From Hollywood the CBS radio workshop. This is Samuel Clemens speaking Word comes to our colony of late residents of the United States that the art form known as the motion picture Makes a pretty good thing of bringing the great American West to the attention of current inhabitants Who are fortunate enough to live somewhere else? As I understand it the movie makers have found three basic ingredients necessary to their presentation of life in the West ingredient one scenery Ingredient to a good man in a white Stetson and a bad one with ten gallons of black felt on his head Ingredient three a rousing chase over ingredient one and involving ingredient two Of course, they add a few refinements now and then such as the love of mankind for horse kind Don't know what I'd do without you Broomtail partner or maybe a battle against the elements Sometimes even a female Come back when you can ranger and thanks now word has reached me that in addition to symphony orchestras Trick horses and guitar players. They also hire writers just to think up these adult Westerns This seems a little silly to me since I wrote a book some 90 years ago Which contains all the literary appurtenances necessary to make a Western as adult as it should be These writing fellows can find it in any library Its title is roughing it and its author is yours truly Samuel Clemens CBS radio presents the CBS radio workshop dedicated to man's imagination the theater of the mind Tonight by tape the workshop offers to writers of Western films a do-it-yourself kit Through the courtesy of one of America's greatest humorists Samuel Clemens Mind you, I don't consider myself an authority. It's just that I was there back in 1863 I Happened my brother Bob was appointed secretary of the territory of Nevada and I was pretty cut up about it Pretty soon. He would be hundreds of miles away on the great plains and deserts and mountains of the far west He would see buffaloes and Indians and prairie dogs and antelopes Maybe he would get hanged or scalped and write home and tell us all about it and be a hero So when he offered me the sublime position of private secretary under him It seemed the heavens and earth passed away and the firmament was rolled together as a scroll. I accepted We left the states at st. Joseph, Missouri and headed west across the plains by fast stagecoach Yep, maybe a bit crowded if that pile of male sacks topples loose will be crowded right through the back of the coach The heft of it is for the engines mail for the Indians To read It was a superb summer morning and all the landscape was brilliant with sunshine So I didn't give much thought to Indians literate or illiterate We felt there was only one complete and satisfying happiness in the world and we had found it We felt a lot different 12 hours later as we slashed through a prairie rainstorm What happened Just what I was going to say thorough brace is that part of a horse what doubtless a vital part of a leg Maybe how could a horse break a leg on a road this smooth? He may have been reaching around to bite the driver You know this rain Little dizzle is all won't melt you here. I'll hold the lantern so as you can see the trouble Yeah, is the animal in pain see that dog on step connected to the other belt and spring can happen right there Under the rear of the coach. Oh, oh Say I never saw a thorough brace used up like that before that I can remember how did it happen? Yeah, it happened trying to make one coach carry three days male That's how yeah, but it's lucky To protect us on the engines our soul right right here in his very spot is where I supposed to leave that whole ton of Newspapers for him in its own nation dark. I might have drove right by if the thorough brace hadn't broke Now if I can ask you dense to help me cross out the sacks I'll get on with mending it. Oh when will the Indians pick up their mail in the morning? Maybe or an extended along this way all I know is that with all this fascinating reading matter They won't be bothering us They didn't and we enjoyed considerably more leg room in the state 56 hours later we crossed the Platte River and rattled into Fort County in the territory of Nebraska 300 miles out of St. Joe 300 miles in 56 hours But they went and spoiled it They pushed the railroad out onto that beautiful prairie and only 12 years later They made the same 300 miles in less than 16 And now I'm given to understand that this record has recently fallen to the new fangled flying machine So it's no wonder that the fellas who make these western movies never get a chance to find out what the West is really like You got a rock along a rutted trail at 12 miles an hour like we did to understand the country Soon we acquired certain blisters When they became calluses the seats became less hard The driver of the stagecoach was perhaps the very first of a hardy breed George Bemis was his name only nowadays you meet him as Gabby or chill or fuzzy or maybe the old timer But if any of those Johnny come lately you think they can hold a candle to George Bemis They'd better start burning it at both ends Yes cause late getting back from the buffalo hunt Well, here's that stupid horses for He saw that buffalo wheel on him. He raised straight up in the air and stood on his heels. He threw you Takes more horse than him to sell George Bemis Well, then a buffalo made another pass And I may wish to die if the horse didn't stand on his head for a quarter of a minute and shed tears But you stayed on through the flood. I stayed on Pretty soon the buffalo made a snatch for us and brought away some of my horse's tail Then you should have seen that spider-legged old skeleton of a horse go and the buffalo cut out after him Which was faster, they never did determine but by George. It was a hot race I in the saddle were back on the horse's rump and I had to bridle in my teeth while holding on to the pommel with both hands First we left the dogs behind Then we passed the jackrabbit Then we overtook a coyote And we was gaining on an antelope when the saddle girts let go and I landed about 30 yards off to the left At the foot of the only tree and nine counties adjacent Buffalo come over to see if I was hurt And one second after that I was a straddle of the main limb It was a little over 40 feet to the ground from where I sat, but you were safe Yeah That's what a tender foot like you might assume mr. Clemens But presently thought come to that buffalo and he started in to clumb that tree What the buffalo course who else but a buffalo can't climb a tree. He can't can he? Since you know so much about it. Did you ever see one try? No, well then the buffalo started to clumb that tree So I Cautiously unwound the laureate from the pommel of my saddle saddle did you take your saddle up the tree with you? Of course, I didn't it landed there when the horse kicked it and it was falling off him when the girts let go Oh, I see certainly So I Unwound the laureate and fastened one end of it to the limb Higher in higher clumb that buffalo. He hit his foot over the stump of a limb and looked at me as if to say You are my meat friend, but buffalo's don't eat meat.  Hey, I scared the buffalo to Must have for when the smoke cleared away. He'd let loose his hold of the tree trunk and there he was dangling in the air 20 feet from the ground So I shinny down and headed for home Well, that's a quite a story, mr. Beam is a little hard to swallow, but still quite a story You wouldn't care to doubt it. Would you young man? No, but did I bring back my late? No, did it bring back my horse? No Miss Hettle No Well then There's something to be said for a liar on a long journey though a really good one makes the time pass more quickly But 20 days is still 20 days And that's how long it took us to reach Carson City the capital of Nevada Territory If you want to know what Carson City looked like back then Just try to recall the little town in high noon with those funny little white frame buildings that seemed too high to sit down on And hardly high enough for anything else Carson was like that and the same sort of things went on there as Gary Cooper and the princess and All the other fine people acted out But as I recall the action that Carson City moved toward its climax without benefit of that old clock on the wall And there was action It began the moment we climbed down from the stagecoach a Tall-ranging fellow that might have been Gary's granddad rode up and shook hands with us from the lofty turrets of his saddle Good afternoon. I take it you're mr. Clemens the new secretary now I am sir, and this is my brother Sam. I am deeply pleased to welcome you I'm mr. Harris the governor sent me to meet you well now that's my name I'm afraid. I'll have to ask you to excuse me a minute Yanda is the witness who swore. I helped rod the California coach some weeks ago a Piece of impertinent meddling gentlemen for I'm not even acquainted with the man get up there Whoa now gentlemen if there is any way I may be of service I Never saw mr. Harris shoot down a man after that without recalling my first day in Carson City. I Was wonderfully fascinated with the curious new country and I set about to become a real Westerner Now every westerner must have a horse to ride a noble intelligent friendly beast Which I understand according to routine film procedures must be acquired by saving it in cold hood from a Stock shot of a Cougar very least from a mob of blackbirds bent on thwarting the SPCA But that is the hard way to get a horse $20 I am beat for this noble beast friends. Don't hate the animals It looks like that one's going pretty cheap don't it strange well, I'm not too familiar with the local market saddle alone's worth the money 22 I was about to bid myself, but if you want him I don't really want him. I wouldn't know what to do with another horse. It's just that I know this one I know I'm well Now you might think he was an American horse when he's nothing of the kind Excuse my speaking in a low voice stranger other people being near and all that But he is without a shadow of a doubt a genuine Mexican plug really yes a genuine Mexican plug I only wish I could use him. See why don't you bid on him? Has he any other advantages 24? He can out buck anything in America You're sure you don't want it.  I heard my new friend say When I came down again the genuine Mexican plug was not there He darted away like a telegram sword over three fences like a bird and disappear down the road toward the Washoe Valley I sat down on a stone with a sigh One of my hands sought my forehead the other the base of my stomach. I Never appreciated till then the poverty of the human machine where I still needed a hand or two to place elsewhere and Subsequent events as you shall see convinced me that the movie maker perhaps is inclined to romanticize the horse's usefulness to man Now this was the time of the great silver fever John Wayne himself searched for the command no more avidly or in deeper snow than the inhabitants of Nevada searched for hidden wealth I succumbed and joined a prospecting party Consisting of a mr. Balloo a mr. Allendorf me and three miserable horses We rode out of Carson on a chilly December afternoon and some days later Oh Mine doesn't pull any easier than yours below the dis one pulse even harder yet. Maybe they don't like it the snow I don't like it the snow either Allendorf We should have stayed at the stage station another day or two maybe till we could see where we was going my head It is like a compass Exactly Val Val going I know by instinct. Well, that's splendid news The last four hours would have been happier if you told us four hours ago My instinct sets a beeline if we was to waver off that beeline a single degree of the compass My instinct she would say whoa. I didn't mean you. Oh, I mean myself. Oh come on We should have traveled with a party left before us this morning. I rather wish we had over here on the tracks of that party Hey, they are tracks of that so we hurry and catch up with them.  It is like a compass come horse We must be catching them tracks look fresher. Yeah, there seems to be more of them Maybe some others also have joined a party come horse More people join in a party all the time.  I'll read some months yet any minute to catch up with them Yeah, any minute boys wait. He's here is our own tracks We've been circling around in a confounded circle for the last two hours. What?  Let us forgive and forget by guns Maybe you have felt hard toward me. Well, I have felt hard toward you, too You're both a couple of doomcocks, but I forgive you.  Yeah But I forgive you too blue Hollandoff I Hadn't traveled one mile with you before I decided you were the biggest boars the maker ever created But I forgive both of you. Well, thanks. I could not die with two final gentlemen Well, let's shake hands and then lie down in the snow and in the morning We'll be frozen to death.  That's what they say So long of the same Goodbye a delicious dream in its wolf its web about my yielding senses The snowflakes were the winding sheet about my conquered body Oblivion came We woke in the gray dawn and not 15 feet away under the shed of the stage station stood our noble horses There's no fault of theirs that I ever got back to Carson City and continued my research on the mores and peoples of the West It was a grueling job and when I became so physically exhausted that I felt the need of a bit of Spiritus frumenti to rub on my corns. I would repair to an establishment noted for its medicinal hospitality Now I have no quarrel with the Hollywood notion that ruffians are found in saloons I have no quarrel with calling these ignoble creatures by the names of states such as Montana Texas or black bar But I do quarrel with their idea of the raw passions that ignite a borrowed quarrel and I give them Arkansas Come on our landlord you can get that bottle in the bar faster than that, can't you? No offense, mr. Arkansas.  Arkansas put this one on my bill, too Well, no, I was reading about Pennsylvania election. I reckon what do you know about Pennsylvania and some of that Johnson What do you know about Pennsylvania? Well, I was only going to say What was you going to say? That's what I want to know Yeah, repeat what you saying about Pennsylvania if you dare Well, I was only going to say that Pennsylvania was going to have election next week. That was all I was going to say I wish I I may never serve if it wasn't and why don't you say it what you come swelling around that way for trying to Raise trouble. Well, I didn't come swelling around. Mr. Arkansas I was already here because I own this place and I just So I'm alive now, please not now, please I never meant such a thing as that I got ears any man calls me a liar now. Come on now, mr. Arkansas Let's take a drink together. Let's shake hands and take a drink. Well Now that you put it that way, come on up everybody. It's my treat By Lou come on up. Yeah, I just leave the bottle.  Give me your hand again old Arkansas. Give me that old flipper Long as you say so and as long as you're buying why sure sure and drink up there by Lou or say By the way, how's your father and that's a good You know my father was upwards of 80 year old when he passed away and if he hadn't land Lord, would you please make that remark over again if you please? Well, I was just saying the bottle that my father was upwards of 80 year old when he died Was that all you said that was all you didn't say nothing about that. No, nothing Look, what's the idea of raking up old personalities and blowing about your father eat this crowd agreeable to you?  Is that your idea? Why bless your soul, Arkansas. I wasn't thinking of such a thing I only said that my father Lord don't crowd a man. Don't do it Don't rake up old bygones and throw them in the teeth of a passable people who wants to be peaceful if they could get a chance What's the matter with you today anyway? Arkansas I really didn't mean no harm But with so many customers a man's got to give each one a little that's what's rankling your heart Is it too many customers you want us to leave is that it now, please please be reasonable I can saw you know, I ain't a man.  I get one chance first you thieving black-hearted white-libered son of a sea cook Roy your weapon Let me see Hollywood stop that one without rivers of blood and mothers dragging their screaming offspring from the theaters never to return Hollywood would never think the carnage could be halted by the tender words and frail beauty of the pioneer woman would it Johnson, what do you mean stumbling through our nice glass door that way and who's doing that shooting? Who's causing all this? Oh, it's you is it Arkansas was Johnson. I don't know tell me what you mean You're the only one with shoot and iron smoking Well when a man can't hold more than two three quarts of whiskey without he has to disturb a poor woman Who's slaving her life away over a boiling hot range trying to prepare a few vitals to keep the customers from starving Theirselves to death and causing her clumsy over of a husband to smash itself through a lovely glass door Which we only had shipped clear out here to make the place a little might more like things was back in Scranton, Pennsylvania Well You fire off that pistol once more and I'll run this butcher knife clean down from your guzzle to your boots Do I make myself clear? Yes, all right? Now do your drinking peaceable All right, dear There's lots more in my book the real information about the West Information appears to stew out of me naturally like precious otter of roses out of the otter So as I previously remarked any writing fellows contemplating an adult Western Can find the book in the public library? Its title is Roughing it and its author is yours truly Samuel Clemens The CBS radio workshop produced and transcribed in Hollywood by William and Robeson has tonight presented roughing it by Samuel Clemens Adapted for radio by Francis van Hardis felt and directed by mr. Robeson Louie van Rooton was heard as Sam Clemens Included in the cast were DJ Thompson Eddie Maher Dawes Butler Peter Leeds Howard McNeer Jack Krushen Hal Perry and Junius Matthews The original score was composed and conducted by Emery go Marino Next week the workshop will be heard from New York in a demonstration of a writer at work By and with Hector Shevny author of the daytime serial the second mrs. Burton Looking for a shortcut to satisfaction There's nothing quite a satisfactory as knowing you've accomplished a good deed and when you do that good deed through your united community fund You really are taking that shortcut When you're thinking about lending your support to the United Fund in your town CBS radio hopes you'll remember that the United Fund is a way to help many worthwhile efforts with just one gesture on your part


Great, so at this point I'll transition us to our first panel of the day, which will be Building Capacity in the Mental Health Workforce. So I'd like to invite our panelists to please come up. And I will introduce our moderator, Katherine Wetzler. She is the regional director for Kaiser Permanentes, doctoral and master's level training programs in Northern California, where she manages approximately 160 doctoral interns, post-doctoral residents and master's level interns each year, as well as 58 training directors. The goal of the training programs is to provide the highest quality of mental health training using evidence-based science-informed treatment throughout Kaiser Permanente. Katherine started her career in sales and marketing for IBM Australia before returning to graduate school to complete a master's and a doctorate in psychology. For the past 15 years she's held various positions within Kaiser Permanentes' ED and outpatient clinics, and she previously served as training director and consortium director for the psychology residency program. So thank you, welcome to our day. Good morning everybody. It's really an honor to be here today, I have to say that, especially on this very auspicious day here in Washington, D.C., as Setchy mentioned, I am responsible for overseeing the master's and doctoral residencies and fellowships in Northern California, and as mentioned we have about 160 trainees, I put them all in together, come in and out each year. And across over about 20 medical centers. And Kaiser takes these training programs very seriously as evidenced by the size of our programs and the incredible support that we get to manage them and to train these folks. And our primary goal with our training programs is to prepare our trainees to work not just within Kaiser, but really within the community, and in fact my goal is really to train for the community. Now we do hire obviously, and when we're faced with this, with the shortage, our hiring within Kaiser has gone up, but the focus really is on hiring for the community, training really for the community. And since I've taken over this position, one of my personal goals for the training programs is to prepare our trainees to work in the workforce of the future. And this is different, it's different to how it was before. We can't continue to train and expect our trainees to work in the way that the field has traditionally worked in. We have to work and we have to be able to collaborate with medicine, broadly not just primary care, but all specialty care as well. We have to have a broader understanding of what mental health and wellness is that includes not just the mind and the body, the soul, but also the community that we work in. One thing that I think is very clear is that we just can't do things the way we've been doing it in the past. We have to change. With the onset of an ageing population, increased access to healthcare, at least for now, the enormous increase in chronic health conditions coming down the pike make it imperative for us to work very closely with medicine and with primary care in particular. And so one of the things that we're doing with our training programs is trying to prepare them for the future and also to work with the schools that they're coming from to also start changing the curriculum away from the traditional model. So what I would like to do, we have three amazing people here today. I did quite a bit of research when I was asked to moderate this panel on our three panelists today and they're super impressive, I have to say. They're very passionate, each one is very passionate about their particular area and I think they just make a huge contribution to the field. So I'm going to start with Dr. Neftali Serrano. Neftali is the Executive Director of the Collaborative Family Healthcare Association, a national organisation dedicated to promoting integrated care as the standard of care for all. He has devoted the majority of his career to working with federally qualified health centres, starting integrated care programs and consulting with clinics in underserved settings to assist with the implementation of primary care behavioural health programs, which I'm sure we're going to hear a lot about today. Dr. Serrano's research interests include program development evaluations and outcome studies related to primary care, behavioural health, particularly in underserved settings. So welcome. Our second speaker today is going to be Cynthia Moreno-Tui, who is the Executive Director of the Association of Addiction Professionals, has an acronym of NAADAC. For over 20 years, she's been the administrator of multi-county, publicly funded school and funded alcohol and drug prevention intervention treatment centres. She's been a trainer in domestic violence, anger management and conflict resolution for over 35 years, as well as an international, national and state trainer in a variety of topics. She also holds a bachelor degree in social work, advanced studies in social work and public administration and a certificate in addiction studies. Welcome. And last but not least, Dr. Glenda Wren is an Associate Professor, Psychiatrist and Health Policy Mental Health Services Researcher at Morehouse School of Medicine, where she serves as the Director of the Kennedy Satcher Centre for Mental Health Equity in the Satcher Health Leadership Institute. She completed her undergraduate education at the United States Military Academy at West Point, earned her medical degree from Jefferson Medical College and completed psychiatry residency at the University of Pennsylvania, where she was the Chief Resident, and then she went on and earned a Master of Science in Health Policy from the University of Pennsylvania during her spare time as a Robert Wood Johnson clinical scholar. Her other research interests include strengthening resilience in vulnerable populations, addressing the disparity in help seeking for post-traumatic stress disorder amongst African-Americans and culturally sensitive collaborative care models. So welcome everybody and we'll start with you, Dr. Newt-Clarke. I'm assuming it's okay if I stand up and pace a little bit. There's no way I can sit down and talk. It's a pleasure to be here with you. I've got a few minutes of your time and I want to make the best use of that. So I'm going to take Dr. Muta's invitation to tell my story. I wasn't actually going to plan on it, but I thought as she gave us that invitation, I thought, yeah, what better way to talk about what we need to do with workforce and to tell my story because I realized, you know, part of what we're talking about here is really, and this is not to sort of pump myself up here, but it's basically how do we replicate what I've been able to be as a professional over the 17 years of my career in integrated care. And I thought, well, yeah, let's see if this, the audience can connect to this and then very practically understand the challenges that we face to developing more workers. So just a step back before I tell you my story, I'm the executive director of the Collaborative Family Health Care Association. And yes, our mission is really about workforce. It's about promoting integrated care, primarily in primary care, but across all sectors as a standard of care because we really believe that integrated care leads to higher quality care. Now, that's my job now. But for really most of my career, in fact, all of my 17 years as a psychologist, I have been in primary care. So I'm one of a rare breed of individuals who actually grew up in primary care and has stayed in primary care. And part of my story, part of what I want to talk to you about is about how that's different than what a standard psychologist, licensed clinical social worker, et cetera, does. So we can understand what it is we want as a final end product. So here's my story. My story is that after many years of training at the very tail end of that training as I'm ready to go into my postdoctoral training, I'm on a trip going across from Wisconsin, I believe, through Canada, through New York to visit my parents after graduating with my doctorate as a clinical psychologist. And I'm traveling with my wife. We're up in the Cascals, sort of at a dinky hotel somewhere because we're still poor individuals. And I am particularly grumpy and have been grumpy for days, probably more like weeks and months. And my wife calls me out on it. And she says, you've got to make a change. There's something going on here. You've got to figure it out. And it was at that moment in the Cascale Mountains that I realized that I had spent a good part of my time, effort, and energy engaged in a profession that I wasn't exactly sure was for me. That's a scary thought to have at that point in your life. But I had to face that. And it was to the degree that I had a postdoctoral fellowship lined up. And I made the decision about 24 or 48 hours later to call them up and say, I'm sorry, I can't do it. I need to take some time. So I took some time off and did all sorts of things, including sign up for a substitute teaching certificate for the Chicago Public Schools.  I thankfully never set foot in a classroom. I would have been horrible. But through that process, I learned of this job at a federally qualified health center on the west side of Chicago called the Lawndale Christian Health Center.  They were a primary care clinic, large primary care clinic. They served at that point about probably about 80,000 unique patients. And I was to be the sole mental health professional to go in there and do this thing called integrated care. 80,000 patients, probably about 30 some odd primary care providers. No clue. Nothing in my training prepared me for that. Nothing in my training prepared me for what primary care was. Or what I was to do as an integrated care professional. Well, I did a lot of failing by trying to import specialty mental health concepts into primary care. All right, I took out an office, an exam room. I turned it into an office, put an Ikea lamp, a bench, a rug, a thing. And I said, open for business. I was afraid. I thought, 80,000 patients, I'm going to be inundated. I really was terrified. And unsure professionally still, the opposite happened. Half of my schedule was full. Half of that would actually show up on any given day. Which meant I was seeing maybe one to two patients a day in this supposedly high needs area in a primary care clinic on the west side of Chicago. So I learned very quickly that I had to change as a mental health professional. Through that process, I got some technical assistance, the Bureau of Primary Healthcare sent somebody out to help. His name is Dr. Kirk Strussel. He came out and trained me. And helps me to understand that to be a mental health professional in this setting required different sets of skills and a different attitude. I had to be flexible. I had to throw away the boundaries of my professional identity and say, how do I adapt the skills that I have for the setting and the patients and what they need? So that meant 15 to 30 minute visits instead of 45 minutes. That meant being flexible enough to go from helping someone with headaches, to helping someone with their depression, to helping someone with their childhood trauma, and to be able to do that in a flexible fashion that met the needs of the primary care provider as well as the patient. Right now we call that the primary care behavioral health model. So going in and out of exam rooms all day long, I fell in love with that. I became a new person and that's the key piece I want to leave you with today. So when we talk about workforce, we often ignore when we talk about the list of professionals that we have licensed clinical social workers, LMFTs, etc. We ignore the reality that what we're trying to do with the integrated care is actually a different thing and it's different enough that it actually requires a different professional identity. So now 17 years later, I honestly have less of a connection to my psychologist colleagues than I have to my identity as a member of the primary care team and that's a really different thing. Now here's the problem. Much like what happened to me, I needed to be retrained to do the work. That is not a smart way of doing it. As someone, one of the things that our association does is provide technical assistance to sites to help build the workforce, right? So we go in and we coach folks. So I've done coaching of folks at hundreds of clinics nationally and I can tell you that I have about probably a 50% success rate because I have this specialty mental health person who's trained in their specialty to do specialty mental health and I've got to transform them into a primary care professional who's going to be able to interact in and out of exam rooms in a fast-paced environment and flex in ways that they were never taught to do and to adapt evidence-based practice in ways they were never taught to do and 50% of the time they just don't fit. And so we have to start from scratch, find somebody else who does have the attributes necessary to make this work. So that's the number one thing I want you to keep in mind. We're actually not, right now we're having to rejigger folks trained for the wrong kinds of jobs, for the wrong kinds of professional identity and we're having to change that professional identity for them to work in these new settings. It's not just about pure skills. I have a lot of skills, great specialty mental health folks, but they cannot fit into the primary care mode of thinking. So that's the most important thing. What that means is that primarily, and I know that there's reimbursement issues, I'm sure there's going to be talk about that today, and I know that there's policy issues. But to me, in my experience, our biggest enemy is us. We as mental health professionals simply have not kept pace with the demand for primary care and other medical setting work that exists in the setting. So let me take a few minutes just to level set you as far as what's out there now. Because we've made a lot of progress in 17 years, in my 17 year career, and obviously this has been going on for longer than that. We have models and clinical pathways at this point that we can train people to do if we're able to help them adopt a new professional identity. You've heard the primary care behavioral health model that I work in, in primary care, right? That's one of them, it's called PCBH. You've heard about the collaborative care model. That's solving a slightly different problem, right? That's looking at improving the quality of our depression and anxiety care and increasingly so tying that to outcomes related to medical outcomes, like diabetes, for example, and that's where you have a registry and you have a care manager and a psychiatrist who monitor populations of patients with these issues and track them over time and support primary care providers to provide evidence-based prescribing practices as well as providing motivational interviewing and other evidence-based practices to assist patients. That's a collaborative care model. Great model. You know what one of the problems is? You can't train a specialty psychiatrist and assume that they're going to do well in that model either. Any more than you can train a psychologist and assume they're going to do great in the PCBH model either. At our clinic in Madison, Wisconsin, where I worked at for 10 years, we developed a residency program just to train psychiatrists in their third year so they can have an experience doing collaborative care work. Once again, some of the students took to it, some didn't. But at the very least, we got to them early enough in their training, and we turned some of them on to this kind of work. And we have some clinical pathways that I want you to be familiar with. You've probably heard of things like SBIRC, right? Screening, brief intervention, referral to treatment. It's a pathway. You can fit that into the PCBH model very easily and have a BHC be the one providing brief intervention for substance abuse in primary care clinics. Works really well when it's applied by an individual who's passionate about their work and passionate about their identity in primary care. And then we've already talked and heard about medication assisted treatment. It's another clinical pathway. It's a way of supporting individuals with opioid and substance abuse issues. Oftentimes, in the optimal setting, what you have is not just a provider prescribing Suboxone, but a provider who is supported by a behavioral health professional who's embedded in the way that we talked about with the PCBH model. So these are models and clinical pathways that exist, that are out there. The issue is we've got a long list of jobs, and I can tell you, the front page of our website, CFHA.net, there's a jobs board. And there are a scrolling list of jobs there. And the consistent feedback that we get is from our members, because we're a non-profit member association, is we've got jobs. We can't find qualified individuals to fill those jobs. And when we do find folks, we've got to do six to 12 months of intensive retraining just to get them to do the work. So a couple of the challenges here that I'll leave you with. You've already heard the Guild Challenge. Let me just expand a little bit on that, because we are, in many ways, our own worst enemy. Because we are so protective of, I'm a psychologist, and I'm an LCSW, and I'm an LMFT, we create problems for ourselves. For example, Medicare. Medicare right now, reimbursement, it's only applicable to licensed psychologists and licensed clinical social workers. So that leaves out a whole swath of workers, LMFTs, LPCs, and other individuals who could be helping us with the workforce challenge, right? But our Guild issues and the battles that we fight between us, often marginalize other professionals who could be helpful to us to meet the workforce challenge. So we really want there to be a greater sense of parity between the Guilds because one of the lessons we've learned, and I've experienced this personally in 17 years of working and training hundreds of students and professionals, is that actually your license, the letters behind your name, are a whole lot less important for how effective you're going to be in the primary care setting than the personality and temperamental attributes that you bring to the job. So in other words, I've got some folks that I've trained who are PhD psychologists, and they are horrible in the mental health setting because they talk too much, they're wordy, they can't possibly do a 20-minute visit with a patient and do anything productive. I can't, and I've had some folks who are LPCs or LCSWs and boy, they're like spitfires. They get in there, they know how to get in and out, they know that providers don't want a long story at the end of each visit, they just want the nuts and bolts, tell me what to do, and we'll get it done. And they know how to make that happen. So those temperamental attributes are far more important than the Guild issues. The final thing I'll say is we really do need a special sort of designation for integrated care work because it affects the regulation of this work. For example, documentation issues. Lots of states have documentation requirements that fit specialty mental health but have nothing to do with what you're doing in primary care. And so documenting in the electronic health record becomes a cumbersome, inappropriate, time-wasting task. So these are two very specific ways in which we really need to rejigger the way we think about the workforce, particularly as it relates to integrated primary care. So I welcome questions as our panel discussion develops. Thank you for your attention. I look forward to the conversation. Good morning. So I'm like the presenting doctor this morning that that passion about good morning is where? Good morning. I love that. It's really important that we're working through together on some of these solutions. And I'm going to move us forward here with my PowerPoint. Thank you. Thank you so much. So I'm Cynthia Moreno-Tue. I'm the executive director of NADAC, which is a professional organization for people who focus on addictive disorders. And so many of our people I'm going to share a little bit about defining the workforce for addiction professionals, because many of us do more than addictive disorders and have been trained and educated in other systems. Just last week we got these statistics back. We're doing a job analysis, a national job analysis with our addiction workforce. We have about 49,000 constituents. And of those constituents, the end on this study right now is about 200. And I say right now because it's a study in process. So you can see the addiction workforce. You can look and look at, see how long people have been working as full-time people in substance use disorder, where their primary focus is substance use disorder. So you see that we have a lot of people in the 11 to 20 years. And then we have a large part, 23 to 30 years. And not unusual now that we're seeing more people in the addiction workforce over 40 years. It's very interesting to me that I will call a colleague that I worked with 20 years ago. And 20 years ago they were in their 60s, or early 50s, late 40s, and they're still working in the addiction workforce. So talk to a guy out of New York. He's 82 years old. He's working three days a week. I really love that. I think that that speaks something about the attitude that you were just speaking about. How important it is that that attitude or that desire to continue to serve people is there. So we're seeing an aging workforce. That's not new to us. Okay. Thank you. We're going to work this through. All right.  Okay. Technology, you know, some of us need techno support. That would be me. Which of the following describes your job function? So you can see, again, the variety of people. Most of the people that we serve are addiction counselors or people that work in counseling. But we have a lot of people who also work as substance abuse professionals, SAPs. And these are people who are trained specifically to work in the workforce for Department of Transportation issues. And so these people have their own special training. And you can see, again, the variety of persons that work in the addiction workforce. The other part that we looked at is what best describes where you're working. And so you can see here that the majority of people work in substance use disorder treatment facilities. Outpatient tends to be a large part of our population and intensive outpatient. One of the changes that has happened over the past 30 years is more clients being served in intensive outpatient and outpatient programs than inpatient programs. And so we're really looking at what is the level of care someone really needs to have in order to treat their addictive disorder? Do they need to be in inpatient care? So you'll see that even the workforce has changed where their setting is. And then how many hours of work do you week? Oh, work do you week? Right, so you have to stay with me. We'll make some of those vocabulary changes. So how many hours do you work? This, again, you can see that the majority of people work 31 to 40 hours a week. I would believe that many people work more than 19% work over their 40 hours a week. Many people are working in treatment centers that have 24 hour service or intensive outpatient outpatient care that starts at 7.30 in the morning and goes to 9.30, 10 at night. And so the workforce has to have that kind of range of acceptability of working those hours. The percentage of race ethnicity of your client population, we know what's true is that our workforce doesn't reflect our clientele in terms of minority status. So minority and race status. So you'll see, again, these percentages moving from Carcassian to African American to Pacific Islander to Latino Hispanic. And then what is your highest academic degree? Again, you'll see that the majority of people who are substance use disorder professionals now have a master's degree. NADAC started 47 years ago, and it really started out of what you would call today the peer movement. So 47 years ago is people in recovery saying we need to do something for people with alcoholism is what they called it then. We need to do something for people with alcoholism because they're ending up in mental health institutions with lobotomies and electric shock and that's not working really well. So NADAC started with people in recovery really trying to bring professionalism and understanding of what does it take to work in alcoholism and help someone in recovery. And 45 years ago, 44 years ago, NADAC, which is a different name then, worked with NIAAA to do a study to find out what are the competencies, skills, and today we say attitudes that it takes to actually work with someone with a substance use disorder. And the Birch and Davis report came out in the late 70s that basically said these are the competencies that you need to do this work. If you don't have these competencies, you won't be effective in what you do. So we have a long history of what does it take to actually treat someone with a substance use disorder. What best describes your major and then again, you're going to see a variety of different areas from psychology to clinical mental health. Many of us wear many different hats and we have all these initials after our names. So I'm a social worker, I'm an addiction specialist, I'm a SAP, which could mean I'm a substance use disorder professional, it could mean I'm a student assistance professional. I'm a designated mental health professional, I've worked in the mental health field. So it's kind of funny when you go to a conference because you see all these initials and you go, what does that mean? To the public, it's scary, they don't know what that means. And that's one of the issues that I think we have to address because people know what an MD is, people know what an MSW is, people know what an RN is. But do you know what a CAC is? Do you know what a CAC DC3 is? Do you know what a NCAC2 is? We don't know these things and so that further not only stigmatizes the addiction profession, it confuses the public, it confuses payers. What best describes your state regulated licenses? So some of our people come from states that license addiction professionals and most of us come from states that certify. So we have licensure in some states, we have certification in others. We really need to have a national, right, a national certification or a national licensure process because it's all over the place and it's confusing. That adds to the workforce confusion. And why would someone want to come into a career in substance use disorder with that specialty if you don't know where you're going to fit in the whole integrated care system? What is your gender? Actually, I was surprised by this statistic because typically, we see much more females in the workforce than we do males. So this gives you an idea about that and of course age. So some of us are getting a little bit older and you can see by this that a lot of our people are over the age of 40 moving into their 70s. Again, what is your racial ethnic background for the providers, the counselors? People that are providing service and you'll see the majority are Caucasian followed by African American. One of the things that NAIDAC has worked on with other of our partner organizations is to get funding for counselor development and minority fellowship money. So many of the other guilds receive that money and have received that money for decades. And substance use disorder did not receive that money. And so we worked with Congress to get a bill passed so that we can actually train people to come into substance use disorder that either minority or want to work with minority populations. And so this is now in existence for four years. And we have trained up just in this program over 160 professionals that are moving to work in the workforce with minorities. So what are the challenges facing the addiction workforce? Reduce salaries for similar counseling disciplines. So if you have a master's in addiction or you're working in addicted disorders, your pay versus someone with a master's in mental health or social work is going to be less just because you're working in substance use disorders. Benefits often are less than other similar counseling disciplines. Difficulty recruiting for some of the reasons I've already talked about, some more that we will talk about. Difficulty in retention, so turnover is at 50% according to Samson, the first year of service in the first 18 months of service. Part of that we believe is clinical supervision or lack of clinical supervision. People need to be supervised. It is not easy coming into this profession or working with people with addicted disorders, mental health disorders. It's complicated, it's more complicated today than it was 20 years ago, with all the different medications that are out there, with all the different drugs that are out there. Long hours of service, evening groups and appointments, not everybody wants to work those kind of hours. I'll say massive paperwork that still has not been reduced. Even with electronic health records, there is a percentage of treatment agencies in addictive disorders that do not have electronic health records yet. And so 60% of their time on an average is spent doing paperwork versus seeing the client. Why do people get into this field? They want to help people. They want to be with people helping them engage them, helping them work through the stages of change and getting to a place of recovery in their lives. So paperwork doesn't always play into that. Stigma by society in terms of, you work in the addiction, you work with people with substance. How can you stand that? When I was single, here's a personal story, I'll just throw this in here. See if you're awake. When I was single, I would go to go, I love to dance. I'd go out to go dancing, I'm not a drinker, but I'd go out. And of course, I'm going to say, well, what do you do for work? And I'd say, well, I specialize in addiction disorders or substance abuse. Do you know how quick they would either go, I don't have a problem. I just want you to know that, or they'd walk away because there's just the stigma. When I work with a lot of, and I train counselors all around the world, one of the things I hear from them is my family is upset with me that I chose this work. They said, why couldn't you choose something else? Why couldn't you do something else? So we see that stigma even in family situations. So challenges, we talked about salaries, we talked about the disparity in salaries. What do we need to do, recruit, retain, and develop our workers? There's a lot of solutions out there to strengthen the workforce, training in integrated care, scopes of practice, looking at the career ladder, trauma-informed, trauma-sensitive care, cross-training, training the trainer programs, recruiting for nontraditional. We can talk more about this on the panel. We're doing some work with SAMHSA on military veterans and their family members, looking at recruiting them into the addiction workforce. So training the trainer programs are really important to do, partly for what you were talking about as well, Nafali is the issue of people aren't, they may get the education, but they're not trained to do the work. And so they need that training. And then retention and attraction ideas, we're doing outreach to high schools and to colleges, working to build that pipeline, helping people to understand. We're coming out with telehealth capacity, training in a platform, and then of course the minority fellowship program. And then working in evidence-based practices, how important that is so that people really understand how to do that. We do a lot of work on independent coursework, face-to-face training. And products that help people understand. So the conflict resolution recovery is really about changing the brain in recovery. And how do you build those neural pathways from the limbic system to the frontal cortex, so that people really understand what their addictive disorder is, how they change that. You'll see co-occurring, basics of addiction, SBIRT, and then MAT for alcoholism and MAT for opioid. So that just gives you an idea of some of those things. Lots of new areas to practice, and thank you so much. I'm down to eight seconds. So forgive my limping. I am recovering from a broken ankle from a summer adventure climbing Kilimanjaro. So happy to share how to not do that if you choose to have that be part of your bucket list. So I'm just glad to be walking on my own two feet. So I'm really glad to be here. Thank you so much for inviting me to speak with you. This has been a really exciting conversation. And I look forward to the questions and the dialogue with you on this. I am feeling a little overwhelmed. This is kind of depressing up till now. So as a resilience researcher, I'm going to really focus on solutions. Because most of the problems have been laid out, and I agree with what everything that has been said. So I'm hoping to kind of share some nuggets of ideas of maybe where we can think outside of the box that we have kind of created with this issue. And maybe in the dialogue, we can discuss that further. So as mentioned, I'm at Atlanta at the Morehouse School of Medicine at the Kennedy Center for Mental Health Equity. And I have a personal vision for mental health equity that I'll share with you. That is a future where everyone can get the help that they need for their mental health and substance use disorders when they need it in settings where they feel welcomed and safe. And for this future that I hope that we all can live in one day to happen, I think we need three things for that. The first is that people need to have confidence that their inherent dignity is not going to be violated when they go to get help. That's a really big problem that reinforces stigma, that makes it very difficult. Because until you have a problem, you don't really care about these issues. Let's be honest. I mean, there's a lot of conditions that you'll never have and maybe you care because it runs in your family. But mental health issues and especially crises is not something that you know how to do until you have to do it. And then it's really hard because of the nature of the problem. And then when you finally get over all of the things you have to get over to make that first step to get help, and you come across barriers, no one can tell you what to do. They're telling you to call these numbers. I mean, I just got a call last week on my office line from someone trying to make an appointment to see me. I don't know where they got. I stopped calling these people back because I just felt bad. I don't know what number they're getting or why they're calling me. I only see patients at the VA at the Women's Center and telepsychiatry at a primary care clinic at a public hospital. But I get calls a lot from people trying to get care. So we need to find ways to create that confidence so that people can feel like when I need help, I can get it in a place that's going to actually be helpful to me that's gonna understand where I'm coming from and give me what I need. So that's one thing I'd like us to work on. The second is knowledge. And we talked a little bit about this, that accurate knowledge about what's out there in terms of mental health disorders, what's there in terms of treatment, what we know works, what doesn't work. That has to be like common knowledge. We can't hold on to the secret special knowledge that makes us feel good about ourselves while the rest of the world suffers with lack of knowledge. Until there's accurate information in our schools, in our public service systems, what you see in media, what you see when you watch your favorite show on TV. And this is getting better, thank God, right? It's getting better over time. But we really have to work harder to make sure that accurate knowledge about these conditions and their treatments are common knowledge to everyone. And the third thing is that this has to do with my interest in how people actually get help for mental health treatment. It's like a personal face-to-face eyeball to eyeball type process, right? It's not like getting referral for who you think is a great dermatologist or in my case, who's a great orthopedic surgeon as I was in Africa posting on Facebook like I would like to schedule my surgery right now. I didn't really need anything other than someone telling me, hey, this is a good person. But when it comes to struggling with mental health conditions, you need access to a personal social network. Now, I'm not going to put it on blast if I need a mental health provider, right? I'm not going to post that on my social media sites. I'm going to need someone that I trust that I'm going to disclose that information to who's going to walk me to that next step. That person also hopefully can recognize that I'm not at my best, that can say, hey, what's going on? Little concerned about you, what do you need right now? So until people have access to that personal social network, we're not going to be able to solve the issues related to the needs. So that's just my three wish list. I hope everyone adopts that and thinks about how they might advance those things in their work. So with my time, I'm going to just share a couple of thoughts about things that haven't been mentioned today, but I think are really important to the discussion. The first that I didn't hear mentioned yet was measurement based care. So who has heard of measurement based care? All right, we're like three quarters of the room, that's good. So just for everyone else, measurement based care is the use of usually patient reported outcomes or validated scales for the use of assessing how a person's doing and monitoring care at the level of the individual patient. So it's a tool that I would use when I'm working with someone to figure out how you're doing, not just by asking that question. This solves a lot of the debates around what model of integrated care is the best one. I've seen sites go years debating, should we do PCBH? Should we do collaborative, like seriously, do something, do nothing, but add the PHQ9, you know, like start somewhere. So until we kind of, and this is speaking to us as a profession, because a very low percentage of behavioral health professionals use measurement based care in their practice. Personally, I find primary care a little bit more excited about this, because they know that they don't know what they're doing and like we don't really know if someone's getting better or not. So they welcome this tool. But in fact, I found it personally very helpful to my work and the data shows that it really helps inform as a data point, not as a directive, but as a data point to know, are you getting better? But most importantly, preventing clinical inertia where you think someone's doing fine and you don't realize it until they're falling off the rails. So there's measurement based care has now become more of an accepted way of comparing across disciplines, across treatment settings, because what matters is that patients are getting better. This is a principle that you can extend to peer environments, you can extend to community environments and faith based initiatives. There are all these creative solutions that people are coming up with, which we need, because there's a continuum of mental health care. Unlike diabetes, everyone hopefully woke up today with mental health, some percentage of it. We all have mental health and we are all vulnerable to threats to that mental health every day. So there needs to be a very broad continuum of care. But if I can go online and check out, hey, I can download what's my M3 and get a number to say, how am I doing today? That's helpful for me to know just as a person, regardless of what my mental health needs are. So that principle of measurement based care is really important. The other thing that we touched on a little bit, but I'd like to say a little bit more about has to do with who is the workforce? We've seen a couple of lists so far of who's considered the workforce. And I think about things like over 10,000 individuals graduate with undergraduate degrees in public health. That's a pretty big workforce. What are we doing with them? Probably not a lot, but how many people go into psychiatry? How many match in psychiatry? Like 700. How many get doctorates in psychology? 6,000, that's good. But how many of those are researchers versus clinicians? How many of them think population health versus traditional models of care? It starts to little down. But if you take a whole new group of people, like public health professionals, and you show them the numbers on suicide, you show them the numbers on co-occurring, depression and public health outcomes, I bet you can get those young people fired up to care about behavioral health. And where could they fit into our models of care? I know that there are barriers. There's reimbursement barriers, there's policy barriers. We've talked about a couple of them, but there's also great spaces for innovation where we can kind of play around and maybe create a different type of workforce that might be good to address some of the people on the different parts of the spectrum. Because you have individuals with severe and persistent mental illness, they have different needs, different needs than other members of the population that have mild to moderate depression or a relational difficulty that if left unaddressed will progress to major depressive disorder. So if we want to really move upstream to be able to prevent what we think we can prevent by offering care, I think we have to move beyond our definitions today of our workforce. And I also think we need to move beyond the health sector, which sorry, because I think what 48% of you are representing the health sector, but I kind of think we're a little bit at our peak in terms of what we can do, right? So who else cares? Who else should care? I think employers should care. Department of Labor, they should probably care. Department of Transportation, they probably care. Department of Education, it requires a multi-sectoral solution to really provide some of the foundation that we need. Like we're not gonna get the pipeline open enough in time, it's just not gonna happen. And yes, we should train existing professionals to work in different settings, but we all know who have done it how hard that is. We should still keep doing it and try, but that's not really gonna move the needle. And yes, we need to change the way in which we're training new professionals, and we are. But for people that are suffering from these conditions, they can't wait. They really can't wait for these types of solutions. So I just have placed a lot of hope in the younger generations of folks that aren't jaded, that haven't been doing this work forever with all the barriers to say, bring your new ideas. And for those of us in the health sector, where can we create opportunities for innovation to occur? And that's where I think measurement-based care is our common ground. So try anything and measure it. And if it makes you better, okay, let's consider how could we bring this to scale. I have four and a half minutes left, so I guess I'll say a little bit about culturally-centered care, because that's also a very important aspect to thinking about how people get help for mental health and substance use disorders as well as the difference between what you need for cultural competence to function as a primary care professional versus what's required in thinking about behavioral health. So engagement is like a constant process in this work. It's not just important to get people into care. It's important to get people to stay in care. It's important to get people to remain in remission when they're faced with the constant threats. And so that quality of being good at engagement, some people have natural skills. I think that's a little bit of what Neftali was speaking about in terms of your personality kind of matters. I grew up with a primary care provider as a father, so that was kind of my life growing up when I became a psychiatrist. Well, before that, I was in medical school and I didn't know what I wanted to do, but I did know that I did not want to be a psychiatrist. I said, I'm not going through four years of medical school to be confused with a psychologist. I mean, there's a direct quote. I think I even published it in an article. It's kind of embarrassing now. But like full circle later, because I saw my first patient, I'm like, whoa, like this is really, this is really something.  Really? Wow, you don't seem like a psychiatrist. That's like the best compliment. I love that. So, but that identity is important as well. But having grown up in primary care, when I was working in primary, I have worked mostly in primary care, integrated care settings, and it's just, I think it is mostly my personality that allows me, I'm flexible, I understand primary care, lingo and health. I didn't have to be taught a lot of things because of my background. Similarly, when you think about cultural competence and cultural humility, you're gonna get a group of people that don't really have to be trained. How do you get those people in behavioral health? Well, you train them. You train people that live in rural areas because they're more likely to go back and practice in that area than someone who grew up in a city. You wanna get a diverse workforce, have a pipeline for people from that racial or ethnic group because the studies show they're more likely to go back and serve in those areas. So, we already know the research has already been clear about how you can address it from that perspective. But what about the rest of us? What about those of us that are here? And I recommend that we think about adopting cultural humility and think about how we can leverage other cultural brokers, other members of the team to help us to really speak both languages, whether that's gender issues, race ethnicity issues, or otherwise. So, I like to leave a couple of minutes extra because I love the conversation and I look forward to discussion. Well, thank you all three of you for your excellent presentations. We will be opening up for questions, but I just have a couple just to start things off a little bit. For Niftali, you talked about increasing the flexibility of the way we see ourselves, the professionals already in the field, in terms of being able to go with the flow in a way. Where do you see some of that professional identity? Where is the best place that you see that changing? At what point should we start to think about redefining how we see ourselves? Well, I honestly advocate for before undergrad. So, part of the issue is that we're creating a new space for folks and so we need to draw people who are gonna be naturally drawn to that. So that's one of the issues right now. We're marketing for a profession, say, hey, you wanna be a therapist? Come to school to be a psychologist or an LCSW. And so then people who are drawn to that concept, that idea of sitting down with a patient in an office, having their own private practice, are going to then attempt to engage that career. So, if we were to, for example, have it be standard practice, say on a television show, Grey's Anatomy, right?  Then you have people saying, hey, that's what I wanna do, who are drawn to that. So we really do have to create this sense. This happened with emergency medicine, actually. Emergency medicine is one of the newer medical specialties. My wife is an emergency medicine physician at UNC. And in the, I think it was the 60s, a show came on, and I forget the name, I think it was called Emergency, and it highlighted the work of the emergency department. And that really was part of what Catapult did emergency medicine as a specialty, because people were like, hey, that's really cool, doing this special thing. Before that, you had psychiatrists staffing the emergency room and things like that. And out of that, you grew a sort of a desire on the part of the workforce to do the work. Right now, we're so downstream that we have to sort of randomly catch people who happen to fit the criteria for working in an integrated care setting and love being part of a primary care team. So it really does happen at that point. Now we are not to be totally negative because we've made progress where there's more fellowships, there's more internship opportunities. The other sort of, I think, not simple because it takes money, but one of the other solutions we can do more downstream is create parity in training resources between medicine and behavioral health. So if we at least had the ability, for example, to have postdoctoral trainees be reimbursable as medical residents are reimbursable, if we had parity like that, I think we could do a great deal to spurring some of the pipeline issues and spurring interest as well. I just wanted to ask you, Cynthia, you mentioned nontraditional ways of addressing the workforce issue, specifically with the vets. Could you say something more about that? So one of the things that we found is that a lot of veterans that served in military overseas have other addictive disorders or abuse disorders along the way of drugs or alcohol and coming back, feeling that they want to change that, looking, their family members sometimes helping to spur that, to get them into treatment and those stages of change, they then get interested in, well, how do I do that for myself and then how do I do that for my buddies, the people I served with? So there's that very strong connection when you've served in the military to help your military buddies and to help them do better when they come back. There's also a job shortage, obviously, for the helping professions in general and the opportunity to look at that workforce and bring them in, I think, is really important. Interestingly enough, we just had this meeting, I want to say, six weeks ago, where we also were visiting with the spouses of the military and many of the spouses, of course, recognize these issues and many of the spouses have gone, started into college programs in the helping professions and so they're saying, now, how do we get keyed in? How do we get hooked in to one of the disciplines or to a variety of the disciplines? How do we do that? And so this is an untapped resource that we're really looking at, how do we engage them? How do we create programs when they come home? They need to be programs that are short-term to get them involved and get them hooked in. So we're looking at one-year programs, two-year programs, that bring them in the door and then continue their education as they move through the systems of care. So I think it has promise. You're helping to serve the military that are coming home, the veterans that are coming home. You're helping to serve families and it also helps them with their own disorders. So you're really doing both and I think many people have post-traumatic. It gives them the chance to work on that too, intellectually as well as emotionally. Thank you. We talked, or you specifically, Linda, talked about broadening who are the mental health providers if you like, who is the workforce going to be in the future. How do you see that kind of evolving? How do you see that actually being implemented and what are some of the barriers to that? Yeah, I mean, I think there's a lot of different ways you could implement that type of a vision but not without really appreciating that spectrum from that person that's doing well but failed a test and is really upset about it and depending on their family environment that might really trigger a serious functional problem to the person that's first year freshman in college and started hearing voices and not sure if people are out to get them. I mean, that whole spectrum needs to be thought about as we think about workforce. I think often when we have these conversations, it's like either or. Like either you care about the SMI population or you're for all those other people that don't really need help. I just reject that soundly and say it's and, it's and until we adopt that we're still, we're fighting ourselves on the stigma is still gonna be there. So I try, I don't personally focus on the guild type conflicts cause I feel like other people have that covered. I just, I let them focus on that cause I'm really interested in these things that we haven't tried yet, like public health, whole different set of levers that you can pull in the public health field and the history of public health is another example of something that evolved out of necessity. Something like, oh, handwashing that helps. I mean, that was transformative. What's our handwashing? You know, we're not gonna probably figure it out. I think we're too deep in to what we're doing to really be the change at that level. So we need to kind of open our arms a little broader in order to do that. Great. Now it looks like we have a few questions from the field but just, I have just one quick one. As we're moving to more integration with primary care and I think that's definitely the trend and you're certainly at the forefront of Tyler, of doing that. What do you, do you ever come across barriers, for example, with perhaps primary care feeling like, well, I don't wanna do that. That's not my area or, you know, that belongs to Tike and I don't wanna touch it. And how do you address that? Yeah, there are barriers. Typically the barriers, however, are a result of sort of the ways in which we might promote what we're asking primary care to do. So primary care is maxed out. I mean, that's the one thing that you ought to understand. Primary care doctors are at their max. They're clicking thousands of times a day and having to go in and out of patients having long work hours. So going in and saying, oh, and by the way, we want you to prescribe Suboxone and we want you to take care of all the other mental health issues and we wanna take you to take care of the social determinants of health and do it in a trauma-informed fashion, right? I mean, that's absurd. It's patently absurd to expect an individual professional to do all of that. So I think the resistance typically occurs when, A, you either have a really burnt out professional who just cannot take another thing on their plate. Or, B, when we go in and we're saying, we're gonna ask you to do one more thing, right? So I never go into a place and ask my primary care providers to do one more thing. I say, what things can I take off your plate? Here, the category of things I can help you with in your day that'll help you get to the end of your day in a smoother fashion. And I think when we adopt that kind of approach, we have a much higher success rate. Are there folks who are more predisposed? Primary care providers are more predisposed to this than others? Sure, that's fine. There's always gonna be variation. But I think, frankly, when you go in with that approach, I haven't seen a primary care doctor yet who said, no, I don't need help going through my day. Very good, I like that answer. We're gonna open it up. It looks like there's a number of people. So would you like to go ahead? Yeah, Nathaniel from Mental Health America. And it seems like kind of partly what everyone's describing is there's a Venn diagram right of like, here is like health and everything we know about that affects it and all the evidence we have today of the determinants. And then here's a circle like, what everyone's doing at work in healthcare. There's some overlap, but in the interstitial is like this complex web of policy barriers and professional identity issues and then competency problems. And part of the dream it seemed to me of like the National Academy of Medicine's proposal on the continuously learning healthcare system wasn't just perhaps that everyone got better at their roles, but if you implement continuous learning at a systems level, like people's roles would actually change and adapt. And the goal would be to, I guess, close the barrier and make it less of a Venn diagram and more of a total circle. And it seems to me there's a lot of problems with like methodological and research, like how do we implement continuous improvement at a systems level. And then we have like a Medicare physician fee schedule which does not change quickly and it makes it very challenging to do these things. And then, oh my God, pre-service training, I don't even, seems like a rudder to the ship. I have no idea how you direct to what people do in school and everything. So I'd love reflections about how we get from here to there. Well, I'll take a quick stab at it and just say that, you know, although, and you did a great job of detailing all those pieces, it feels complex on the big meta level. On the ground level, I can tell you, it's actually not as complex. Yeah, because, for example, what has happened to me in 17 years of working on the ground with my primary care colleagues is that I am better at what they do. I am dangerous, I'm dangerous as a primary care physician. I wouldn't, you know, trust my judgment as a primary care, but I've been in the milieu enough to kind of understand the logic and algorithms that primary care providers are thinking through each day. So I'm better at the stuff that they do. And because they are rubbing shoulder with me all day long, they're better at what I do. And I think that's part of the organic solution is that if we break down some of the walls that divide us on a day-to-day level, and I mean that also on the sort of public policy end as well, where, you know, on the ground, primary care is not positioning itself as saying, well, we answer everything, including housing issues, food issues, all this stuff. No, there's a recognition on the ground, hey, when I see a patient, I don't have all the answers. I maybe have 15% of the answers for this patient. The other 85% are community-based, right? And so when you're on the ground and you say, well, I need to be near the people who are solving that other 85 because I'm not gonna make headway with the 15 that I got, right? So, and sort of this may sound simplistic, but what we've learned in integrated care applies in that way too. What we did is we put a mental health professional to be in the setting and change the way they look at who they are so that they can fit the needs of that setting. In the same way, if we kind of follow that same attitude, we create relationships across a continuum, each of whom get better at what each of them do. So in a month, I'm gonna have a meeting with someone from the local food bank in North Carolina because they wanna learn how to get better at behavioral health. Ah, how about that? A food bank who wants to get better at behavioral health. You see that overlap there? Because they have folks coming in with food issues and they wanna know how do we get this food to the folks who have these behavioral health issues that may keep them from getting adequate nutrition? So that's the kind of thing on the ground that works really well. And it's a lot less complex when you're on that level than it is, I think, on the higher up levels. So hello, my name is Alma Roberts. I'm in the community health department for this region. And in our Baltimore region, we have a barbershop in beauty salon initiative. So a beautiful segue from your discussion. How do we tap into that network of trusted confidants that exist in our communities? How we do that and how do we build their capacity to be our first line of response? I can address that briefly. So I think that definitely extends along the lines of education and our roles as leaders, as behavioral health professionals, part of that identity should include a community service component where we are going out to churches and giving lectures and giving information where we are in our communities, visible in our communities. That is desigmatizing to personally know a psychiatrist that's not weird. It is helpful to have that as part of your life in case you need one. Similarly, you may not know what all these initials are after people's names, but if you know someone that's talking behavioral health and speaking about it, then if you have a friend that has a problem, you're probably gonna be, you're gonna call that person, not even knowing whether they can help you. I have a medical student that just got a grant from the APA Foundation to do a barbershop initiative. So I think especially in certain cultural communities, there's so much mistrust towards systems in general.  So you have to earn trust. So one way we can do that is by going out into the community and not requiring people to come into our four walls. That's just, that's something, I just think you have to make a personal commitment to that. I think that's just like, if each person made a personal commitment to give back to their community in that kind of way with some regularity, if we just started that today, I think there would be a lot of change in the way knowledge is diffused into our communities and the way stigma is thought about. I'll go a little bit beyond that. I think there's a personal commitment component, but I think it's also something we can do as far as professional identities because you have medical schools that have renamed over the last five to seven years, such and such medical school of public health, right? Or population health. It's an intent to change the identity from, hey, I'm a physician or I'm a psychologist and my job is to see this one person in front of me to a sense of belonging to the community and frankly, belonging to the larger health system in the United States and having a sense of responsibility for that. That's one of the things that happened to me when I entered primary care. My professional identity changed where I felt part of the health system. I don't really think that many mental health professionals feel like part of the health system. They feel like part of their own practice. And that's a really different way of thinking about it. So if you do that, think that way, then extending out to the barber shop or to the neighborhood leaders or things like that makes a whole lot of sense because you're part of something bigger than just your little corner. Let me just add something to that as well. It is that community-based building that is important. There are some programs across the US that do that. There used to be funding at the local level for that kind of work where you would do community outreach and you would do community education and do it from elementary school to the police department. So we need that kind of ability. That's a policy and a funding issue that years ago was a policy that you did community outreach and you did community education. And so those silos, even the criminal justice silos got created with less ability for that interdisciplinary and trans communication. And I think those things would be helpful because it would cause people to talk to each other. And some of that myth, how do you say that? Myths about who you are and what you do and whether or not you're even a human being gets changed. And I think that we've missed some of that over the years by actually building more silos than causing that interdisciplinary interaction going on. I'll just not to belabor, but just to piggyback off of that whole silo mentality. So part of my concern has been, so we have identified some of these issues in the health system and so we've developed new roles like care managers, right? My concern is that we've just like created a whole other silo of care management, right? And I think part of this is looking at things not in these professional silos, but as functions. So like I as a psychologist, can I do care management? Yes, I ought to know how to do care management. I do, I call patients up, I look at registries, I do things like that, right? And so if we think about funding things, we wanna, I think wanna think about funding functions, not funding separate departments that just add on onto the sort of the conglomerate of the healthcare industry. Yes, and just to finalize on that, in our training programs, we actually require all of our trainees to go out a minimum number of hours in the community because I think it's such an essential part of their training and again, we're trying to broaden their view of themselves along the lines of what you're talking about. We have, we'll have a few people here. Go ahead. Linnea Koopmans with the County Behavioral Health Directors Association of California. So as a result of the state legislation that was passed last year in our state, there is a work group that's charged with developing recommendations about implementing a screening for trauma system-wide in our state Medicaid program. So my question's broader than screening, but really about what's needed from a workforce perspective to prepare our professionals and providers to implement trauma-informed care from a, that's also culturally competent and with the goal of decreasing disparities. Well, I'm working with the Kaiser-funded project on trauma-informed primary care. They're just now started with a learning collaborative of several sites that have been working in that type of a format to adopt trauma-informed practice. And I didn't speak on that with my time, but I do think that that's another example similar to measurement-based care as a broadly applicable set of principles that just are good for people to have. Whether or not that's a trauma-focused treatment or an evidence-based intervention for PTSD or just a set of guidelines around patient voice and choice and those types of principles that will cause shifts in how we approach our work. So I think there can be a lot of challenges in implementing trauma screening as like a thing in and of itself that will often cause great distress and difficulty to the individuals that are only given that as a resource, but the principles around trauma-informed care are as knowledge that is knowable that we can also use our influence to translate that into communities as well as across the healthcare system broadly, which could greatly benefit from trauma-informed principles primarily towards themselves, right? Because a lot of the, when I work in primary care, when they start to talk about these issues, they realize like, well, I'm burnout and oh, yes, this is actually a huge issue with physicians. So being able to look at yourself in that way is really about healing ourselves as a workforce and something that I think is also really important. I think one of the things that we're doing is really educating around trauma-sensitive and trauma-informed so that that initial interview when somebody first comes in, that person when they first come into whatever treatment setting they're coming into already have a sense of trauma coming in because it's very stressful. And so if people aren't taught at the very beginning of that initial contact, that initial interview, that this person is coming in, their limbic system is ignited and how are you gonna help them move that through to be able to sit in that session to decide that they wanna come back because what we know at least about addiction treatment is 50% of people don't come back. And so if that initial interview is not successful and people are not trained how to make that successful, then people will not be back, we will not be treating them. We say currently we're treating one in 10 people with substance use disorders. And then I agree with you that secondhand trauma has got to be part of that professional development plan for any staff person that works in the helping professions, from physicians to peer recovery support. To receptionists. To receptionists. Right and I was just talking actually about that yesterday that that person who greets at the door is just as important as anybody else in that facility because that person has the first contact. That person answering the phone has the first contact. So if they're not trained in those manners and those methods, so it's not just talking about how do you do that, it's actually training through methodology because people need to see it. I was just in the South Pacific training in the Marshall Islands in American Samoa. The culture, the way that people integrate in community is very different than here in the mainland. And what's really important about that is that they understand through their culture how important it is to make that initial contact. And it's, it just hit me like, oh my gosh, we taught that 30 years ago and we're not teaching it anymore. So these are important, I think, pieces to remember about that. You have one more question? Ron Manderscheid. So I want to put a pin in a couple of things that have been said here, particularly what Glenda said, that I hope we have the courage to redefine the problem, do some disruptive innovation and move beyond our traditional argument about the need to fill slots here of people. Population health management has huge potential moving forward. The integration of our work into communities and the social and physical determinants of health has huge potential for us. The Surgeon General is getting ready to do a report in this area. We need to be at that table. And if we spend too much time working within our group without doing appropriate outreach, we will miss the ball here as the ball passes by. So I want to thank Glenda for making those particular comments. I'm Denise Doherty. I'm a senior scholar in residence at Academy Health and also working with a group called Adolescents and Children Together for Health. So you can see where my question is probably going. 40% of the mental disorders emerge during adolescence, whether they're recognized or not, 60% of adolescents who need mental health services don't get them. So I wonder if you could talk a little bit about adolescents and the workforce and how you deal with that issue. So there are good, children and adolescents are a good example of the many links in a long chain that need to be functioning adequately to both foster normal, healthy development and to catch issues early when things are not going right. So I represent sort of the primary care side. So we are just one link in that really long chain. So what we would do at our setting is hopefully adequately screen folks in that setting. I would be part of, for example, a well visit along with the physician. And we would be asking questions that help us be attuned to the child's environment, to precursors of certain issues that may develop over time. But we're just one link in that chain. So we need folks in the school setting to be part of that. We need folks in the church setting to be part of that. And so, yeah, that's my quick answer to that. I'll take that back to what I've been saying about getting into the community.  So one of the programs we have at our center that we're very proud of is our smart and secure children parent leadership development program, where we're taking all the research and knowledge about positive parent chain that can be delivered in a primary care setting, but can it be delivered in a culturally centered way? I'm not so sure. But we train individuals from underserved communities to be able to deliver this knowledge in a way that feels authentic to them. And then they support other parents. We've been doing this for about 10 years now. It was initially funded by SAMHSA, and now we're in 13 different states. And it has really been a really wonderful way of thinking, how do you translate medicalized knowledge into ways in which you can transform communities? And on that note, I'm sorry, we're over time a little bit. So we probably have to finish up. But I want to thank all of our panelists today. I think it's been a very interesting, thought-provoking discussion. Thank you.