2020 Washington State of Reform Keynote: The State of Behavioral Healthcare in Washington

2020 Washington State of Reform Keynote: The State of Behavioral Healthcare in Washington

[Music] you know I think I did one of these with you maybe 10 years ago maybe at least 9 years ago and it wasn’t a keynote so the fact that you know 10 years later we get a keynote on behavioral health I got to think everybody in this room for that so I’m of course hopelessly biased about how important that is so I’ll start off with that so 10 years ago I would have spent most of this presentation talking about why we should care about behavioral health we have woken up to that most everybody in this room has woken up to that we know why the brain matters we know why behavioral health is actually a really important part of overall health so I’m gonna say just a little bit about that in case you need some ammunition but those who are not believers and then I’ll try to say some things about some things that we can do about it and hopefully finish up with inviting everybody to sort of think about ways in which we can put our heads our hearts our minds and our resources together to really do something about behavioral health so why should we focus on behavioral health so I’m gonna say and I don’t usually read my slides but there is a lot of information so if you need information to convince someone else why this matters I’m gonna just say brain health and behavioral health are an incredibly important part of all health and when we talking about brain health disorder we’re talking about things that most of you either have dealt with in your own lives in your own families or you certainly heard about them we’re talking about people who struggle with addictions with depression with bipolar disorder sometimes with autism sometimes with really serious mental illness like schizophrenia and these days you can’t open the Seattle Times without reading about something related to behavioral health and brain health so that’s not news to people these things will affect nearly half of all people living in the state of Washington at some time in their lives so this is not something gets out there that’s rare this is incredibly common and maybe the most compelling thing I can say about behavioral health problems is the fact that they cause more health related disability than any other health problem that we have so just to be very concrete the brain health problems cause you know 10 15 times more disability than things that we care about a lot such as heart disease diabetes cancer more than 20 times more disability than cancer so you could say how the heck could that be if I got cancer it could be really terrible and it might even kill me the big difference is most of us who will deal with cancer at some point environ in our lives it’ll come at us in our 60s and our 70s maybe in our 80s and then it can be a tough road and you might have to take really difficult treatment and you might it might even shorten your life by a couple of years but remember you’ve had a good life up to then the big difference with behavioral health stuff is those of us who deal with behavioral health problems at some point in our lives 50 percent of us will have presented by the time were 14 years old seventy-five percent of us will have presented by the time we’re 24 years old and then if we don’t do something about that you’re living with that illness and it’ll cause you disability for the rest of your life so the cumulative burden that comes from things that affect your brain from things that affect your health behavior is enormous you know and it’s not just disability it’s also mortality so we now have a tremendous interest in the fact that suicide rates are going up drug overdose rates are going up we have a person ending their life by suicide every 13 minutes in this country so while we’ve been here today talking you know every 13 minutes someone ends their life by suicide and every eight minutes somebody dies from a drug overdose and finally and I put that last because of often people mention it first and I’m gonna put it last because I think money is important but it’s not all we’re about you know behavioral health conditions are also incredibly expensive ten years ago governments knew this you know people were spending a lot of money on police on jails and prisons and we talked about you know how that’s a problem now employers are talking about it in a way I’ve never heard them talk about it now a Boeing is coming to me and saying you know depression anxiety addiction is a bigger drain on our workforce and on our product than anything else we have in healthcare what are you guys doing about that that’s new and I think it’s really important because people are realizing this isn’t just something that effects some people who are homeless who are on the street this affects everybody so I think that’s really important if we take all these little people you see on these slides let’s say these are all the people who live in Seattle or live in the state of Washington or we live in the u.s. who have a diagnosable behavioral health disorder so one of these things that I just called out earlier how many of them will see a psychiatrist I’m a psychiatrist I’m a doctor trained to deal with people who have behavioral health problems how many of them will see a psychiatrist in the next 12 months anybody want to call out a number somebody said 10% you looked at the slides all right fine twelve percent okay but now you’re gonna say there are lots of other people who are doing behavioral health there are psychologists there’s social workers there’s you know masters level counselors there’s peers there is pastoral counselors how many of them will see somebody who is a professional who’s got some sort of formal training and I’m gonna make a very broad definition of this to help somebody with a mental health problem in the next 12 months 20 percent one out of five okay all right forty percent of people will say sometime in the last year I had an encounter with a primary care provider who did something about my behavioral health and this is you know for me this is actually encouraging because 25 years ago when I got into this field 30 years ago now when I got into this field this number was tiny at this point especially those folks who are primary care providers in a safety net sitting I’ve gotten pretty savvy about the fact that you know a lot of what they see in their offices is you know medical some of it is surgical a lot of it is behavioral health and so they’ve actually you know made a pretty good effort to do this but the sad news is 60% of people live with a diagnosable mental health problem behavioral health problem will see no professional help whatsoever in the next year now that’s interesting I just told you that these problems cause you know maybe 10 50 and 20 times as much disability as cancer what if I had to say to you that of all the people living in this state of Washington with cancer one out of ten will see a doctor sometime in the next year who’s got training and taking care of a person with cancer and one out of five will see somebody who’s got any kind of health care training you know who can help with cancer we’d find that totally unacceptable but that is pretty much where we are in behavioral health so this is a challenge so access is a huge huge challenge two-thirds of primary care providers say this is my number one challenge if I need to get help for from a specialist for one of my patients behavioral health is a huge problem the second bullet on this slide talks about a recent analysis that Milliman did looking at healthcare claims from people who have good commercial health insurance and what they found is that out of network use so when somebody has to go out of their insurers network is about 5 10 sometimes 15 times greater when you need behavioral healthcare than when you need medical surgical care that suggests to me that while we now have really great parody legislation we haven’t really lived it you know there is probably some serious issues with network adequacy and parody even for people who have good commercial insurance in you know when you look at the numbers even with good commercial insurance it can be a month in child psychiatry can be five six months until you can see a specialist that’s not okay that’s not something we would put up with with any other type of healthcare if you have a person if you’re a purse who has a substance use problems one out of ten will see an addiction specialist sometime in the next 12 months so huge access problems if you look at different ways that people look at us you know Washington State is an amazing state when it comes to virtually any health indicator we are you know near the top of the heap in virtually all health indicators not in behavioral health this is from Mental Health America they put out an analysis this is about two or three years old but things haven’t changed that much that ranked us near the very bottom in all states in terms of access to mental health care so this is not something we can be super proud of there is some good federal statistics on workforce and you know we have all over the country but we have especially in rural areas such as Washington state lots of places where you have little or no access to a mental health professional so this is data that says that we have in Washington state nearly a hundred sixty federal designated mental health workforce shortage areas concretely this analysis says there are four million Washingtonians who don’t have access to psychiatry they’re estimating we need another two hundred psychiatrists to meet the bare minimum of what you would say would be an adequate workforce uh-huh this is another way to look at this we have a with 39 counties in our state and only about half of them have even just one psychiatrist or psychologist so we have real challenges you know with regards to workforce now what about facilities where do we take care of people with mental illness this is a picture this is a slide of Western State Hospital that’s a hospital that was built in 1871 it is the place where those with the most serious mental illness still go for their care today we have almost a thousand patients who get care there and a huge portion of the state budget and a huge portion of all the effort that we have you know the the funded effort that we have in this state goes to this one place to take care of a thousand people now we’re a state that has nearly a million people living in it that on any given day have a mental health or substance use problem so this is an answer that probably didn’t even work in 1871 but it’s not obviously working terribly well today and you know if you believe CMS or if you believe you know the Joint Commission or if you talk to patients who have spent some time there they would say it’s time for something new or something better the one other thing I want to say about this and I’m not saying this to make people who work there feel bad you’re working in a really really tough environment what I want to say is we’re at the University of Washington one of our jobs is to find and inspire the next generation of healthcare providers to want to go into behavioral healthcare because we have such a big shortage right and if I show them that they can go work in a facility that was built in 1871 that looks kind of scary that feels kind of scary and on some days it is kind of scary or they could work in a beautiful shiny new facility here in downtown Seattle called the Seattle Cancer Care Alliance that’s nice and shiny and bright and it looks like you know 21st century healthcare you know it can be really hard to motivate people to go work in a place like this so so far I’ve presented a whole bunch of problems and now if you think about it we don’t need one hospital that’s gonna take up most of our resources we are evolved from 1871 so I think we recognize now you know to do a good behavioral healthcare is more than just one place one facility one kind of provider so I’m not going to narrate this whole slide but you have it and I think it’s a kind of a useful way to think about what are people who live with behavioral health conditions really need on the left side is a thing called housing I just want to echo I could do a whole session but we already had a lunch talk on housing and I agree with almost every single thing that you know the lieutenant governor from Hawaii said people need a safe place to go at the end of the day if we don’t have that there’s a whole bunch of healthcare we could throw at people that’s probably really missing the mark so it’s incredibly important that we have housing I do think that you know we can’t forget that and and there isn’t a one-size-fits-all answer to that on the right side is you know behavioral health care and behavioral health care most of it should not happen in hospitals most of it should happen in your home in your community and there’s a whole range of well evidence-based interventions approaches that we could use that we can bring to bear and if we had a healthcare system that looked more like what’s on the right side of this slide you know then we could be competing with the kind of folks who are doing really good quality care for cancer for diabetes for other things we are so under invested in work force in facilities in you know in the kinds of ways we take care of people with behavioral health problems we probably a decade off from catching up to with the rest of healthcare is but we have to go there all right so how do we close this gap I’m gonna say a couple things about that so the first thing we can do is we do need to invest in some better facilities and I’ll say a bit more about that later and I think the state is making some pretty serious earnest moves in that direction and I think that’s great the most important thing I think we need to invest in people I mean yet to train people we have to recruit people we have to retain people who are making a commitment to working with this really you know difficult to help population this is hard work to do and we have huge dropout rates not so much for the doctors and the psychologists but for many of the other behavioral health providers that are working in this field this is tough work and you have a huge rate of burnout it’s a little bit like our teachers you know we teach them we train them they teach for 10 years and they’re like I can’t do this anymore they’re burning out they’re not paid all that much they’re doing really really difficult work it’s not all that different and then finally I think we have to think about we can’t do the stuff we were doing in 1871 we have to do something different we have to do we have to be smarter how do we use technology in our work how do we leverage to people we have so we can help more than a thousand people who are locked up in a state hospital so I think those are the kind of approaches that I’ll say I’m gonna say a little bit about technology we are living in a tech city here I just walked over here past a whole bunch of big fancy buildings you know that are using technology to get stuff to your door so if Amazon can get you a package they could certainly get you you know behavioral health services so I think we need to be smart to think about you know how do we use you know information technology how do we use stuff that we can get into your home or wherever you are in a much smarter way than a very traditional approach where you have to take time off from work you know get into a car drive to a facility sit there and wait and then have an interaction with somebody so there’s probably lots and lots of opportunities for us to think about using technology that would be good for families that would be good for patients in there but also make the lives of providers interesting this is just one example this is from one of our investigators drawer Ben’s AF he’s developed a smartphone app called focus and the interesting thing is this is a tool that is used to help people with schizophrenia people have really serious persistent mental illness who might be psychotic hallucinating on any given day and he did a really nice study that showed that giving them a tool like this on a smartphone allows them to stay in touch with their healthcare team you know that actually works as well or better than a whole bunch of really good traditional outpatient mental health care and we’re now actually doing a big project to try to test this in a whole bunch of settings around the state the other concept that I want to mention is the notion of collaborative care so this was a pretty radical idea 15 20 years ago when we first tested it but it’s now gotten a fair amount of recognition and that is just the fact that you know I showed you that 40 percent of people actually will get mental health services in primary care so we looked at that and we said that’s not a bad thing because back then my colleagues in psychiatry when I started working in primary care they would say you know what are you doing you’re teaching these primary care doctors to eat our lunch that’s what we do we’re psychiatrists we’re psychologists and I would say you have no idea how much I’m serious I wish we could teach them how to eat your lunch but these guys are already helping a lot of patients that we never see what is it that we can do to help them do a better job and so the concept is basically you take some primary care a team and you enhance it you teach somebody in the practice how to do a good assessment how to do a good brief behavioral interventions how to measure if things are working and if things are not working if things are not improving that’s when you bring your psychiatrist to bear you bring that psychiatrist in to consult of that primary care team on the patient’s that are not improving and if you do that in a systematic way you can help and reach a lot more patients we have this concept now implement it in every single one of our 20-plus neighborhood clinics that are part of our UW Medicine health care system and our psychiatrists who are working in this and we have a couple of them here today what they’re saying to me is this is really neat because I used to help a handful of patients who came to see me in clinic and if I work in this collaborative care model I’m helping a lot of patients because you know I’m helping a primary care provider who has a big panel of patients and I’m consulting to them on the patients that they’re really struggling with and they can do a lot of the rest of the work and the longer I do this the smarter this primary care provider gets and after about eight or ten years these guys are really savvy and they’re doing a lot of really good behavioral health care and now they’re calling me for the really difficult patients and that’s exactly how it should be that’s a wonderful way to leverage you know what a specialist can do okay there’s a couple of core principles that we’ve learned along the way and if you go on the aim Center website you can see them and see them explained a little bit more the first one is when we are working together we really have to collaborate we can’t silo the care we can’t say somebody does your this and somebody does your that the behavioral health and the primary care really need to be working together and the patient needs to be feeling like these people are working together they’re talking to each other the second one is we have to do this for a whole population so one of the biggest problems we have in this field is people drop out they fall through the cracks and if they don’t come back to Clinic they’re out of sight out of mind especially in a busy primary care clinic so what you have to do is you have to set up a system or you systematically reach out to them if they don’t come back the clinic you’re going after them that makes a huge difference we have to do things that work we now are not in 1871 anymore we have actually a whole bunch of super effective treatments for people we have drug treatments at work we have psychotherapy treatments that work talk therapies we have psychosocial interventions that can be incredibly helpful and if somebody’s not getting better we can’t just say oh well I guess they won’t get better that’s when we need to make a change so we need to bring all the effective treatments that are available today in a systematic way to bear and when we do that we can really get people better and we can get a lot more people better the finances of this are kind of cool too this is an article from The Wall Street Journal 2013 they wrote an article that basically said that when you do this when you do a good collaborative care and primary care for every dollar you spend on this you’re saving six and a half dollars in reduced health care costs over the next four years that’s an ROI of you know six and a half dollars a return for every dollar we’re spending that’s about as good an ROI as anything I’ve ever seen in health care we do a lot of this work here at UW we’ve proven the concept but others do this now this is an article from the Mayo Clinic they looked at a thousand a seven thousand of their patients and they looked to see when they implemented collaborative care in their primary care clinics they looked at patients before and they looked at patients after they put this in place and what they published is that before they were doing collaborative care it took them you know 600 days for the average person with depression to have a serious improvement and after they implemented collaborative care that was down to 86 days that’s a huge difference in the lives of people this is a study we did here in Seattle this is a study done in high risk moms who are depressed and what we have here is a survival analysis where we look at the number of weeks that go by until somebody’s really improved from their depression the blue line is mostly before we implemented good collaborative care and what you see is it took almost a year for about 50% of the moms with depression to have a significant improvement after improving this program and doing really good collaborative care what we can see is we shorten this to a couple of weeks maybe 10 14 weeks that’s a huge difference if you’re a mother who’s just had a baby if you have serious depression I going to be depressed for a year or is this depression gonna get better you know in 810 weeks that makes a huge difference in people’s lives if you’d like to learn a little bit more about collaborative care the Ames Center has a great website that I would recommend to you some of our colleagues have written a really great book on how to do this work in primary care and we’ve been fortunate to get some funding from the state of Washington over the last couple years to train others in how to do primary care this is the integrated care training program on a rat sloth who directs our residency program is in charge of this program and this is some really cool slides that I’m going to show you here when we started in 2015 we had trained providers in two counties how to do good integrated care and by March 2018 we had trained a provider in virtually every county in the state of Washington on how to do good integrated care we also started a program called echo or PAC this is a program that meets every week that primary care providers and others who provide mental health services can login to it’s a televideo learning kind of exercise where you call in and the first half of the meeting is a presentation on a common behavioral health problem and the second half is actually discussing cases that people have that they’re bringing that are challenging to them and it’s a wonderful way to engage people and to really share knowledge we have done over 165 of these pack sessions with you know 4,500 attendants for over 500 individual patients so that’s you know thousands of training hours that we could use a piece of technology for that really reaches the entire state my last couple slides I’m gonna mention a couple of really neat things that are recent many of you know this so right before the last legislative session governor Inslee stepped out and went out and said we need to do something big on mental health we meet and we need to move beyond 1871 and made a really bold proposal for the state to spend a lot of money and really upgrading our mental health capacities there’s a lot of components to this there’s a big bill on it there’s a big price tag on it the governor’s proposal called for spending six hundred million dollars on improving behavioral health care and there’s three components that I’ll talk about one of them has to do with better facility one of them has to do with training more providers and this is a piece that we’re pretty engaged with at the University of Washington and the last one has to do with how do we help all those providers who are not mental health specialists but they still need to help people who have mental health problems I’ll say a little bit about each of those there was a wonderful bill that in the last legislative period of Frank chop and others brought this is actually as far as I know the only bill that then speaker chop ever brought himself and it called for a substantial amount of funding to build an alternative to Western State Hospital that were in the planning phase now called the university of washington behavioral health teaching hospital actually earlier this day I took a couple hours to interview architectural firms for this and it’s really interesting when you have smart people sitting around a table to say what would a place look like that’s not 1871 that’s you know 2023 and it’s the kind of place where if you had a behavioral health crisis you’d want to go there and you’d want to heal and you want to go through recovery what would it look like and it’s really amazing to think about that it took us so long you know there is no you know opportunity that I’ve seen other than this to put some really smart people in a room and say let’s build something that’s really going to be great for our the people we serve but also great for the trainees that we have because if we show them a 20:23 facility and it’s a nice place and it’s just as nice as what you would get if you went to cancer treatment somewhere here in town people will be feeling like this is a good place to work this is I see patients getting better here this is what I need to do and I need to tell other people about it so I’m super excited about this the last thing I’ll mention is one of the things in this bill is we said we can’t wait til 2023 to have a new hospital that’s that’s when it’s slated to open we need to do something today so the one thing that we committed to that we could today is we said we can set up we have a lot of psychiatrists in our department at the University of Washington and I said many a counties don’t have a single psychiatrist we’re going to set up a program or any prescribing provider anywhere in the state of Washington that’s either in primary care or in a community hospital or in a jail in a county jail you know who is dealing with somebody who’s a mental illness can call us and get a consultation on what to do with the patient we started this we started this in july 2019 right when the legislature funded this it’s up and running it’s I would say we’ve gotten calls from all over the state and it’s open right now Monday through Friday from 8:00 to 5:00 you can talk to a psychiatrist or a psychologist and starting next July it’ll be operating 24/7 so if somebody walks into a community hospital emergency department in the middle of the night with psychosis in withdrawals you know we’ll be happy to talk to you so what I need from you all is you know we’re putting a substantial amount of effort and resources behind this I’ll please help us get the word out about this really really important share this there’s a couple hundred people in this room it’s each of you shares this with a couple people in your environment you know we really want to make good use of these resources this is another slide and you have these slides and I’m happy to share brochures about it this is how to reach us we have a few other things that are along these lines this is something that’s been operating for 10 years we have something called the partnership access line this is for child psychiatry so Monday through Friday 8:00 to 5:00 you can call up and say I’m taking care of a child with a behavioral health problem can I talk to a child psychiatrist and will give you a good consultation on that we have a similar service that we offer providers that are taking care of women during or after pregnancy this is called PAL for moms and because my feeling is the best we can do in mental health is not wait until you’re 25 years old and really sick we need to be taking care of you ideally before you’re even born the single best thing we could do is take care of a pregnant woman who’s struggling with a mental health or addiction problem because when we help a person like that the chances that there is mental illness in a child you know down the road is actually significantly reduced and we’re happy too we have eight perinatal mental health specialists at UW and they’re happy to talk to midwives to Obie’s to family doctors or other mental health professionals who are taking care of a woman who’s got a mental health or addiction problem just to summarize so there’s a couple things we’re doing to try to help there’s a lot of detail on this slide and Mandic I’m not gonna narrate all of it but basically what we tried to do is we tried to say where is it that we could provide you really good care if you were in a crisis today so if you’re here in Seattle we operate an emergency department at Harborview that’s staffed 24/7 with psychiatry it’s a super busy place and one of my goals for that program is to say not only do we want to kick pair of people who come to Harborview within a year we want to make available that capacity to any emergency department in the state 24/7 no there isn’t going to be a psychiatrist in most of those places but if you can call up and say we have a person who walked in here was psychotic they’re struggling help me we can either give you a provider to provide a consultation or we could maybe even see the patient using televideo we have lots of Technology tools now that we didn’t use to have we’re going to build a new hospital I talked a little bit about that I’m super excited about that we’re also building a behavioral health Institute at Harborview which will try to do work and research on new ways to help people and we have been super fortunate we’ve had a huge gift at the University of Washington in the last year to build a new Institute for brain health solutions so the goal for that is to say 10 years from now not only do we need a new hospital we need new treatments there are still a lot of patients that even with all the treatments we have they’re not all that much better so we’re making a huge investment in improving treatments as well so I’m gonna stop here thank you for your time thank you so much for giving this much attention to behavioral health if I have one ask for you like I said help me get out the word about our behavior our psychiatry consultation line we want this to be a resource that gets used and you know a month in we were already getting calls from all over the state but I’d love to hear from more people thank you you see variation in this model across urban and rural geographies because just of the reality of the rural setting and fewer providers is it actually more efficacious in rural settings because people need to be more creative as providers or is it less so because of the dearth of providers in general yeah so you know we’re an interesting state we have very urban we have very rural and we have some frontier and I would say it could be both so in some of the rural settings providers are used to having to do a lot of stuff on their own and they’ve come up with some pretty creative ways to manage you know patients that you might not see in an urban primary care clinic but having said that if they do need help there isn’t a specialist you know several counties away so I think collaborative care especially if you support it with telehealth technology can be really really powerful in a rural setting but it can also be really helpful in an urban setting you might it might look a little bit different you might staff it a little bit differently in a very rural setting you might never have a psychiatrist on-site but with televideo technology now I can put a psychiatrist into every clinic that has internet access in the state of Washington the interesting thing is I came to the University of Washington as a fellow in 1994 so 25 years ago and even in 1994 I had a Tuesday afternoon clinic where I could see patients in a little town called Driggs Idaho two states and a plane ride away and they were getting pretty good psychiatric care so we had this technology 25 years ago you know it was a little more clunky than what we have today but if we’re smart and committed we can put mental health in a lot of places now so one of the things that I take from your presentation which maybe I miss hearing and maybe this is not the intent but it it’s pretty psyched psychiatry heavy it seems to me and I know there must be some mid-level baked in there but I also wonder you know obviously you’re a psychiatrist you lead the Department of Psychiatry so you’ve got a perspective on this but it seems like one of the things we’ve learned is we’ve become more culturally competent is that that community health worker a community-based worker that may not be licensed in any meaningful way might be the exact right kind of mental health provider how do you sort of reconcile what appears to be a needed psychiatric focus with this other thing that we’re becoming more savvy about about community level workers yeah I would say if I had my say I would make every single person living in the state of Washington you know behavioral health competent the person who needs to know the most about it is the person living with the illness the person who maybe needs to know the next most about it is you know the family that people are around them appear can be incredibly helpful a peer can do things that a psychiatrist either doesn’t know how to do or doesn’t get across peers are a huge part of our workforce now at Harborview for example we have a fabulous peer bridger program family members can do things that you know they might have not thought they can do we’re never gonna have enough psychiatrists you know but it’s not all that different in other parts of healthcare if I get cancer care at the Seattle Cancer Care Alliance I might spend a couple minutes with my oncologist but I’m gonna spend a lot of time with nurses with physical therapists with occupational therapists behavioral health is no different it requires a real team right so I want to make sure that I’m not communicating that everybody needs to see a psychiatrist as you saw only one over ten people will see a psychiatrist what I’m trying to say is all of the other behavioral health professionals they’ll eventually run into a really challenging situation and I want to use the psychiatrist’s and the psychologists we do have not to see a handful of patients but I want to leverage them so they can help others you know who are doing really really important work in behavioral health yeah one of the things we have learned on this stage over the years is the importance of not asking people what’s wrong with you but asking them what has happened to you and that the the trauma that people experience over the course of the life of course manifests in physical health ways compared to ten years ago when he first spoke its data reform or compared to what twenty five years ago when you first were fellow how have we gotten smarter about trauma-informed care screening for it or or listening for it some states are becoming very active on that score like California where are we in Washington I think we have a lot of awareness you know I think you know really just in the last ten years people have gotten very savvy about the fact that if you’re a person who’s had serious trauma and trauma can be many many different things you know um we probably have to be very thoughtful about how we approach a person like this you know so trauma-informed care it’s interesting it’s one of those things that we probably all need to be good at and it at a minimum it means being thoughtful about the experiences that a person has had and thinking about what does this mean for how I’m gonna interact with them how I’m going to help them being you know thoughtful about listening to them I think 10-15 years ago people either paid no attention to this at all and a lot of people would had trauma experiences were getting kind of health care that they just couldn’t handle really or they wouldn’t come back you know we had a small number of people in psychiatry who we said you know they have post-traumatic stress disorder you know they were traumatized in the war you know so we paid attention to them but the average person who’s had a try maduk life event we just didn’t pay attention to and that’s changed a lot I think there’s almost no more health care organization left it doesn’t say how are we thoughtful about the way that we work with in patients who have had traumatic life experiences well doctor thank you for coming and being a capstone on a busy day dr. Jurgen and it search era the you dev site kaya tree Department let’s give him a round of applause you

Jürgen Unützer, MD, MPH, MA, is an internationally recognized psychiatrist and health services researcher. Dr. Unützer is also Professor and Chair in the Department of Psychiatry and Behavioral Sciences at the University of Washington. His work focuses on innovative models of care that integrate mental health and general medical services, and on translating research on evidence-based mental health care into effective clinical and public health practice. He has more than 300 scholarly publications and is the recipient of numerous federal and foundation grants and awards for his research to improve the health and mental health of populations through patient-centered integrated mental health services.