BTM71 Transcription

Welcome to Episode 71 of Behind The Mission, a show that sparks conversations with PsychArmor trusted partners and educational experts. 

My name is Duane France, and each week I'll be having conversations with podcast guests that will equip you with tools and resources to effectively engage with and support military service members, Veterans and their families. Find the show on all the podcast players by going to www.psycharmor.org/podcast.

Thanks again for joining us on Behind The Mission. Our work and mission are supported by generous partnerships and sponsors, who also believe that education changes lives. This episode is brought to you by PsychArmor, the premier education and learning ecosystem, specializing in military cultural content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations. You can find more PsychArmor at www.psycharmor.org. 

On today's episode, I'm having a conversation with Dr. Michael Genovese, Chief Medical Officer of Acadia Healthcare, the largest standalone provider of behavioral health care in the United States. Acadia operates a network of 238 behavioral health facilities in 40 states and Puerto Rico. Dr. Genovese co-founded the multidisciplinary medical practice, Long Island Mind and Body in New York while practicing as an attending physician at NYU Winthrop University Hospital. Before beginning his medical studies, Dr. Genovese earned a Juris doctorate degree at the University of Pittsburgh school of law. You can find out more about him by checking out his bio in our show notes. Let's get into our conversation and come back afterwards to talk about a couple of key points. 

DUANE: So as a clinician, you have experience in both substance abuse, recovery, and behavioral health, but also have experience in supporting law enforcement community. It'd be great for listeners to hear more about you and what brought you to the work that you're doing now. 

MICHAEL: Sure. Thanks, Duane. I started treating the law enforcement community when I first started practicing psychiatry in New York. A lot of my friends that grew up in New York had gone and gotten jobs in the NYPD. They were officers themselves. They would bring their colleagues to see me, that is a culture in which it is frequently difficult to get people to seek out the treatment that they need.

My friends would tell their colleagues. Don't worry about it. I'll take you to see Mike. They would come in after hours or before hours, they would only take samples. I couldn't give them a prescription, anything to keep it off of their record. When I was lucky enough to come to Acadia, they had law enforcement specific programming.We did a lot of work with the FBI National Academy associates. It grew out, we now do a lot of work with first responders of all stripes. So law enforcement, firefighters, EMTs; all the people who take care of others and are reluctant to ask for help for themselves.

DUANE: And that's very similar to the military and Veteran community.  I know listeners have heard this before. My father is a Vietnam Veteran, but he left, the military and became a St. Louis city cop in the seventies. We don't know where the PTSD from one ended in the other began. And so there is a lot of, then as in now in the military and Veteran community, and there's a lot of similarities between those two populations. 

MICHAEL: They are, what branch was you dad? 

DUANE: So, he was in the Army. 

MICHAEL: My dad was in the Army as well. My dad was a medic before he went to medical school himself. But you're correct. You see a lot of overlap. You see a lot of people, who show up saying they're a police officer, they leave out the fact that they served in the military before or vice versa. What they have in common is that they are generally speaking as a population reluctant to ask for help. They still adhere to that school of thought where it's almost a sign of weakness to ask for help. Other people are able to pull themselves up by their bootstraps. Why aren't I able to do so? So, it really it's incumbent upon us to recognize that cultural phenomenon, among those in the military community and respect that and proceed accordingly.

DUANE: And you'd mentioned that,as you started out in your practice, you weren't specifically working in substance abuse and recovery and things like that. But, I imagine working with law enforcement and especially with anyone working with the military and Veteran population, needs to understand that's a significant part of both population. 

MICHAEL:Yeah, it is. In the military, I think less than 7% of our population has served in the military. It's a very small, tight community. So if you look at things like drinking alcohol, it's common in the military. When you're off duty to use alcohol, to relax, it's common to use it to celebrate. It's common to use it to grieve. Unfortunately, being in the military does not prevent you from the same sorts of problems that can arise with alcohol that can arise in the general population. And, people in the military are, as we said, more reluctant to look for help. So they tend to look for help later on when it's become a problem.

Like you said, I did not intend, I was a general psychiatrist. I was practicing general psychiatry. To tell you the truth, what got me more into the field of addiction was the rise of opioids, which is another common problem in the military. Opioids are good medications when they are used acutely post-surgically or for acute injury.The problem is that people get habituated to them very quickly. They also use them to mask emotional pain. And what I was practicing, it was around 2009 was when the opioid epidemic was really starting to impact, where I lived really greatly. People were sending me people who were opioid dependent because they didn't know what else to do about it.

And I remember seeing patient after patient come and complain to this same thing. And at some point I said, uh, a patient really good guy who happened to be a Veteran. I said, “There's a new medication that is indicated to treat opioid use disorder.” He had tried everything. He tried NA, he tried psychotherapy. He had done all the work you could ask somebody to do.

So this new medication is called Suboxone. I'm going to find somebody for. because you need a special license to prescribe it. I'll find someone for you who is an addictionologist, who can prescribe it for you, and we're going to help you get off of these. And at the time I looked to the county, east of me to the county west of me all over the place.

I was going to have to send this person into New York City from Suffolk County out on Long Island in order to get treatment. So I ended up saying, you know what, I'll get the license and I'll manage it myself. Thereafter, I became the de facto addictions guy on Long Island. It turns out though it's probably one of the most valuable lessons I learned during my career because behavioral health issues that we see in the military, like post-traumatic stress, depression, they often go hand in hand with substance use disorders. So I feel like we really needed to be well-versed in all of these to provide the holistic care that our patients deserve.

DUANE: Yeah, my, one of my mentors, is as we were talking about this, who was a professional counselor, who then became a substance abuse counselor specifically for active duty, he said it's 80 to 85% comorbidity of, if someone is struggling, and again, not just depression, anxiety, or anger concerns or post-traumatic stress, but things like moral injury or lack of purpose and meaning trying to fill that space with substances or manage their chronic pain, that it goes along with that.

And it's unfortunate, but it does. And then taking that experience that you had as an individual practitioner and now working at Acadia. Most people are aware that Acadia is leading provider behavioral health care across the country. But specifically there is a part of the organization that supports the military affiliated population: Acadia’s  Military and Family Support Services. That is a branch of Acadia that really does specifically take this viewpoint of, the behavioral health, the physical health, the psychological, this holistic look at military and Veteran population. 

MICHAEL:Yeah, those individuals are an amazing group of people who work as hard as anyone I know. And what I'll tell you about one of the benefits of being with Acadia is that we're large. We have a large scope. It allows us to exchange ideas across the country. We're in 40 different states. We treat about 70,000 patients per day. Our clinicians speak with each other regularly. Our programming on one side of the country can benefit from that, which we've learned on the other side of the country. We've built a strong program with the military family services, because of this collective knowledge. There's not just one person who is the holder of all of this knowledge, it’s a team effort. And we take it really seriously and we've developed specific military programming because it's really important to be culturally aware of what either someone who's active duty, or a  Veteran or a dependent expects where they're coming from in life. Their worldview might not be the same as everybody else's. Someone who is a Veteran, or an active duty soldier or sailor, their primary concern could be existence staying alive. And if you put them in a process group with someone who's gotten very different world views and experiences, those two don't work out as well together. So we've gone out of our way, to develop programming that will benefit each individual patient. And the military programming I have to say is very robust and really takes into account the cultural lens through which our military personnel view the world.

DUANE: And I think a system, the size of Acadia, lends itself to the idea that you have providers that elect to be providers for the military and Veteran service members, because it's not for everyone. If somebody goes to be a provider at the VA, they know that's going to be their population. But I even have fellow Veterans who become mental health providers who say, I want to treat kids, or I want to work in geriatric.

I don't necessarily want to specialize in the military and Veteran population because just as it's necessary to provide the right kind of support for the clients, it's also necessary to provide the right kind of support for the providers supporting this unique population. 

MICHAEL: It really is. I think you certainly make a choice. It's a decision to work with the military population and people are passionate about it. And, we talk about ideas of either secondary trauma, because the stories that they hear from Veterans or active duty, are very different than people who are working outside of that community.

And we are lucky to have people who are devoted to that work. And we also have to be mindful to take care of them as well. You're a clinician yourself, you know how you can be affected by those you're that you're charged to help. So we have to make sure I tell people all the time, you're not getting any good to anyone unless you're okay yourself. So we do a lot of work around trying to keep each other healthy. 

DUANE: And I think again, there's that idea of being able to provide that wraparound support. It's not like it and again, it is almost the diametic posed of a small two person practice in a city somewhere, but I can also imagine that just as we were talking about the complexities of the needs of service members, Veterans, and their families, that Acadia has a range of services where it's not just for example, outpatient psychotherapy, there is medication management and it can all be wrapped into together. 

MICHAEL: Absolutely. You can go to one of our programs and you could be getting medication management, you could see one therapist for EMDR and a different therapist for DVT, and another for accelerated resolution therapy and on, and all sorts of programming. That is evidence-based that we know that works specifically for the population we're treating. And I will say this also, we have to keep the mind that when we say we have a military program, we can't think of people in that program as a monolith, even within that small population, each individual patient is different. Each person is different and brings something to the table.

One of the first things you ask people is what branch were you in? People who don't work with military populations might not even think to ask that question. So there are so many things that you have to take into account, when you're dealing with this population.

DUANE: And so that's one thing that I've always valued about the clinical space. We have the clinical training, trauma informed care, regardless of whether that trauma is as a result of combat or a vehicle accident, or adverse child experiences and so on. And so we have the clinical training, but like you said, it does take some specialized training and understanding to support this part of the population, just like it would for, as you said, first responders.

And that's something else that Acadia healthcare has recently made sure that in addition to the clinical experience, we're providing that cultural competence training. When you partner with PsychArmor, you provide Veteran ready training to locations across the country that provides support to the military affiliated population. 

MICHAEL: Yeah, I have to tell you how much people actually enjoy the training, which is very rare to say, when you're talking about health care personnel, it is usually completely obligatory when you say we want you to do this sort of continuing education. The PsychArmor training, I tell people, is as interesting as any documentary you're going to see.

And you learn with it, I did it with our staff while we were doing it. Each module we would watch together. You would feel about 50% more informed than you did before you started it. And to a person, our clinicians telling me, I used something from that when I would speak to them about it later.

And I do think that you're right, you really need to be culturally competent. That's not just a phrase, that's actually a way of practicing because if you're not, people can see through it. It's not something that you can pretend. It's really been very valuable for all of our clinicians at Acadia.

DUANE: And I think that's one of the things that when people talk to me and even Veterans, talk to me say that, I can't go see a mental health professional unless they are a veteran. There's just simply not enough of us. Those who have served who then go on to be clinicians in the field. There's just no way, but at the same time, me being the retired senior NCO, maybe I'm not the right clinician for this person, who's concerned in the military was their retired senior NCO, you know?

 And so I think this is one of the things that is a good way for clinicians who don't have lived experience or even those with a different type of lived experience and maybe different areas or different services to be able to understand more about, like you said, those unique clients they're seeing. 

MICHAEL: Yeah. Did you hit the nail on the head. There are certainly not enough providers of behavioral health period. Then when you go down to the subset of those who have served, you're really getting into quite an elite group there, but you have this sort of teach the teacher model. So if we can learn from those who have served, what's important, and then we can disseminate that knowledge.

That's the key. We have to work collaboratively. We have to continue to be curious. We have to be purposeful in our desire to learn and then translate that learning into healing. And I feel like, what the people at PsychArmor have put together is, it's a perfect vehicle for that. We're really lucky to have that.

DUANE: And I think the idea of the military as a separate culture. Just like any other intersectional culture. You've mentioned how, especially with the current all volunteer army, how few Veterans there are service members and Veterans and family members. But also it's a measure of, like you said, Acadia looking as an organization with cultural humility, just like we would have cultural humility for any other diverse population saying we don't know enough about this population. We're treating them, they're in our clinics, but we need to be able to learn more. 

MICHAEL: Yeah, I think that we have collectively taken a step back and said, there's no cookie cutter way of doing this. There's no cookbook that teaches you how to treat any patient in general or any culture specifically. So yeah, to your point, the military culture is one of a number of cultures that we have to educate ourselves about.

I think gone are the days where wearing the white coat can noted that you knew everything and that you were done learning when you left school. I referenced that my dad was a doctor and he told me if you ever think that you're done learning, it's time to hang it up. The opportunity to continue to educate ourselves so that we can treat our patients holistically.

And I don't mean holistically in the sense that we're using herbs and those sorts of things. I mean, holistically treating the whole person, body, mind, and spirit. They all do come together to advance healing because a lot of the patients that we treat, this, we can't cure.

Absolutely the way you would, if you set someone's broken arm and then said, okay, it's fixed. But I do think that we can all get behind the idea of a road of healing and reaching a better place. 

DUANE: Yeah. Absolutely. And it's not just treating illness, but it's actually helping service members, Veterans and their families build better lives, going on the other side of that trauma. Mike, I think this has been definitely great. I'm sure our listeners, we get a lot out of this conversation. If people wanted to find out more about Acadia Healthcare’s Military and Family Support Services, how can they do that?

MICHAEL: Oh, so there is some great information, right on the website. If you go to www.acadiahealthcare.com, the military has a section of its own. Just click right on that. You can do that. People are certainly welcome to email me directly. I can provide you with my email address if you want to put it up. We are devoted to helping as many people as we can. We want to thank people for their service. And we think that the people that have sacrificed the most certainly deserve the greatest care they can get.

[00:15:52] duane---he---him---his-_127_05-17-2022_160243: Absolutely. And, and that is, uh, on, on behalf of a fellow clinician that's appreciated. And I know on behalf of our listeners, thank you so much for coming on the show today. 

[00:15:59] michael-genovese--he-his-_1_05-17-2022_180243: Thanks for having me, Duane, my pleasure. 

 Once again, this show is brought to you by PsychArmor, the premier education and learning ecosystem, specializing in military culture content. PsychArmor offers an online e-learning laboratory that's free to individual learners as well as custom training options for organizations, you can find out more about what they're doing at www.psycharmor.org. 

The first point that I'd like to talk about is the stigma against help seeking the Doctor Genovese described as being a hallmark of both military and first responder culture. Just as it is in other cultures and society in general, especially when it comes to help seeking for mental health conditions. 

The stigma is certainly changing both in the military and Veteran space as well as generally, but many people still speak in whispers about the places that they go when they're in psychological distress. Psychiatric hospitals are still derogatorily called the loony bin or the nuthouse. 

The reasons for the lingering stigma are not just related to traditional machismo, ego or pride. There's a very real concern that psychological distress could mean that the service member or Veteran are not able to do their job. And that they're not able to be trusted, that they're not even able to trust themselves. 

There's a fear of not being able to engage in activities they enjoy or something that brings value to their lives. The simple truth is military service is inherently dangerous and with that danger comes psychological stress. With psychological stress comes the need to address it. The military community will not effectively address it without reducing the stigma against seeking help. 

A 2014 study by the Rand Corporation identified a number of priorities in developing stigma reduction programs. 

A significant focus is for organizations to move beyond reducing stigma, to increasing treatment seeking behavior. Number of their recommendations include decreasing the impact of stigma, meaning while there is a concern that mental health conditions may lead to being “benched or sideline”, reducing the impact of stigma means not doing that. Other recommendations include increasing peer support and changing the wider culture of the military and Veteran community towards seeking care. In addition to these, there are two points that the Rand report recommends that specifically applied to my conversation with Dr. Genovese and Acadia Healthcare’s Military and Veteran Family Services. Those are changing their perception about the effectiveness of mental health care and reducing barriers to that care. 

Not only does the broader society have concerns about the effectiveness of mental healthcare in general, the military and Veteran population have concerns about the effectiveness of mental health care specifically in that maybe it works for some people, but I need someone who can understand my unique circumstances. I need to talk to a therapist or provider who served themselves. Or who has worked with Veterans before. By taking the time to ensure that their providers understand military and Veteran culture, they are certainly increasing their own effectiveness in treating this population. But they're also changing the perceptions about that effectiveness. 

We can improve something all day long, but if the perceptions about it don't change, then the usage doesn't increase, which is a barrier to care. 

When a service member, Veteran, or military family member knocks on a door to seek mental health care, whoever's on the other side of that door needs to be ready to answer it and provide effective care at the lowest level possible. Part of that affective care is understanding military and Veteran culture. And it's great to know that Acadia is taking steps to develop that understanding. 

The other point that I'd like to make is something that Dr. Genovese mentioned how service members, Veterans, and their families see the world through a different filter than others do. As true for any one of course. We see and interpret the world through the lens of our own experience. Those who live in a city, have different experiences than those who live in small towns. And those who live in different cities like New York or Los Angeles have different experiences from each other. 

But the military and Veteran lens, that many see-through is laid over the top of other experiences. And as a combination of internalized values, ingrained discipline and exposure to challenging, and sometimes even traumatic events. This can consciously or unconsciously trigger memories and behaviors that are unique to the military and Veteran community. 

Here's an example. A number of years ago, I was sharing a shuttle to an airport and I saw something that immediately tripped a memory from years before. I'm not talking about a flashback necessarily, but a weird sensation of the past overlaid on the present. As we were driving through the low industrial buildings that surround many airports, I saw a tight ball of dense black smoke in the middle distance. It could have been something like a fire or maybe the exhaust of some heavy machinery starting up. But it was big and it was pretty noticeable. The driver and the other passengers didn't notice it though. And it didn't interrupt their conversations. I on the other hand was instantly reminded of an incident in June of 2009 while stationed on the Jalalabad airfield and regional command East Afghanistan. And my memory that tight fist of black smoke was the remnant of a controlled detonation of a recently discovered cache of unauthorized explosives and munitions outside the base. 

When a pile of explosives is located explosive ordinance disposal specialists usually use their own explosives to destroy the find. And what's known as a controlled debt. As a matter of fact, when I looked over to my right and I saw that cloud, that exact phrase leapt to my mind controlled debt. 

All of us in the shuttle that day saw the same thing, but the meaning of it was different to each of us. That's an example of the Veteran filter. 

 It's important for those who are working with Veterans to understand that filter, especially if you're working with Veterans in a meaningful way. It wasn't important for the shuttle driver that day to understand my Veteran filter as it had no bearing on my need to get to the airport or his need to get me there safely. 

But when it comes to helping Veterans get mental health care or housing or employment, understanding the Veteran filter can be very important. Again, it's great to know that Acadia is taking steps to help their providers understand that lens through which service members, Veterans, and their families see the world. Hopefully you enjoyed my conversation with Michael. If you enjoyed the show, let us know, drop a review in your podcast, player of choice, or send us an email at info@psycharmor.org. 

For this week, PsychArmor resource of the week, I'd like to share the link to the PsychArmor course Substance Use Disorder In Military and Veteran Populations. 

As Dr. Genovese has a background in treating substance use disorders and we touched on it briefly in our conversation, this course is one that is specifically designed for healthcare providers and helping them understand how substance use disorders can be identified and addressed. You can find a link to the resource in our show notes.