, and have much higher risks for heart attacks, strokes, and dementia. If mental health providers were aware of this relationship, if sleep apnea were routinely evaluated through a simple overnight at-home sleep study, and more people were supported in treating their sleep apnea (typically through CPAP treatment), they would have much better outcomes in their emotional state currently and in their overall health in the future. Similar interventions include awareness of the role of obesity and its effect on hypertension, diabetes, and sexual arousal disorders, such as erectile dysfunction. The integration of mind and body is essential in our treatment.
5 . We need to promote mental health at a larger scale. Rather than waiting for mental illness to treat, proactive models emphasizing social engagement, regular exercise, and avoidance of alcohol and other drugs needs more attention.
If all of the items on your list were magically implemented tomorrow what change might we see in the world? What are the signs (big and small) that would show us that the system is being healed?
There are no simple or magic approaches. The changes are cumulative and often interactive. Having more well-trained therapists who can afford their training, who are more well-educated in the mind-body interaction, who can use more flexible approaches to treatment that can extend their reach by using group therapies (with enhanced payment for these approaches), and a focus on wellness could go a long way in combination.
What is a project you or others are working on today that gives you hope? How can our readers learn more about this work?
Writing a book on Dementia Prevention has been the single most important focus for my work at this point in my career. As we live longer and the numbers of people with cognitive problems grows as a result of longevity means that we have greater demands on both the older people in our society and the children and spouses of those who must care for them. We can reduce caregiver demands by improving support services and we can do even more by preventing many of those who need this care. The research is compelling that one in two cases of dementia can be prevented. This must be a focus for us now in order to protect our society in the future.
How do you see technology shaping the future of mental health care and its accessibility?
As I wrote earlier, technology has tremendous opportunities. I would love to have a virtual assistant, armed with the ability to offer support to my patients, to provide well-supported answers to common questions and concerns, and to link my patients with pre-recorded interventions (a short video guiding someone with relaxation instructions, reminders to take their medications, instructions on how to analyze problems and break them into well-proven steps to change behavior) to supplement what I can tell them in a session. Some of these are available already but could be organized for my patients in a menu of programs that I could offer them when I am not available.
In your view, how do social factors like poverty, education, and culture affect mental health care and its effectiveness?
The importance of social and cultural factors means that we must be training therapists or developing better programs for those in our society with the least means. We need to have greater technology availability for those who do not have access to or training to effectively use technology. And we also know that those of us with greater disadvantages often still have greater stigma for accessing services. They often only come to treatment when there is a crisis rather than through educational initiatives that promote better emotional wellbeing.
In light of the growing mental health crisis among young people, what innovative approaches or interventions have proven most successful for children and adolescents?
I have a daughter, Leah Clionsky, Ph.D., who lives and works in Houston, TX. She is an expert in Parent Child Interaction Therapy (PCIT), a well-researched and very effective intervention for parents whose children have significant behavioral problems. PCIT is cost-effective, applicable across the socioeconomic spectrum, and results in real, sustainable, and positive outcomes. She has recently started an online practice, PCIT Experts, where treatment can be delivered online via well-trained therapists to families within their own homes.
Are there any books, podcasts, or other resources that have helped you understand or manage your condition better?
For a variety of podcasts about dementia prevention, the interested viewer or listener can obtain these for free through our website, www.BRAINDOC.com. We also have a 20+-item Dementia Prevention Checklist that can be downloaded and completed as a first step to reducing a person’s dementia risk.
We are very blessed that some very prominent names in Business, VC funding, Sports, and Entertainment read this column. Is there a person in the world, or in the US with whom you would love to have a private breakfast or lunch, and why? He or she might just see this if we tag them. :-)
We sorely need a big name endorser who can reach a much larger audience. Some names that come to mind are Lady Gaga (through her connection with Tony Bennett, who died with Alzheimer’s disease), Seth Rogen (whose mother-in-law had dementia and he and his wife have a foundation) Victor Garber, Scott Conant, Ramona Holloway, Maria Shriver, Rick Steves, Own Wilson, and Anderson Cooper. Oprah Winfrey, of course, is someone who would make anyone’s list when they are trying to publicize a book.
How can our readers further follow your work online?
Our website is www.BRAINDOC.com. I also have a Psychology Today blog.
Thank you for your time and thoughtful answers. I know many people will gain so much from hearing this.
About The Interviewer: Stephanie Greer, PhD is the Co-founder and CEO of Akin Mental Health — a company dedicated to guiding families on their journey supporting a loved one with mental health challenges like bipolar disorder, schizophrenia and severe depression. Stephanie is passionate about this topic from her own personal experience growing up with a mother who struggled with bipolar 1 disorder and found a path forward to overcome the obstacles and live well. Stephanie’s professional experience includes a doctorate in neuroscience as well as design research roles at Hopelab and Apple. Stephanie brings this personal passion together with her world-class science and technology background to support families across the US in their personal journeys supporting loved ones with mental illness. To learn more about Akin Mental Health and join our community, visit us at akinmh.com.
