As first reported in The Columbian, a family of therapists has opened a new mental health urgent care clinic in Vancouver. Birchstone Mental Health Urgent Care aims to fill a gap between the emergency room, where people experiencing mental health crises often end up, and weekly therapy sessions. The clinic does not accept insurance, though it does offer a sliding scale for some patients who cannot afford the $150 fee for a visit, which includes an assessment and referrals for medication management and follow-up counseling. Three co-founders of the clinic join us to share more: Brandon Fielding, a licensed clinical social worker; and his parents, psychologist Kelly Fielding and licensed clinical social worker Gayle Fielding.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. A family of therapists has opened a new mental health urgent care clinic in Vancouver. As first reported in The Colombian, Birchstone Mental Health Urgent Care aims to fill the gap between weekly therapy sessions and the emergency room. I’m joined now by three of its four co-founders. Brandon Fielding is a licensed clinical social worker, as is his mom, Gayle. His dad, Kelly, is a psychologist. Welcome to all three of you.
Gayle Fielding: Thank you.
Brandon Fielding: Thanks for having us.
Kelly Fielding: Glad to be here.
Miller: Gayle, first – I understand that you’re the one who said you should create this clinic …
B. Fielding: She gets all the credit.
Miller: [Laughter] Were you going to say no, that’s not accurate?
G. Fielding: I have to give credit to our daughter in Utah who said, “I saw this idea.”
Miller: Is she a therapist also?
G. Fielding: No, but she did get her bachelor’s in the family sciences.
Miller: So she saw this idea and what did you say?
G. Fielding: As soon as she mentioned it, it just sounded super exciting.
Miller: Why?
G. Fielding: Many years ago – I won’t say exactly how many years ago – when I was training for my master’s in social work, [I] was the ER medical social worker at Providence Medical Center. And it was so evident that that is not the setting for emergent mental health issues.
Miller: And that was some number of decades ago.
[Laughter]
G. Fielding: Rude.
[Laughter]
Miller: I mean, it could have been one decade ago, at the beginning of your career. But you’re saying that that’s not the place where people in the middle of mental health crises can get their best treatment?
G. Fielding: That’s my opinion. Now, there are certain things that, like if someone’s extremely suicidal and their risk assessment says it’s off the charts, then yes, they need to go.
B. Fielding: And they need to be kept safe.
G. Fielding: And they need to be kept safe. But there are so many things like what we experienced during COVID – anxiety, depression, panic attacks – that the chaos of the emergency room intensifies the problem. It doesn’t help it.
Miller: So, Kelly, what was your first response when Gayle said I heard about this idea and we can start this?
[Laughter]
K. Fielding: Well, the other two are laughing because I said, “oh heavens, I’m already so busy.”
Miller: You already … the four of you, with your wife, Brandon … My understanding is she’s the one minding the store right now. So you already have a private practice. So you said, “I don’t want to add something more to our plates,” basically?
K. Fielding: That was my initial reaction.
B. Fielding: They said, “too bad.”
K. Fielding: Yeah, they did.
B Fielding: There’s a need, Dad.
K. Fielding: But the more I heard about it, the more I recognized that this is a need that we see quite frequently in private practice. Even if we are working with someone on a weekly basis in psychotherapy, sometimes they will fall into crisis and not be able to get a hold of their therapist or other resources that they might have. And what we’ve set up here is an opportunity for people to be able to access assistance quite quickly. We assess, and provide support, and provide referrals and recommendations that can assist them to be able to deal with their crises at the time.
Miller: So Brandon, obviously, your dad is fully on board now. But, at first, less so. What about you? When you first heard this idea, what did you say?
B. Fielding: I was pretty excited too. I had worked in a couple of behavioral hospitals and there’s just a huge gap between what we can offer as therapists weekly versus what the ER can do. They do their best, just like our police officers. They do their best. But that’s not what they got into their training to do. And we’re hoping to bridge that gap.
Miller: What happens when somebody shows up? And my understanding is we’re just about a week-and-a-half in, so you’re early on here. But either in practice so far or ideally, somebody walks in your door, what happens first?
B. Fielding: We like that it’s in our clinic now, because our clinic’s a pretty welcoming space, on purpose. They come in, they complete some paperwork, we get them back, and talk to them. We like the term “triage therapy” because this isn’t a long-term thing. This is to get them stabilized in the moment, help them feel heard, and hook them up with resources, so that they’re not suffering.
Miller: Kelly, what kinds of issues have people already come in with?
K. Fielding: People, generally, have been coming in with some of the more generic things that we see in mental health, significant anxiety, significant depression. We’ve already had someone come in who exhibited some pretty significant psychosis too. Now, those issues permit us to be able to use an array of different referrals that we can provide. We have a number of prescribers who are associated with us now, who will receive our recommendations quickly. We also have a number of different clinics and groups who are agreeing to take people on into psychotherapy.
Miller: If the idea is that not everybody needs to go to the ER, have there been people who came just in the last week-and-a-half who you’ve said, “Actually, you should go to the ER right now’?
K. Fielding: Actually, not yet. In other words, none of those individuals were so severely suicidal. In other words, there was not a risk to self or others at that moment that they needed to go into the ER.
G. Fielding: Now, I did see one person who was delusional. And in that situation, what I’ve done is continued to keep in touch with the family and help them find a resource for this person.
B. Fielding: Placement, in-patient.
Miller: Meaning, the idea was to be a kind of triage, to assess and then ideally refer. And then move on to the next person. But in this case, it’s a little bit more of an ongoing relationship?
G. Fielding: Well, it is in this situation, because it is so hard to find [resources]. I mean, we immediately contacted a psychiatric hospital in the area, sent them there, and the hospital immediately kicked them out and said they didn’t meet their criteria.
B. Fielding: What’s been neat to see is that we’ve had parents come in with their teenagers that have been in crisis, too anxious to go to school, and didn’t want to comply. And that gives us a chance to work … so it’s not always just people that are suicidal or having a panic attack. But it’s everyday stuff that you may not know how to deal with at the moment.
Miller: It does seem like one of the big pieces here, though, is referrals. Your job that you’ve given yourselves is figuring out where folks should go or who they would benefit from seeing next. And Kelly, you were saying that you have lined up some relationships with other providers to sort that out. But are there enough people or places down the line? I mean, is it a robust enough system for those other places?
K. Fielding: Exactly. This is part of the problem that we’ve run into and COVID highlighted this issue. That was the people who are familiar with how to access services for mental health. As soon as COVID hit, all of those folks were quickly in touch with therapists who could help them. Then all the others who are not familiar with the system were left waiting and waiting on long, long waiting lists. That’s why we have reached out the last little while. And since the article went into The Colombian, we’ve had a number of other resources reach out to us also.
So we do have some folks in hand who are willing to take on some of our referrals. But in addition to that, we’ve also put into our paperwork that we can, at times, see people for one or two sessions until we’re able to get them into other referrals for services.
Miller: Kelly mentioned starting your career working at an ER when you were getting your master’s in social work. How have you seen community needs changing over the course of your career?
G. Fielding: Oh they’ve definitely increased. If you look at the money spent, there was just a research study done at Columbia University in May of this year that [reported] $282 billion a year is spent on mental health. And that’s up $2 billion in two years. So we just keep seeing it increase.
Miller: Do you see that as an increase in need primarily, or an increase in the same amount of need but more people actually seeking out help?
G. Fielding: Both. Definitely both.
K. Fielding: COVID highlighted that for us.
Miller: In what way?
K. Fielding: People were isolated, in a state of isolation. They looked for help and I think we found that our resources were lacking when that kind of a concern hit. You look at the people down in the Southeast right now who are waiting for their second hurricane to hit. Oh goodness, the resources that should be made available that aren’t going to be available.
B. Fielding: Imagine the panic and the depression. You lose your home. You don’t go to the ER for that. That’s not a helpful place.
Miller: Is there, Brandon, an existing model that you can emulate here? I mean, existing clinics in other places that are doing the same thing that you’ve just started to do?
B. Fielding: Kind of. Crisis centers already exist and that’s mostly for case management, to give referrals. But we really like the idea of triage therapy because not only are we referring and getting them connected, but people need stuff and they need connection in the moment. If they’re hurting, that’s part of what we’re offering too.
Miller: That’s a key point here then, right? So, a case manager would not necessarily be a licensed therapist. They could help out in getting people, ideally, to the people that could help them. But you’re saying you’d be doing both – a little bit of therapy in the moment combined with the referrals and figuring out who they can talk to next?
G. Fielding: Absolutely. The two theories that I feel like really come together for our clinic is crisis intervention. But that can tend to be more case management. But factoring in and combining with it, trauma informed care. One of the things that people do when they first come to our office is take what’s called an ACE test (Adverse Childhood Experiences). That helps us know what’s happened in their past so that we can see a more complete holistic picture.
K. Fielding: And we have all benefited from Gayle being in the middle of her doctoral program now, in social work, because she’s the one who’s bringing in a lot of these theoretical perspectives for us, helping us to better understand how to approach these issues.
Miller: From theoretical perspectives to money, which is not at all theoretical understanding. And Brandon, maybe you can take this first – you’ve made the decision not to accept insurance. What went into that decision?
B. Fielding: A movement amongst mental health providers in the U.S. is to move away from insurance. We’ve tried, with our interest groups, for a long time to influence legislation and it just hasn’t happened. So, generally, we’re taking a step back and asking for more help. So if people can understand that it can’t just be the groups of mental health professionals that are advocating. But everybody can advocate for mental health help and legislation. That would make a huge difference.
Miller: We did actually, just a couple weeks ago, talk to a therapist and a reporter who’s a part of a nationwide look at a huge trend of people taking themselves out of various insurance pools for a variety of reasons. What are some of the things that you experienced?
G. Fielding: Can you tell he’s our policy guy, by the way, with his PhD in policy.
[Laughter]
Miller: You are a diversified therapist family, you all have your roles. But what were the problems with insurance for you? And why wouldn’t it work?
B. Fielding: There’s so many barriers to access. We have worked with insurance in our private practice for a few years. And we’re just moving away from it because frankly, we don’t want other people telling us how often we can see our clients. They get to decide what our rates are and how and when we get paid. If we get paid.
G. Fielding: And there’s never a raise in those rates. It’s very rare.
B. Fielding: And it’s rejected often. So we end up losing a lot of revenue that we need to pay our own bills too and maybe pay back our student loans. And it just makes it so much harder to keep a business afloat. So that’s why we’ve decided to move away from insurance with the mental health urgent care and just the flat rate.
Miller: It’s $150, which for some people could be a lot. If you’re actually trying to run an office and you see somebody for an hour-and-a-half or two hours, and you’re paying rent, pretty quickly, I am wondering how that could pencil out?
K. Fielding: I think the goal is to assist people perhaps in a little less time than that. But some of the people we’ve seen over the past week-and-a-half have certainly been more than a 45 minute or hour experience. It’s been longer than that. And we recognize that that’s going to be the case.
B. Fielding: We have to be flexible in this. These aren’t check boxes, they’re people.
K. Fielding: Right.
Miller: Do you all talk shop at the dinner table? I mean if you have a family dinner is it all about DSM-5 or whatever number you’re on?
[Laughter]
K. Fielding: My mother-in-law used to say that when Gayle and I would disagree about something, she had no idea what we were talking about because of the jargon we would use.
B. Fielding: And when we have siblings that don’t live in the state, come to visit and they have dinner and we’re all there together, they’re like, “Can we please stop talking about psychology?” We’re a resource to each other though.
Miller: So you’ll talk about cases?
G. Fielding: We can staff cases.
Miller: What does that mean?
G. Fielding: That means you don’t provide names or identifying information.
Miller: Even among each other?
G. Fielding: Even among each other.
K. Fielding: Oh heavens, no.
B. Fielding: Now, we refer to each other. And in that case ...
G. Fielding: Then that’s different.
B. Fielding: My mom is a better fit for so and so, or I’m a better fit for this person. So we give the information. But when we’re talking about cases specifically, we do everything we can to keep that confidential.
K. Fielding: The concept of confidentiality is incredibly important.
Miller: Where do you hope this clinic is going to be in five years? Gayle, you can take that first.
G. Fielding: Well, I would love to see the concept expand and not just with us. I mean, we need as many of these kinds of clinics as there can be.
Miller: Kelly, are you still dealing with stigma? I mean, you were saying earlier that COVID did change some things and more people, it seems, were amenable to seeking out care when they needed it. Do you think that enough people are doing that? Enough people who are in crisis or approaching crisis are ready to say, “I need help”?
K. Fielding: Less than 50% of people who are suffering from significant mental illness are actually reaching out and obtaining assistance – or will ever. Those are the national statistics. And that’s incredibly sad, if there are resources available and people are not reaching out. So people still tend not to reach out as much as they ought to.
B. Fielding: And age and gender, or biological sex tends to play into that. People who identify as male, much less likely to reach out for help.
K. Fielding: And older people are much less likely.
B. Fielding: Younger generations now are. I think social media has been good for that.
Miller: So young generations are more likely to say, “I’m dealing with this and I’m going to seek help for this.” Kelly, what message would you give, say, to older men?
B. Fielding: Is that because of his silver hair? That was a call out.
[Laughter]
K. Fielding: That’s a good call out.
Miller: But I can ask myself that question [Laughter].
K. Fielding: So the simple statement that I would make is that reaching out for help is so much not a sign of weakness. It is a sign of strength. And it not only strengthens oneself, but it strengthens the people around us and it strengthens the relationship we have with people around us, if we are willing to reach out for help when we truly need it.
You know, I went in to have an audiology test last year and they told me that my hearing was having a few issues ...
B. Fielding: Cause he’s old [Laughter].
K. Fielding: Well, I denied it for a year. I finally went back this last time. They gave me the same test. I got the same results and now I have an appointment set up for perhaps some hearing aids to help me hear a little bit better.
I reach out for hearing assistance. It’s just an aspect of our health. Mental health is another aspect of our health that can be extremely destructive to one’s individual capacities, but also to the capacities of everyone else around them who care about them.
Miller: Kelly Fielding, Gayle Fielding and Brandon Fielding, thanks very much.
All: Thank you.
Miller: These three members of the Fielding family are three of the four co-founders of the new Birchstone Mental Health Urgent Care Clinic in Vancouver. It just opened last week.
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