Mar 15, 2021
Data Never Lies: COVID on my Mind Part 2 — Interview with Dr. Katie Hale, Post-Doctoral Resident at the Emory Adult Outpatient Psychiatry OCD & Anxiety Disorders Intensive Outpatient Program
Georgia has some unique challenges regarding mental health. The pandemic has brought to light issues to which people working outside of mental healthcare have limited to no knowledge. My goal is to help increase awareness and encourage discussion about mental health in the state. The best way I know to do that is to talk to people working in mental healthcare and let them give their perspective. In the first interview of this series, I talk with Dr. Katie Hale from the Emory Adult Outpatient Psychiatry OCD & Anxiety Disorders Intensive Outpatient Program. To set the landscape of our discussion, let’s first look at the state of mental health in Georgia.
The Data — What is the state of Georgia’s mental health?
According to the 2021 State of Mental Health in America report published by Mental Health America (MHA), Over 47 million adults in the US have some form of mental illness. In Georgia, 18% of adults have some diagnosable type of mental illness. So, over 1.4 million Georgian adults are dealing with mental illness daily. Overall compared to other states in the country, the prevalence of mental illness in adults living in Georgia is relatively low. Don’t get me wrong, 1.4 million is no small number of people in need of mental healthcare. That’s more than the total population of Maine. However, what is more troubling is that according to MHA’s report Georgia ranks dead last in overall access to mental healthcare. In terms of available mental healthcare providers, only four states have a smaller workforce. For every 730 people in Georgia with some sort of mental illness, there is only one mental healthcare provider.
So, as COVID-19 hits Georgia the stage is already set for a potential mental health crisis. Anxiety disorders are the most form of mental illness in the US. In 2020 there was a dramatic increase in the number of Americans seeking treatment for anxiety.
Georgia has also seen an increase in those seeking treatment for anxiety since the onset of the pandemic. To get a window into what it’s like to treat people with anxiety disorders during a global pandemic, I reached out to Dr. Katie Hale of Marietta, GA. I sought her out because I thought her experience would offer a unique perspective. Imagine you are finishing dual doctorate program in psychology with a clinical internship at a V.A. hospital helping veterans every day. Then a pandemic hit. Suddenly, you are at home in a tiny home office locked away from your husband and two small children all day. You host virtual therapy sessions trying to build on connections you made with existing patients. As you transition to your residency, the number of patients you see steadily increases, and the severity of their symptoms are on the rise.
The Interview — Dr. Katie Hale, Post-Doctoral Resident at Emory Adult Outpatient Psychiatry OCD & Anxiety Disorders Intensive Outpatient Program
The following interview with Dr. Katie Hale took place on 2/18/2021, with follow up on 3/4/2021
DNL: Can you talk about your position and the nature of your work?
Dr. Hale: I just finished my PHD program at Georgia State University in May of 2020. I studied clinical psychology & community psychology. It was a dual PHD program. When the pandemic first started, I was completing my clinical internship at the Atlanta V.A. Hospital. I worked with veterans in several different clinics including the residential substance abuse clinic, chronic pain, and trauma recovery. That ended in July of 2020 and in September I started working as a post-doctoral resident in the OCD & Anxiety Disorders Intensive Outpatient Program at Emory.
DNL: What in general did you typically help veterans cope with?
Dr. Hale: So, in the mental health service line we provide therapy for veterans. I worked in a few rotations in training capacity as I was finishing my internship. I switched rotations, so a lot of my work through the first half of the year focused on substance abuse recovery in the residential program at Fort McPherson. I also helped veterans with trauma recovery. The second half of the year I focused on women’s health and chronic pain. Those were my main points of focus, but you know, no matter where you are with mental health, you might be focusing on something like chronic pain but then depression there, loneliness is there, anxiety is there. So, it’s not like I explicitly focused on one thing. It can be a more wholistic approach.
DNL: As someone who meets one on one with people every day, how much has COVID-19 impacted your work?
Dr Hale: I mean, in just one day it completely changed. At the V.A. you do what is called a tour. So, you have your tour hours, which for me was 7:30 AM to 4:30 PM. I was onsite 7:30 to 4:30 every single day seeing veterans either at the hospital or at Fort McPherson. And when the pandemic hit, that day about the middle of March we got word that we were all shifting to virtual services. And I was initially quite worried about how it was all going to work. I know that sometimes infrastructure cannot be set up for that type of work for so many so quickly. However, I actually was unbelievably impressed with how quickly we were able to convert to video calls. Sometimes we did phone calls with veterans, but mostly it was video calls. We were able to maintain our full caseload of mental health appointments.
DNL: What impact did the epidemic have on the veterans you met with regularly?
Dr. Hale: One thing that I noticed, especially at the women’s clinic was a huge downturn in no-shows and cancellations. I think that might have been because a click was much more accessible than finding transportation or finding childcare. So, more people were showing up to their appointments more often. Now, it was totally different because when you are in the same room, you can give each other 100% of your attention. Once we hit virtual, it was like mom’s locked away in bathroom with a five-year-old banging on the door. Situations like that gave me a deeper glimpse into my patients’ personal lives which gave some more context for therapy. I think also that while the virtual format made therapy more accessible, with the pandemic’s impact on childcare maybe made it harder for veterans, particularly the women. It perhaps made it harder for them to have time to themselves to focus on what they wanted to work on with their mental health treatment.
I also noticed that, particularly with older veterans, some of them that struggled with technology caused us to do more sessions over the phone. Particularly for older veterans that may not have a huge social support system, and getting out of the house to go to their therapy or mental health appointment was kind of a big deal socially in their lives, a phone call felt like it might have held less impact for them. But we stuck it out, from the whole transition on to my last case there, I kept a full caseload.
DNL: When we talk about looking at the data based on the experience you had at the Atlanta V.A., to find that you had improved attendance makes sense in hindsight. Although that would not have been my first thought. It’s also interesting to hear that those with children in their care, liked the accessibility of telehealth appointments, but also may have had the toughest challenge of being ‘present’ for the sessions.
Dr. Hale: Exactly. We have a lack of mental health providers in this country. We have for a long time. Psychiatrists and therapists in particular are in short supply particularly in rural areas. So, there has been a push in the last 10 years to do more telehealth for mental health services. It makes sense in terms of a medical appointment for a physical injury, that you need to examine it person. But for mental health we really can ascertain a lot from a video call. There is some data out there that shows telehealth actually works quite well for mental health appointments. In terms of efficacy for treatments there’s not a large decline. In the studies I’ve read, it’s actually the providers themselves, rather than the people seeking treatment, that are more skeptical. I think the pandemic has pushed us to navigate this newer medium for therapy and adapt to it. There are of course pros and cons to that.
DNL: Do you think as things slowly open and transition back to something approaching “the way things used to be” that by default telehealth will be offered as an option for mental health appointments?
Dr. Hale: I hope so, because of in terms of accessibility. Think about the veterans or even patients that I see now. There is just a lack of good, affordable mental healthcare. They may live in Winder, GA for example, trying to get up to Emory for an appointment may be a hard thing to do. For accessibility, I really hope it just becomes a regular part of our offerings. If you do weekly therapy, it could even be a combination of say one in person session and three telehealth sessions in a month. It all depends on the insurance companies. The insurance companies have changed their policies during the pandemic to cover these telehealth sessions. However, it remains to be seen if they are going to continue to pay for them after the pandemic.
DNL: Let’s talk about the work you currently do at Emory’s Adult Outpatient Psychiatry OCD & Anxiety Disorders Intensive Outpatient Program. How have your patients with anxiety or OCD been impacted by the pandemic?
Dr. Hale: The underlying ideology or foundation OCD and anxiety is risk aversion. It’s a desire for certainty and to avoid risk. I think in the context of the pandemic there has been so much uncertainty. There’s so much that is out of our control and so much that has shifted and is still changing. Even with the guidelines from CDC for example, at first, we were told different things regarding masks than what we follow now.
So, the level of uncertainty during the pandemic notched up the level of existing anxiety even more. At first with some of my patients there was a sense of vindication. Like, “See I told y’all. I was just being safe all along”. Though, what I have been seeing over and over again is this uptick in severity of symptoms. The program that I work with is a step up already. It’s an intensive outpatient program, so, most of the time people think of therapy and picture going to see a therapist once a week, once every other week, or as needed. For a lot of people with anxiety that is not always enough. This is an intensive outpatient program which is a step up from that and a step down from residential care. People come to eight hours of treatment a week from us. Since it is this niche level of care, there are not many intensive level programs around and certainly not a lot of intensive level programs that accept insurance.
With the pandemic, we have this base level of anxiety rise in all of us, but for people already with a higher level of existing anxiety, their level has notched up even further. So, there’s a much greater need for more intensity and more dosage in treatment. Our program is full. We’re booking out to two months now. Even our usual referrals are full now. We just don’t have enough mental healthcare providers in the area.
DNL: With the dramatic increase in demand for mental health services and limited providers that are booked months out, what has your organization been doing to help people in the interim while they seek available treatment?
Dr. Hale: We have tried to be creative and suggest many things. We first look to our resource lists, which are trusted provider referral lists that the Emory residents use to assist patients they can’t give immediate assistance. Right now, through our work with OCD Georgia and a few other foundations, we direct people to free resources so people can get connected with peer support groups. For instance, we have a peer group through OCD Georgia where people can talk to others who have been a part of our program and know what it’s like to live with anxiety and OCD. We have directed people to tools online like tool kits that are available and training videos to get them oriented to the treatment model.
There are also some innovative treatment options out there like one called NOCD which is a fully online therapy program for OCD. It allows patients to use an app to connect with a real therapist virtually that may be anywhere in the country. They accept insurance and they have a lot of resources because I think they’re using technology in a way that is very efficient. So, it’s accessible, and that’s an example of one resource we’ve had success with. These new national app-based therapy programs that connect people with real therapists and are more accessible and maybe more affordable.
DNL: That’s interesting. Sounds like there’s legitimate options for people to leverage technology or get help from advocacy groups to overcome a shortage of mental healthcare providers in their area.
Dr. Hale: Definitely. There are also other advocacy groups out there too. Emory has a wonderful group that I’ve been involved with for a few years now called Atlanta Behavioral Health Advocates. They take all of these issues at a systems level, and are working though Grady systems, through the Georgia legislature, and other systems level means to address the issues related to a shortage of mental health providers.
Also, with the mental health providers we do have, a lot of them won’t accept insurance because insurance does no pay well for mental health appointments compared to medical appointments. So even if you find someone with availability, you may have to pay up to $200 a session.
DNL: Yeah, that’s tough if you want to see a therapist every week.
Dr. Hale: Yes. That’s just not sustainable for most people who need help. So, with Atlanta Behavioral Health Advocates we try to think of a systems level solution for making mental health and behavioral health services more accessible. That can start at advocacy and with policy to build our case for having insurance companies reimburse us better. This would enable more mental healthcare providers to accept insurance which will increase accessibility.
DNL: It’s interesting. I was diagnosed with ADD in high school and never got treatment for it. I picked up some tools, best practices, I guess. As I got older, and life became more difficult that high school, I realized some of my old routines and tools weren’t enough. It wasn’t really until I got married and my wife was like, “Now that we are together 24/7, I think you need medication”. I found it much easier to get insurance to approve prescribed medicine. It is much harder to find someone you like in network that insurance will cover the costs. It’s like if there are drugs involved it’s approved, but if I just want to talk to someone to work things out its more of a challenge.
Dr. Hale: Exactly. Drugs are a lot cheaper than paying for an hour with an expert to help you process things. It’s the difference of paying ‘cents’ compared to $100 — $250 a session that a therapist may charge.
DNL: It’s funny how there is always a financial equation or calculation to wellness.
Dr. Hale: In this system there sure is, but we have a for profit healthcare system in this country. So like any business, if it’s not going make money, it’s not going to get supported.
DNL: What trends have you noticed in the course of your work that you don’t think are being talked about enough as it relates to COVID-19?
Dr. Hale: Yes, when you contacted me for this interview, you sent me the numbers of Georgia COVID cases and deaths and the data was broken down by age, gender, race and ethnicity. I could see which groups were most impacted by the pandemic. When you look at the Georgia numbers there’s this insane over representation of African Americans in the death statistics. What I find is that it creates this unbeatable cycle where the black population in Georgia is experiencing ridiculous overrepresented levels of loss related to the pandemic. We know loss and grief and death increases stress, there’s trauma, and anxiety which increases the need for mental healthcare — which is not as accessible due to lack of insurance covering it and not enough healthcare providers. So, it perpetuates this cycle of disparities within our healthcare system and particularly our mental healthcare system.
DNL: When you just see those statistics, and we talk about “what’s the narrative around the data?” There’s a whole other universe of issues that are created by just having a higher percentage of deaths within a particular community. So, now other problems will rise statically because of that.
Dr. Hale: Absolutely.
DNL: (Interrupts) When you deal with a traumatic experience like a loved one becoming gravely ill or somebody dying in your family. How does that impact everyone around you? How does that impact your community?
Dr. Hale: And how does that impact people’s engagement with the system? So, if you are engaging with the healthcare system and you see a loved one being mistreated or not being treated — or experience racism, if you see blatant racism within the system that triggers stress, anxiety, even trauma-like reactions. If you need support for that, you’re less likely to go back to that same system to get the care that you need.
So, it’s not just about accessibility and affordability, it’s also about mistrust of the system. It’s about engaging with the racial disparities at the system’s level. We (healthcare providers) have to really make that a priority. Otherwise, we are just perpetuating cycles of disparity when we are not meeting the needs of all who seek treatment.
DNL: Based on your experience during the pandemic at the Atlanta V.A. Hospital and at Emory, has the pandemic brought to light any policies or procedures within our mental healthcare system that hinder providers like you in treating people?
Dr. Hale: At a 30,000-foot view, the things we touched on already like mistrust in the system, insurance reimbursement, lack of available healthcare providers all have an impact. However, I can tell you that in the foundation work I’m doing with OCD Georgia and Atlanta Behavioral Health Advocates we are focused on evaluating the system and bringing issues to light. At the Emory Anxiety and OCD program where I work, we are looking at our pipelines and procedures to uncover where we have bottlenecks and understand why. One of the things we come across often is that the system can be confusing as Hell.
For somebody having a mental health crisis, to get to the right place can sometimes be hard to do. There’s been a concerted effort to build awareness in our community of the resources that are available and how to connect those resources to people. Along with that we are helping those resources promote themselves and get their information out there. The goal has been to help people understand how to better navigate the mental healthcare system. However, the system is taxed right now across the board. Sometimes it feels like it would be extra or feel like a luxury just to pause and figure out how can we make our process more efficient. We are all just under so much pressure because of the pandemic and with the system being so taxed right now.
DNL: Speaking of pressure during the pandemic, I’m sure you had a plan of how you would treat people once you started your residency. How has the pandemic impacted you personally and changed your method for treating people?
Dr. Hale: It is something I’m still grappling with on a personal level. I am an extrovert through and through. My energy gets fed by being with other people, by working on a team. Luckily, both my teams at the V.A. and at Emory have just been phenomenal, professional teams to work on. However, being a therapist, has a sort of a quiet one-on-one feel; you don’t interact with that many people. Switching to the virtual format has made me that much more removed. I think that may be why, when we look at studies about telehealth, there are some concerns coming from providers.
I wonder if just being a therapist can be a somewhat lonely profession. Especially for those with a private practice, you don’t have a lot of colleagues to bounce ideas off. There’s not a lot of team effort in that situation. High confidentiality is our number one priority, so we’re often doing a lot of solitary work. It feels even more solitary these days. I think I’m just now, almost at a full year of being virtual, and I’m learning how to lean into my computer screen to get my patient to lean in too and connect. We have to find ways to build intimacy and trust through a screen transmitting zeros and ones over the internet.
DNL: There’s a story by itself right there. ‘How has the move to virtual appointments impacted the psyche of the people providing the therapy?’
Dr. Hale: You got it! It’s rough for all of us, but we’re all trying to figure it out. It’s especially hard because we are lonelier than we used to be. I’m locked behind two closed doors because of confidentiality all day, every day. Therapists like me are isolated in a room alone all day, and they’re seeing a lot more patients, and more severity in patient symptoms. So, there’s a ton of burnout occurring in this profession right now.
DNL: I would assume that you fall into one of the categories of people with early access to a vaccine. Did the move to virtual have a negative impact your ability to get vaccinated?
Dr. Hale: I don’t think it’s been a negative impact because everybody’s goal is to get back into the clinic. Emory has been great about providing patient-facing healthcare workers with the vaccine early on. So, I do have access to the vaccine. I think even for those of us who are remote, the goal was to make the vaccine available because we’re forced to be working from home because of the pandemic. It wasn’t our choice. So, while I hope virtual will always be an option like we talked about earlier, there is a need for in person sessions as well. We use something called exposure and response prevention therapy to treat OCD and other anxiety disorders, which has really transitioned well to the virtual format, but we’re also ready to offer in person sessions again as soon as it’s safe to do so. So, Emory is doing a great job of getting us access to the vaccine so we can start phasing back in and seeing our patients in person.
DNL: You treated many women during your tour at the Atlanta V.A. Women’s Clinic and I’m sure you see several patients that are women now at Emory. How has the pandemic impacted them? Have you noticed any trends?
Dr. Hale: A huge part of what’s happening for a lot of women are childcare issues. Women I’ve seen are trying to make decisions about career, and childcare, who is making money, and who has more flexibility. There have been other trends specific to the pandemic’s impact on women. We noticed a huge uptick in new moms coming into our program suffering from a severe increase in intrusive thoughts and anxiety during their postpartum period. I realized we needed a specific, focused approach to help the huge influx of new moms. I started a Post Partem Anxiety Group providing psychoeducation, assistance with intrusive thoughts, and dealing with increased sense of isolation. We implemented via web meetings. The group helps them set new expectations for themselves in the context of being a new mom in the middle of a pandemic.
DNL: Wow, yeah. I could not imagine being home with a new baby when the COVID lockdowns started. Especially if that’s your first child too. That’s usually when family and friends come and pitch in, but that can’t happen during a pandemic.
Dr. Hale: Right. The only kind of contact that feels is often social media. We know that has its own impact on mental health. Across the board, it tends to be fairly negative in terms of social comparison anxiety and depression.
DNL: That is fascinating. Data is the starting point for my column topics and tangentially technology in terms of how we access data. Since the pandemic, how much has social media become a part of what you talk about during your sessions?
Dr. Hale: So much. That is people’s main connection with their social systems right now. I mentioned exposure therapy earlier. A lot of my patients’ anxiety is centered around how they’re presenting themselves online, how many likes they are getting, who is seeing what they post online, and what kind of responses they are getting. So, with exposure therapy, often I’ll have patients take a random picture of themselves and post it without over thinking it. Their anxiety stems from really latching on to these online identities they have that feel very salient now because they don’t have the opportunity to engage with their person-to-person identities as much anymore.
DNL: I’m a Gen-Xer so I remember when you didn’t have to care about any of this stuff.
Dr. Hale: You took a picture, it was two weeks before anyone was going see it.
DNL: Right. My generation was coming of age with the internet and came up with a lot of what the internet is based on now. But there are generations coming of age now that have never known a world without the internet. Hell, my kids act like the internet powers appliances.
Dr. Hale: (laughing) I know what you mean.
DNL: I’m like, “No the Wi-Fi can be down, and we can still make food okay”. So, I could see how if you have a circle of like 8 friends that now you can only see online, then every interaction on social media must be heightened and feel more important.
Dr. Hale: Yes, and in that scenario you and your circle of 8 close friends are going out to dinner, going to concerts, and hanging out. Then all of a sudden that stops. So, what felt like a very intimate, supportive, fulfilling inner circle, surrounded by a peripheral larger group that kind of follows what you guys do, is gone. So, now those same needs met by your circle, are trying to be met in this giant, almost limitless social world.
I’m seeing people trying to get their needs met on a platform that was never designed to do that. It’s quite unfulfilling and frustrating. That’s how the anxiety builds. So, they keep trying to make it work, and it doesn’t work. So, they try a new thing, a new app, over and over. Before they know it, they’re spending all of their time trying to curate an online identity that gives them some sort of connection.
DNL: Do you think issues that have been brought to light by the pandemic will be addressed post herd immunity or will they get pushed back under the rug?
Dr. Hale: I am hopeful. It’s going to be an uphill battle, but I spend a good bit of time with OCD Georgia and the Atlanta Behavioral Health Advocates where people are passionate about uncovering disparities then doing something about them. I don’t think that those places, those spaces where there’s intentional work happening already; I don’t see that going anywhere.
In fact, the pandemic is helping us figure out those problems. I see a resurgence and a recommitment. I see more people getting involved with advocacy and joining boards to say let shift our focus here to racial disparities within the healthcare system. I’m hoping this push to be more inclusive in these spaces where decisions are made continues. I think it will.
DNL: I am hopeful as well. The pandemic has forced us to adapt and change how we work, shop, and interact. In a way, the pandemic has made us become more thoughtful about how we do things. So I think it’s possible that we can adapt and make necessary changes that impact our collective mental health.
Dr. Hale: I think the pandemic has forced us to be flexible and be creative. We are doing work virtually, that used to feel scary and now it just feels normal. And it’s working in a way that actually improves the system. It is smart for us to make mental healthcare more accessible and more inclusive. It’s what we care about and reflects our values, but also from a business perspective it makes sense. So, I think the good things that have come from having to make such abrupt changes are going to last.
DNL: Sometimes it takes a dramatic change or a disaster to force us to pivot.
Dr. Hale: That just made me think of this great program in the mental health community called PSYPACT. So, just like medical providers, therapist licenses are managed at the state level. You must practice in the state in which you are licensed. However, over the last few years PSYPACT has pushed for and enabled cross state licensing. This makes it possible for you to see clients from out of state virtually. Since the pandemic, they have gained a lot of support and momentum, in fact North Carolina just came on board. Several state legislatures are considering joining. So, hopefully that’s a sign of more positive changes to come as a result of having to adapt to the pandemic.
DNL: Well, I appreciate you offering your time and talking about your unique experience during the pandemic. It was a pleasure talking with you.
Dr. Hale: It was my pleasure as well. I’m glad you are talking to people about this.
References
- Reinert, Maddy, et al. “2021 The State of Mental Health in America.” Mental Health America, Mental Health America, Inc, 2020, mhanational.org/issues/mental-health-america-printed-reports.
2. “Facts & Statistics: Anxiety and Depression Association of America, ADAA.” Facts & Statistics | Anxiety and Depression Association of America, ADAA, Anxiety & Depression Association of America, 17 Feb. 2021, adaa.org/understanding-anxiety/facts-statistics.
3. “Mental Health Resources in Georgia.” Resources to Recover — Gateway to Mental Health Services, Rtor.org, 2021, www.rtor.org/directory/mental-health-resources-in-georgia/.
Resource Material — For more information on topics discussed in the interview see below.
Emory Adult Outpatient Psychiatry OCD & Anxiety Disorders Intensive Outpatient Program http://www.psychiatry.emory.edu/programs/ocd_program/index.html
Telehealth
“The Future of Telehealth: How COVID-19 is Changing the Delivery of Virtual Care” https://adaa.org/sites/default/files/Statement%20for%20the%20Record%20(Hasselfeld)%20FINAL.pdf
Advocacy Groups
OCD Georgia http://www.ocdgeorgia.org/
Online Programs
NOCD https://www.treatmyocd.com/
OCD Challenge https://www.ocdchallenge.com/
The Psychology Interjurisdictional Compact (PSYPACT) https://psypact.site-ym.com/
Racial Disparity
Clinical Research Scientist in Racial Health Disparities & the Promotion of Health Equity https://www.drsierracarter.com/
COVID-19 & Mental Health Data Reports
Georgia Department of Public Health Daily Status Report https://dph.georgia.gov/covid-19-daily-status-report
Population & Demographic Data
US Census https://data.census.gov/cedsci/profile?q=United%20States&g=0100000US
Business Insider https://www.businessinsider.com/generation-z
Pew Research https://www.pewresearch.org/topics/millennials/
