De-stigmatizing mental health care through integration, specialized support, and space design

De-stigmatizing mental health care through integration, specialized support, and space design

One in five Americans suffer from mental illness. But many don’t have access to mental health care. Community-based health care groups known as Federally Qualified Health Centers (FQHCs) are trying to combat that challenge by integrating primary and behavioral health services and offering specialized support for communities disproportionately affected by mental illness.

These strategies improve care and decrease stigma – but need is ever-increasing and funding is ever-decreasing. That’s why IFF supports FQHCs with financing and real estate consulting, helping ensure they have high-quality spaces that can meet patients where they are – both physically and figuratively.

“We shouldn’t only be treating people who can afford treatment, or who feel less stigma in seeking it,” said IFF CEO Joe Neri. “Everyone deserves access to quality health care – and that includes mental health care.”

Since its founding, IFF has provided FQHCs with more than $110 million in financing and consulted on more than 50 community health care real estate projects. In honor of May being Mental Health Awareness Month, we spoke with four of our long-time Chicago-based health care clients about the intersection of primary and behavioral health services, specialties that are crucial to mental health support, and how physical space affects treatment.

‘It’s all so interconnected’

Embedded. Integrated. Multi-disciplinary. These are the ways IFF’s health care clients describe their approach. But they all basically mean the same thing – mental and physical health issues should be treated together, not separately.

“Mind, body, and spirit – these are not separate things,” said Almu Ruiz, Director of Behavioral Health for Erie Family Health Centers. “I would love for people to see their mental health as part of their whole human health.”

Howard Brown Health Senior Director of Behavioral Health Services Kelly Ducheny agreed: “No matter what you’re dealing with – cancer, HIV, asthma, high blood pressure – it’s so much more difficult to manage health conditions if you’re struggling with mental health. It’s all so interconnected. Research has shown, and our experience has shown, that if you help folks be mentally healthier, then all parts of their life improve.”

Patients at both Erie Family and Howard Brown see their primary doctor and their behavioral health care professional at the same time. Their leaders said this approach decreases the stigma associated with mental health care and also increases the likelihood that patients will follow-through on their care.

No matter what you’re dealing with – cancer, HIV, asthma, high blood pressure – it’s so much more difficult to manage health conditions if you’re struggling with mental health.

“Because we see the patient at the same time, it doesn’t come across as ‘we’re referring you to a therapist.’ It’s just, ‘you’re going to talk with Almu now.’ We are just team members who are both helping the patient,” Ruiz said. “As medical and behavioral health providers work hand-in-hand, people are starting to view mental health as part of their physical health.”

Friend Health CEO Verneda Bachus added that patients are at higher risk to have depression, anxiety, or other mood disorders if they also have a chronic medical condition. Her organization tracks data on hospital re-admissions and emergency room visits that are often due to a patient being treated for only the chronic illness but not the behavioral health issue – or vice versa.

At Heartland Alliance Health – which specializes in treating people experiencing homelessness – those chronic conditions often go beyond the more common forms of depression and anxiety to serious mental illness like schizophrenia, bipolar disorder, or post-traumatic stress disorder. That’s why their multi-disciplinary team approach includes not just a licensed clinician and behavioral health professional, but also a substance abuse counselor, a nurse, and people with “lived experience” – meaning they are in recovery from their own mental health condition and may have experienced homelessness themselves.

“If you have very serious mental illness – if you’re hearing voices or dressing inappropriately for the weather – you are less likely to prioritize your health, less likely to go to a health care provider, less likely to follow through on recommendations that a health provider would make,” explained Heartland Alliance Health Executive Director Ed Stellon. “So in order for people to achieve good physical health outcomes, we have to address the behavioral health issues.”

Meeting people where they are

Like most FQHCs, Friend Health and Erie Family focus their services on people with lower incomes. They both believe this population suffers disproportionately from mental illness.

“The needs are much, much higher in lower-income communities,” Erie Family’s Ruiz said. “There’s lack of insurance, so people have been neglecting their health for years. There’s also more stress due to lack of stable housing or lack of financial support.”

But Howard Brown’s focus on the LGBTQ+ community and Heartland Alliance’s focus on the homeless population are even more specialized.

According to Howard Brown’s Ducheny, prejudice and micro-aggressions can take a toll on mental health – but so too can a lack of organic support mechanisms.

“For other groups that experience discrimination and oppression, the family of origin – the family you grew up in – is a protective factor. They help buffer the barriers you experience, help you interpret what’s happening in the world, help create resilience,” Ducheny explained. “But for LGBTQ folks, a significant amount of the time the discrimination and harm are coming from inside the family. That can leave folks feeling isolated and without community and without attachment.”

You start seeing yourself and seeing a system that has been sculpted to be welcoming and radically informed.

To combat those feelings, Howard Brown designs its space and services to be as open and welcoming as possible. As soon as patients walk in the door, they see pictures and images that represent them. And they see offerings that speak to their life, such as PEP/PreP (medications for preventing HIV infection), alternative insemination, gender affirmation services, and more.

“You start seeing yourself and seeing a system that has been sculpted to be welcoming and radically informed,” Ducheny said.

Heartland Alliance also tries to see their services through the eyes of their patients. One way they do that is through their Street Outreach Team – a group of specially trained professionals who go out under viaducts, into alleys, and onto street corners to engage people experiencing homelessness.

“This is highly-skilled work that takes a different kind of skillset,” Stellon said. “These people have very carefully created bonds and relationships with street-level communities who normally wouldn’t trust outsiders or any kind of authority figure.”

Once trust is earned, Heartland Alliance starts working with individuals to keep them housed and healthy. That work might include not only traditional health check-ups, but also taking them to the grocery store, resolving conflicts with families and neighbors, counseling them about their drug habits, and more.

Stellon explained: “This is a really different approach than a clinic-based session where someone would show up for a pre-determined appointment and see a counselor – that is good stuff, and we do that too, but because the homeless population sees such high rates of serious, persistent mental illness, we also have to take the treatment to the people, where ever they are.”

Meeting needs through the built environment

Of course, this kind of innovative, integrated treatment requires funding – something which was drastically cut in the last state budget crisis.

“Illinois still ranks at the bottom of states for the amount of funding it invests in mental health treatment,” Stellon said. “Medicaid expansion is a noble and wonderful thing, but when it comes to behavioral health services, it’s almost a ticket to nowhere because – over the years – we disinvested so much in mental health services that there really aren’t any providers to meet the participants on the other end.”

Health care represents the third-largest portion of IFF’s lending portfolio, and one of the top sectors for IFF’s real estate consulting services.

“In the last budget crisis, mental health care was cut a lot,” IFF’s Neri said. “We’ve stepped up to support this sector because we know how vital they are to communities. Without them, many people in our communities would not have access to primary or mental health care.”

Each of the health care clients we spoke to stressed the importance of quality facilities to achieving quality treatment.

At Heartland Alliance – where IFF has worked on three real estate projects and provided more than $1.5 million in financing since 1997 – one user-focused aspect of their facility offers both laundry and showers to their patients.

Medicaid expansion is a noble and wonderful thing, but when it comes to behavioral health services, it’s almost a ticket to nowhere because – over the years – we disinvested so much in mental health services that there really aren’t any providers to meet the participants on the other end.

“This is different than a traditional health center. We have built things into our environment to meet the unique needs of homeless people,” Stellon said, adding that the shower and laundry facilities aren’t just friendly bonuses – they have a clear health benefit. “Some things, like scabies or bed bugs, can happen to anyone. But if you’re homeless, how do you deal with it? A hot clothes dryer is actually part of the treatment for that.”

Howard Brown’s Ducheny explained that Howard Brown has designed their spaces “really intentionally to blend openness and privacy” so that patients feel both welcomed and protected.

“The things that people bring up can be intensely private. They are talking about sexual wellness. They are talking about hormones. They are talking about identity. So we actually try to go beyond HIPPA so that folks feel comfortable,” she said. “At the same time – we want the space to feel open and flowing. It’s not uncommon for people to have taken a train and two buses to get to us. By the time they arrive, they’re worried about being late, they’re hungry, they’re tired. We need to help ease them and give them a place to breathe – and the space has to be easy to understand so the experience doesn’t get overwhelming.”

Going to the doctor is not fun, so we really want our patients and their families to feel welcome. If the space is not inviting, they will not feel comfortable.

IFF has provided $7.2 million in financing toward Howard Brown projects, as well as real estate consulting on one project, since 1996.

But even when not serving a specific population like those at Heartland Alliance or Howard Brown, space design can have a significant impact on the patient experience. As Friend Health’s Bachus said: “Going to the doctor is not fun, so we really want our patients and their families to feel welcome. If the space is not inviting, they will not feel comfortable.”

IFF has provided real estate services to Friend Health seven times since 2010 and also provided a $400,000 loan toward a facility build-out in 2016.

Erie Family Health Care has partnered with IFF the most and the longest, with 14 different real estate projects and two loans totaling $1.6 million going back to 1995. According to Erie’s Ruiz: “The design of our clinic is conducive to our multi-disciplinary approach. We have a behavioral health desk in the provider’s room. We have specific space for behavioral health personnel in the exam room. This makes us a visible part of the team.”

Awareness

Visibility is key to each of the strategies these providers are offering to combat stigma – integrated, whole-body care that normalizes mental health treatment; specialized services that meet patients where they are, literally and figuratively; and thoughtful facilities that welcome, inform, and protect patients who may feel marginalized.

I wish we as a society would not be ashamed to ask for help,” she said. “We shouldn’t wait until we’re at crisis stage.

Despite these efforts, awareness of mental health issues has a long way to go.

“Needing or wanting mental health support is still seen as a fatal flaw by some families, some religious or spiritual communities, some geographies. Those communities sometimes see mental health care as disrupting the privacy that should exist within them,” Ducheny said. “That’s why it’s so important that we are embedded in our community, and that our mental health care is embedded in our primary medical care.”

According to Bachus, these approaches are critical to not only de-stigmatizing but also to ensuring people receive care sooner.

“I wish we as a society would not be ashamed to ask for help,” she said. “We shouldn’t wait until we’re at crisis stage.”

To learn more about Mental Health Awareness Month, please visit the National Alliance on Mental Illness’ website.

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