Advocacy in Mental Health

Dr. Ilse Wiechers (00:06):

Being able to mobilize in the moment as things come up is the key to advocacy, right, so you have to have the ability to stand up a response and stand up your advocacy efforts when that opportunity presents itself.

Dr. Laura Roberts (00:28):

Hi, I'm Dr. Laura Roberts, editor-in-chief for the books portfolio of the American Psychiatric Association, and welcome to the APA Books podcast.

Dr. Laura Roberts (00:42):

So excited to talk with several of our wonderful colleagues who put together a book, The Psychiatrist's Guide to Advocacy, and with us today is Mary Vance and Katherine G. Kennedy ... I know her as Kiki Kennedy ... Ilse Wiechers, and Saul Levin is also a co-editor of this book, but he's with us in spirit. He's not with us today for the podcast. I'm really thrilled, this is a special book, and prescient. I mean, it really focuses on issues of social justice and it's accessible, and I'll sing its praises as we go. But I really love that this was the product of a mentorship and a collaboration and colleagueship that really distinguishes it among our books.

Dr. Laura Roberts (01:35):

Mary Vance has really been involved with the APA. She was on the board. She was among the psychiatry fellows, was the vice chair of the Committee on Wellbeing and Burnout, the Disaster Committee. Even when she was a resident at MGH McLean residency program, she got very much involved with the APA, and we're so appreciative of all that. And Kiki now is the chair on the Council and Advocacy and Government Relations for the APA. She's a faculty member in the Department of Psychiatry at Yale University. Ilse Wiechers is here in California at UCSF, an associate professor of clinical psychiatry. She also has an ongoing voluntary appointment at Yale University School of Medicine. Nobody wants to let go of her, and she works as the co-chair for the Public Policy Caucus for the American Association of Geriatric Psychiatry. Also, was on the board of directors for AAGP.

Dr. Laura Roberts (02:34):

Mary, hi.

Dr. Mary Vance (02:36):

Hi there, Laura. Thanks for having us on the show.

Dr. Laura Roberts (02:38):

Yeah. And Kiki, just so everybody can hear your sparkling voice.

Dr. Katherine Kennedy (02:42):

Hi there, Laura.

Dr. Laura Roberts (02:44):

And Ilse.

Dr. Ilse Wiechers (02:46):

Hi Laura. Thank you for having us.

Dr. Laura Roberts (02:47):

Yeah, so great. Mary, would you tell us a little bit about the genesis of this particular book? I understand that it has kind of a special beginning.

Dr. Mary Vance (03:00):

Of course. Yes, we'll be happy to. I can start off by telling a little bit of my quote unquote "origin story", how I got started thinking about advocacy, because that really played a central role in my decision to pitch this book. And it really started all the way back and training during my PGY2 that I got my start in advocacy. When I started working in the psychiatric ED at my training program at Mass General Hospital, I noticed immediately the incredible disparities and difficulties that my patients with mental illness faced just at every level of the system from their treatment in the emergency room to bed availability and more.

Dr. Mary Vance (03:44):

And this really incensed me and I wanted to change things for the better, and I spoke with my fellow residents about it, and we ended up forming an advocacy committee for the residency, but then we quickly realized that we really had no idea what advocacy was, how to do it. And we knew there was this whole literature on it, and we really had to learn a lot and not reinvent the wheel. That's how I started learning about advocacy. I realized I had to teach myself, I had to teach my residents, and we kind of had to teach the program about it.

Dr. Mary Vance (04:16):

And so I spent the next several years really trying to do that and further respond to the concept and doing advocacy as well. Eventually, it got to a place where I felt pretty knowledgeable about it. Initially, I found myself fielding questions from other residents and other programs saying, "Hey, I heard you do this. How do you do that? Can you help me with this? "And I found myself having long conversations or writing long emails about it. At some point, it just popped up in my head, "Why don't I just write a guide book or something? That way I can just disseminate the information and say, 'Just look at this. This is everything that I know,'" and that's really how the book got started.

Dr. Laura Roberts (04:52):

I mean, you took an experience that many of us have and feel so distressed about, but you did something extraordinary with it, so that's amazing. And Kiki, how did you get, I think, brought into this book process, but also just you're such a champion and such a strong advocate, and I think that's been the case throughout your entire career, so what drew you to this work?

Dr. Katherine Kennedy (05:12):

Well, for this book specifically, Laura, I was actually Mary's mentor, assigned mentor on the Council on Advocacy and Government Relations. And so we were meeting regularly to talk about advocacy and I was delighted to be invited by Mary to be a co-editor for the book. But my origin story, if you will, for advocacy really began back about 20 years ago and it was not physician advocacy, it was actually grassroots environmental advocacy that got me started.

Dr. Katherine Kennedy (05:57):

Yeah, and so basically, there was an interstate natural gas pipeline that had been approved by the Federal Energy Regulatory Commission that was going to devastate nature preserves and Long Island Sound. And just like Mary got incensed, I got my ire up about wanting to protect the environment. And I organized just over several years a very large group bipartisan bringing in old and young and all sorts of different voices, and actually, we were able to actually stop at the level of the Supreme Court this interstate natural gas pipeline.

Dr. Katherine Kennedy (06:43):

That really told me or demonstrated to me that advocacy works and that if you have a committed group of citizens who are passionate, you can make anything happen. And so after that, I really started getting more involved with physician advocacy and have really worked to both educate myself and my residents and fellows at Yale about how to advocate before state legislative committees and how to get new state laws passed that can help our patients and our greater community.

Dr. Laura Roberts (07:25):

Yeah, it's so meaningful when you can see the difference it makes. And I imagine that many people feel like there's so many big issues, big system issues. It's really hard to address. And I would say Ilse, it's so clear that public policy and tackling large issues is not something you shy away from.

Dr. Ilse Wiechers (07:47):

Yeah. Public policy and medicine has been kind of combined for me since the beginning, going back to undergraduate actually. I had been accepted into college at Case Western in a pre-professional medicine program, so I knew I was accepted and headed to med school and dutifully started college as a biology major. And the minute I took my first college bio course, I was like, "Oh crap, this is the wrong thing for me," and I went back to one of my other passions, which was political science and ended up as a political science undergrad and really thrived in studying and learning about our systems and policies, and actually took time off then in the middle of med school to get a master's in public policy.

Dr. Ilse Wiechers (08:40):

And that was where I spent time during my graduate school summer working on Capitol Hill as a staffer for the house ways and Means Subcommittee on Health. About 20 years ago, I was actually on the floor of the house whipping a bill for Medicare prescription drug coverage back in 2001. And it was such a transformative experience for me seeing how the wheels of government work and how policy and legislative action can impact thousands and millions of people's lives at once. It stuck with me and all of that happened before I even started my clinical training. Everything I've done since then had this lens or this view of public policy and thinking about how our government actually impacts the care we deliver and the ways that we can impact that policy.

Dr. Ilse Wiechers (09:34):

And so that's been with me since the beginning, and coming out of training, became really involved with the American Association for Geriatric Psychiatry, being a geriatric psychiatrist myself, and have really taken a lot of time and energy to develop the role of our grassroots member-driven advocacy through that organization, trying to ensure our older Americans have access to high quality mental health and substance use treatment.

Dr. Laura Roberts (10:03):

Yeah, that's amazing. Part of what I love about the book is its structure. And so just for the listeners, it'd be great if you take a look at this book, because one thing is it has beautiful visuals. It has beautiful visuals. The writing is so clean. I can see where you all worked very, very hard to write in a crystal clear manner. And also, again, the structure of the book I thought was really neat, just bringing people in to understanding what advocacy is, its application in the work of practicing clinicians, but then you have individual chapters looking, for example, at older adults, looking at members of our military, looking at individuals with medical illness or medical and psychiatric disorders, different groups. And you clearly put a lot of thought into that. For all of you, who wants to jump in, but how did you arrive at this wonderful structure of this book?

Dr. Katherine Kennedy (11:09):

Yeah, I mean, I'll just say Mary got us started, but we really all worked together on this. And just to highlight again what you're saying, Laura, we have a whole section with four chapters just about the very problem that Mary had been describing earlier about what is advocacy? How do we define it? What does physician advocacy look like? How do we sort out advocating for ourselves and for our patients? And then there's a whole section about the different levels of advocacy, which we conceive as starting at the interpersonal level with just patient level advocacy, progressing to more organizational levels at the health or hospital system, as well as advocacy at the state and federal levels to create new laws, and then how do you advocate and educate people using popular media, like podcasts like this?

Dr. Katherine Kennedy (12:18):

And then as you described, there's a whole section about advocacy specifically for special populations. And so we just felt that we really did want to be crystal clear. I'm glad it came across that way to you, because we really want to help ... The whole purpose of this book is to help foster new physician advocates and to help our colleagues feel that they can, after reading this book, dip their toe into physician advocacy.

Dr. Mary Vance (12:47):

Yeah, absolutely. And what I would add is that this is a result of many hours of brainstorming, and yet it's not complete. This field will continue to develop. This field, as we figured out as we're writing it, physician advocacy is a relative frontier. There's not too much written about it. And it was hard for even us and our contributors at times to wrap our minds around how do we distinguish clinical interventions from advocacy interventions. And that's why we wanted to make it very specific, lay out the levels, lay out the populations. And I'm sure that as time goes on, there'll be other levels and other population and other methods that will emerge from that. But we really see this as a blueprint, as a starting point to start building best practices and we wanted to make it so that there's something in here for everyone. And that's what it's all about. We really believe that our readers will be able to flip through the pages and see at least one chapter, probably multiple chapters that pertain to them and the population that they work with.

Dr. Laura Roberts (13:49):

Ilse, did you have a perspective on that process of developing the structure for the book and how to make it as valuable to potential readers?

Dr. Ilse Wiechers (13:58):

Yeah, I'll just echo I think some of the key points from Kiki and Mary, which is that it was an iterative process for us. This was, as Mary mentioned, kind of a frontier and to bring it together with some clarity, which thank you for thinking it's written so clearly because there was a lot of blood, sweat, and tears that went into making it.

Dr. Laura Roberts (14:20):

I believe it.

Dr. Ilse Wiechers (14:22):

But it was an iterative process. It was multiple times going over the structure and the outline, lots of rounds with our contributors, and for which we thank them profusely for bearing with us as we did all of that work together. But also, I think the idea that we wanted this to be a guide book for people. We didn't want it to be as hard as it was for Mary when she first decided she found interest in this passion. We didn't want it to be everyone having to recreate the wheel for themselves each time de novo. We wanted there to be a guide book for people to turn, to to learn new skills, to create a toolkit and then to be able to implement that on whatever their passion may be or whatever their population and focus is within psychiatry. It's got something for everyone, and yeah.

Dr. Laura Roberts (15:18):

Yeah, it really does, actually. It really does. And then as I said, it has these amazing visuals, which I imagine you guys agonized over too, but they really lift a lot of the key messages in the book, which I think is wonderful.

Dr. Laura Roberts (15:31):

Well, I would say, I mentioned in my intro that so many things that you wrote about were prescient, and it makes me sad that there were so prescient, but the experiences of the last several months with so much that we're dealing with with the coronavirus and COVID-19 pandemic and how it's unveiled the complete lack of an adequate infrastructure for people with lived experience of mental health issues, and then has really caused us all to look at social justice issues, issues of racism, recognize that wanting to be inclusive and respectful and to create context of belonging is really wonderful, but it's really not the same as being an advocate for social justice and fighting against racism or forces that undermine social justice.

Dr. Laura Roberts (16:25):

And I see your book as being extraordinarily thoughtful and a useful guide for people who can't sit still, and they shouldn't sit still. Right now I can't sit still. I'm sure you all feel the same. I think it was a book that was meant to be and a book that was meant to help people in general, but it's certainly especially useful right now. I don't know if you have thoughts on that.

Dr. Mary Vance (16:52):

Yeah. Thank you, Laura. I would absolutely agree with that observation and thank you for making it so eloquently. We wanted this book to be applicable to any kind of advocacy that we might engage in as a physician advocates, as psychiatrist advocates. We intentionally discussed the general concept of advocacy and that is the prevailing principle there, overriding specific advocacy issues. But at the same time, we do find it to be pertinent to a lot of the very tough dilemmas that we're facing in this country right now, including the opioid epidemic, including the rise in suicide rates and really, as you mentioned, including the ongoing and pervasive structural racism that we're confronting right now, but that has been going on in this country for generations.

Dr. Mary Vance (17:44):

And so we do think this book is very timely in that sense, and in fact, producing lasting change in any of these issues, and we can focus on the structural racism in particular, it necessitates an understanding of how to engage in advocacy at each level as we described from the interpersonal level to the level of national policy, and our book talks specifically about how to do that with each level and with each type of advocacy. And so it can be applied to a broad range of really detailed issues within our society and in particular to structural racism as well. I'm wondering if Kiki, if you would want to describe some of our lessons at each level?

Dr. Katherine Kennedy (18:28):

Again, at the interpersonal level, for example, if we're looking at how to advocate to reduce structural racism, we have a chapter on patient level advocacy that contains case vignettes about specifically advocating for historically marginalized groups. We have a chapter, as I'd mentioned before, at the organizational level with suggestions for how to advocate within your hospital system or institution how to address structural issues, such as racism. And again, at the legislative level, we have a chapter that discusses how to work on policy issues to affect changes in state and federal policy so that we can undo racist laws and policies.

Dr. Katherine Kennedy (19:25):

I think that what Ilse had mentioned before about this book is a toolkit that helps to describe various different skills and how to go about at these different levels using those skills to affect real change, this book will, I think, hopefully help be a field guide to how to address these big issues such as structural racism. I don't know, Ilse, if you want to add anything to that?

Dr. Ilse Wiechers (20:04):

Well, I simply want to add that having the skills practiced, having the toolkit in front of you and practicing these skills so that they're at the ready to be used is an important part of why we created this book. And so being able to mobilize in the moment as things come up is the key to advocacy, right? You have to have the ability to stand up a response and stand up your advocacy efforts when that opportunity presents itself, COVID-19, the horrible acts of violence against black Americans that have occurred and led to the rise in efforts to fight against structural racism in recent months.

Dr. Ilse Wiechers (20:58):

People who have practiced some of these skills, especially physicians and psychiatrists have stood up very quickly responses to these lived experiences as they're happening. And so if you have the skillset practiced and ready to go, then you can respond quickly when advocacy is needed. And I think all of us, the group today, have had to do that in recent months. And I think we hope that others will start to practice these skills and have the toolkit ready to use moving forward, and we hope the book can provide that for them.

Dr. Laura Roberts (21:34):

Yeah, no, I appreciate that. And I also appreciate Mary referencing how we've actually been dealing as a profession and as a field with multiple, I don't know, crises, epidemics, pandemics with suicide, really changing the numbers of people it affects, the populations, the ages of people who are at much greater risk of suicide somehow in this period in comparison with others and the opioid epidemic. And I think we all foresee that with the social isolation and the lack of mental health care access that the pandemic has exacerbated, that there are many, many challenges to come. And so I like this idea of being able to respond quickly and frankly in a sustained way, because I think that's where we are now.

Dr. Mary Vance (22:30):

Right. And I would add to, to jump off on your point, Laura, and Ilse's point as well, we talk in the book in chapter two about theories of advocacy and what Ilse's really talking about is that there are windows of opportunity for when change can really occur. And so it's important for us to stand at the ready to jump into action when those windows of opportunity come up, and COVID-19 is a crisis. And and because of all the changes that have occurred, it presents a window of opportunity to enact some of those changes that will really benefit our patients, our profession, for example, telehealth and the loosening of restrictions around that, in addition to the issues of structural racism that we're reckoning with. And in fact, I think that Ilse could talk about some of the recent advocacy that she's done with telehealth.

Dr. Ilse Wiechers (23:20):

Sure. I mean, I'll just say that the APA and AAGP among several other professional medical societies really stood up quickly an effort to advocate with CMS to lift restrictions on telehealth services shortly after the shelter in place began and we realized people weren't going to be able to do face-to-face encounters with their patients going forward because of COVID-19. And because of those advocacy efforts, CMS did in fact temporarily lift restrictions on telehealth services, and also ensured that payment for mental health and substance use disorder services provided during a COVID-19 public health emergency would be on par with what the face-to-face encounter payment would be. And we're really grateful that we were able to stand up such a quick and ready and strong advocacy effort among the medical profession, but this is all temporary, and it actually will sunset later this month here later in July.

Dr. Ilse Wiechers (24:21):

And so just literally earlier this week, I drafted the letter that AAGP is going to be sending to Secretary Azar asking HHS and CMS to continue some of the lifting of restrictions around telehealth for a longer period of time. This is the opportunity for us as a field to show that we are able to provide high quality care using telehealth services, and that in and of itself will improve, I think, our patient's ability to not just in time of crisis and pandemic, but our patient's ability to access care, especially those from older populations, like the home-bound elderly who have challenges coming in for face-to-face visits, people who are living a great distance from care providers, either in a rural setting or who just have no access to transportation to get to their visits. There's any number of reason why expanding our telehealth ability to provide mental health services and substance use treatment could really benefit our patients in the long haul. We're taking this opportunity that COVID has presented us and acting on that.

Dr. Katherine Kennedy (25:34):

I'd like to jump on what you're saying, Ilse, to also underscore how this pandemic has exemplified how critical advocacy training during residency and even medical education is. And so here at Yale, we actually have a number of opportunities for residents and fellows to get a range of advocacy experiences and training. And so the residents here were very well-prepared when the pandemic hit. They had already had experience, for example, writing op-eds testifying before public health committees organizing the community. And so they were able to immediately mobilize those skills and their relationships outside of the hospital to persuasively communicate with diverse nonmedical audiences, to mobilize community activities and action. And so I think that this book also, we hope, will serve as a reminder that advocacy training does need to take place in at the same time as clinical training both in undergraduate medical education and during residency training.

Dr. Laura Roberts (26:56):

That's great. Well, let me thank you for all of that and really for this wonderful book. I actually would like to transition if we could, as we just have a few minutes left, but just to talk about the passion for developing a book. I think ... Is everybody, this is your first book? Is that right?

Dr. Mary Vance (27:16):

This is the first book that we all edited, correct.

Dr. Laura Roberts (27:19):

Yeah. Right.

Dr. Katherine Kennedy (27:20):

Yes. And I love the fact that you're saying first book, Laura, because it's sounds like it means there might be subsequent books we all might be writing.

Dr. Laura Roberts (27:29):

Yeah. Well, you're reading my mind per usual, because I really look forward to your future work and it might be individually or as a team. But as you say, this particular area is underdeveloped. And so I'm excited about the potential for additional work in this space. But also, I mean, part of what I think is lovely about APA Publishing is that we really care about our authors and our editors and we want to build longitudinal relationships with extraordinarily talented people and give voice to issues and people and perspectives that have not had sufficient attention historically.

Dr. Laura Roberts (28:10):

And so I look to each of you for your next book, next book project or others, but I guess I would ask if you wouldn't mind commenting on whether it turned out to be harder, whether it turned out to be easier, what made it, because ... and you finished. I mean, you did it. And some authors, they start and they have big ideas or many people have an idea for a book and it never actually makes it to paper. If we could pivot and you could just talk a little bit about what is it like to edit a book and collaborate on a book, write a book? Just because I think some of our listeners might be very interested in that. Mary, I'm going to turn to you again. This was your core idea. What was the process like?

Dr. Mary Vance (28:58):

Yes, absolutely. Would be happy to comment. It was a lot of blood, sweat, and tears, and I think I'm speaking for all three of us when I say it was a lot of work, and I'd been warned of that beforehand by experienced editors. And I found that to be true. We were first-time book editors. We contributed chapters before, but we never edited a book before. We really had a lot to learn about the process of creating a book, meeting timelines, following up with contributors, working with them to shape the chapters, the logistics of how to edit, how to work with APA publishing staff, which you are all amazing. We just didn't know how to do it.

Dr. Mary Vance (29:44):

These were all issues we have to tackle without prior experience and we figured it out on the fly, but as a team, we made it work and that's where I'm so grateful, and I really want to express this. I'm so grateful to Kiki and Ilse and Sol as well. Sol was the senior editor on our book, because you can really make it work if you have a good team. And this was a relatively large editorial team, but I wouldn't trade it for anything because we really, really made it work together. The three of us had so many conversations about how to structure and how to frame it, a lot of late nights I can tell you and a Sol was there too providing us guidance at each step and supporting us and giving us contacts and he wrote the foreword for the book and described his advocacy story. We really couldn't have done it without each other, I think.

Dr. Laura Roberts (30:30):

Well, we've kind of come to the end of our time, but I so loved talking with all of you. I'd love to keep talking with you. And I look forward to future books and future podcasts with each and all of you. Thank you so much for being with us on [inaudible 00:30:44] today.

Outro (30:54):

Our original music is by Willa Roberts. Our executive producer, Tim Marney. This podcast is made possible by the generous supporters at Stanford University. We are a production of American Psychiatric Association Publishing. John McDuffie, publisher. To purchase copies of this book or other books by our guests or hosts, please visit www.appi.org. That's A-P-P-I dot org. If you'd like to contact us, drop us an email at [email protected]. We hope you enjoyed this podcast, and thank you for listening.