Colonel David Benedek, chairman of the Uniformed Services University of the Health Sciences’ Department of Psychiatry, opened the session for the closing keynote given by Representative Seth Moulton, U.S. congressman from the Sixth District of Massachusetts. Benedek remarked that quite a bit of attention had been given during the workshop to identifying the drivers of mental health outcomes stemming from the social determinants of health (SDH). There were also lengthy discussions on the importance of educating health care providers, students, and trainees on these issues and on how they might advocate for changes to improve and reduce disparities and inequities that drive mental health outcomes. It was also stated that, in the end, legislation and public policy may help the most—even more than the delivery of quality health care—in reducing these inequities.
With those few comments, Benedek welcomed Representative Moulton to the stage, asking him to help the forum members and guests better understand how, as educators, “we can teach not only ourselves but our students about our role in trying to work on the legislative process.” He encouraged the congressman to share his story and to perhaps remind the audience how, over the course of a lifetime, those drivers of mental health outcomes can change for people, such as how life decisions and circumstances can alter the trajectory of one’s mental and physical health outcomes.
Congressman, Sixth District of Massachusetts
In response to Benedek’s charge and following the path laid by Kennita Carter of the Health Resources and Services Administration in the opening session, Representative Moulton shared his personal journey with mental health stemming from his military service. He also discussed how his combat experiences motivated him to pursue broad-scale changes to federal policy. As background, Moulton said he joined the Marine Corps in 2001 and served four tours of duty in Iraq. After his time in Iraq, he sought treatment for posttraumatic stress,1 and in 2019 he became the first presidential candidate in American history to openly discuss his own mental health issues. During Moulton’s run for the Democratic nomination for president of the United States, he opened up about his mental health struggles, not knowing what the response would be or if it would end his bid for the presidency. The response was “fantastic,” he said. Because of his openness, both veterans and non-veterans who had been silent for years told their
1 Moulton said that he, like many veterans, chose not to use the word “disorder,” saying that after what they went through in battle, it would be a disorder not to be affected by the experience.
stories and began the process of getting help. Supporting these people in telling their stories, Moulton said, “is the most important thing” that he did while running for president.
Along with sharing his personal story, Moulton developed a three-point mental health plan that he would seek to implement as president. While his bid for the presidency has ended, Moulton said he continues to work on his plan as a member of Congress. The first point of the plan is to establish a national mental health hotline. This proposal has been written into a bipartisan bill that Moulton said has more than 100 co-sponsors in the House and co-leads in the Senate. The second point of the plan would ensure that everyone in the military gets an annual mental health exam, in part because there is a high incidence of mental health issues in the military, but also to emphasize that regular mental health check-ups should be normal and routine for everyone. A related but less comprehensive provision is in the current defense bill; it would ensure that military members coming back from a combat deployment would be seen by a mental health professional within 2 weeks and then would have annual follow-ups. The third point of Moulton’s plan is to extend the annual mental health screenings to every high school student in America.
The two main goals of this plan, Moulton said, are to improve access to mental health care and to destigmatize the idea of getting regular mental health exams and seeking additional help when needed. He said that if a person tells co-workers he or she needs to leave early for an annual physical exam, no one bats an eye, but if the same person has to leave early for a mental health appointment, the reaction is not the same. This difference is “fundamentally what we have to change,” he said. Moulton added that in the military, seeking mental health care can result in losing security clearance, which means that “some of the people who need care the most are not getting it.” If everyone got a mental health exam annually, it would ensure that all military members could get help without fear of being stigmatized or punished. Kimberly Lomis, vice president for undergraduate medical education innovations at the American Medical Association, commented that there are similar issues in health care as well as similar proposals. Health care professionals deal with stressful situations and death on a day-to-day basis, she said, yet seeking help for mental health issues is still stigmatized within the profession. Lomis applauded Moulton’s plan and said “the idea of normalizing it and fighting against that stigma is really critical.”
In addition to the barrier of stigma, many people—veterans and non-veterans alike—do not know how to access mental health care. Moulton asked the workshop participants if anyone knew the National Suicide Hotline number, and not a single person could accurately recall it. This, Moulton said, is a big problem. “If you wake up tomorrow night and … your house is burning down, you don’t have to go looking for a phone book
to figure out who to call,” he said. When people are having mental health crises, he continued, it should be just as easy to know whom to call for help. His proposal would make 988 the phone number to call for mental health help and would expand the hotline beyond suicide to all types of mental health issues. Moulton said that many people—including himself—feel as if their issues are not severe enough to warrant reaching out for help. It took him awhile to seek help, he said, because he was not feeling suicidal or having symptoms as bad as some of his fellow veterans. This is a mindset that needs to change, he said, so people can seek help for a range of mental health issues rather than only the most severe.
Implementing some of these proposals, Moulton said, will involve a significant amount of money and require recruiting and training more mental health professionals. While this is a tall challenge, Moulton said, he has learned that “it’s better to set the goal and say this is something we want to achieve, and then we’ll figure out how to get the people to fill the spots.” Pamela Jeffries, professor of nursing and dean of The George Washington University School of Nursing, suggested that school nurses would be excellent partners in the effort to screen high school students. Moulton agreed but said he believes that screenings for both high school students and military members should be conducted by trained mental health professionals, rather than by primary care providers simply asking a few questions during an annual exam.
Some of the solutions that Moulton advocates for on the national level are already being implemented on the state and local levels, said Carl Sheperis of Texas A&M University. For example, he said, Texas has passed a law that requires every classroom teacher in Texas to have mental health training.2 In San Antonio, one of the poorest school districts in the state, students led a 4-year effort to make a mental health wellness center available for students, parents, and staff (Phillips, 2019). Sheperis asked Moulton how to continue and expand on these types of grassroots efforts. Moulton responded that while there is still a long way to go, the public perception of the issue is changing rapidly. He noted that his mental health provision was passed in the current defense bill with full support from both Democrats and Republicans, which is “incredibly encouraging” for future efforts on both the local and national levels.
Benedek asked Moulton how to get students involved in the political process in order to make changes for mental health on a broad scale. Moulton replied with a story about the first bill that he passed in Congress, which was aimed at using technology to improve access to the Department of Veterans Affairs (VA). A staffer in his office made a video of a fellow staffer, who was a veteran, calling and trying to get an appointment at the
2 Texas Educ. Code § 21.451 and 21.054.
VA but getting caught in an endless loop of automated menu options. The video captured the problem and ended up going viral. Other members of Congress heard about the video—and the issue—from their constituents and reached out to support the bill. Moulton said that members of Congress have a lot of ideas and proposals but that people at the grassroots level, including students, can really influence what gets prioritized (see Box 5-1 for an example of policy priorities impacting mental health).
THE ROLE OF HEALTH EDUCATION IN POLICY
In an attempt to apply previous discussions at the macro and meso levels to specific life situations (micro level), workshop participants gathered in small groups to discuss case studies that were presented by the planning committee as “case histories.” These case histories dealt with the role of social determinants of mental health (SDMH) at three stages of life: pregnancy and birth, young adulthood, and older adulthood. Although the planning committee selected these three points in time, Sheperis noted that when using case histories for education, any point along the life course could be used to illustrate how mental and physical health are both affected by social determinants, how social determinants are affected by policies, and how learners can work toward influencing policies. The case histories (see Appendix E) involved patients who presented for care with seemingly straightforward medical issues, but through a gradual unveiling of information it became apparent that each case was affected in some way by the SDH that affected the person’s mental health and well-being. Participants worked through the case studies and discussed how the situations could be used in health professions education to encourage thinking about social determinants, how these determinants may influence care decisions, and how health professionals could address the determinants on individual, community, and policy levels.
Participants reconvened to share takeaways from the group discussions as well as from the workshop as a whole. The discussion primarily focused on competencies that educational institutions should seek to instill in health professions students. In addition to the more in-depth conversations summarized next, participants identified a variety of potential areas for educational competencies among faculty members, including the following:
- Looking at how policies connect people with each other and the environment using relational theories
- Assessing community needs and assets that align with community-engaged learning objectives (i.e., bidirectional mutuality)
- Building and maintaining sustainable community projects
- Learning from effective interprofessional, collaborative teams
- Establishing cross-sectoral relationships
Making the Link Between Patients and Policies
Students and health professionals need to learn to put the patient in the center in order to make sound decisions, said Robert Keefe, associate professor at the University at Buffalo School of Social Work. Putting the patient in the center means seeing the whole person—including the patient’s
family, job, community, and unique situation—rather than just his or her medical issue or diagnosis. Once health professionals see the patient as a whole person, Keefe said, they will be better equipped to care for the patient as well as to potentially address social determinants and mental health challenges through broader scale initiatives. Kennita Carter, senior advisor in the Division of Medicine and Dentistry at the Health Resources and Services Administration, added that health professionals need to be prepared and willing to work across sectors to address social determinants. A patient’s needs might be best met, for instance, not through the health sector, but by connecting the patient with housing, food, or other resources or by advocating for change in these areas.
Policy and Advocacy Training
Julian Fisher, research associate at the Peter L. Reichertz Institute for Medical Informatics at the Hannover Medical School in Germany, said that everyone needs a skill set in policy and advocacy training regardless of his or her eventual career path, and that this skill set is “very weak and underdeveloped within the health and social workforce.” Fisher said that while there is some attention paid to social determinants on the individual or community levels, there is far less attention paid to the ways in which policy affects structural determinants. These structural determinants (e.g., housing policy) have a major impact on health and well-being and accentuate individual or community determinants. Students need to be trained in “health in all policy”3 approaches to be able to advocate for health in all sectors and across all levels, Fisher said. In order to do so, he said, students will need skills such as tracking legislation, reaching out to representatives on multiple levels, and advocating for policies in areas in which they are not experts. Carter added that in addition to advocating for new policies, students should be trained to leverage existing policies and resources to make change.
Lomis cautioned that some health professions students will be passionate about advocacy and will pursue it as a major part of their career, while others may be overwhelmed or simply uninterested in the idea of policy and advocacy. She suggested that there be a broad continuum of engagement in advocacy, with a core foundation of advocacy skills in which all students are trained. Mark Merrick of the Athletic Training Strategic Alliance added that simply training students in the mechanisms of advocacy does not create advocates. Students must feel a connection, Merrick said “You create
3 Health in All Policies describes an approach that integrates health considerations across sectors. For more information on Health in All Policies, visit https://www.cdc.gov/policy/hiap/index.html (accessed February 11, 2020).
advocates when you connect students powerfully to issues in which they are invested and want to make a change.” Fisher agreed and suggested that one goal of health professions education should be to give all students basic skills in advocacy, so that when students find themselves in a situation wanting or needing to advocate, they can “fire these skills up.”
Jody Frost, president of the National Academies of Practice (NAP), stressed the importance of teaching and conducting interprofessional advocacy rather than advocacy based on the needs and structures of a specific health profession. She said that this type of advocacy is “powerful” and that policy makers want to hear about new approaches that are supported by multiple health professions. Kennita Carter, senior advisor in the Division of Medicine and Dentistry at the Health Resources and Services Administration, added that in addition to interprofessional advocacy, students should be taught cross-sectoral advocacy so that they can work together with people outside of the health professions.
Self-Awareness and Self-Care
Part of preparing students to address the mental and physical effects of the social determinants and to advocate for change, one participant said, is helping students learn about themselves and about where they fit in their schools, communities, and professions. When students begin their health professions education, many do not have the skills to navigate the systems they are in and to maintain their physical, mental, emotional, spiritual, and financial well-being. Educators and administrators can help students by giving them the space and the opportunity to process their own life experiences and to reflect on their new experiences as students and health professionals. A second participant suggested that a school could use bereavement and loss as an “entry point” to get students to have these reflections and conversations because many, if not most, students have experienced loss. This led to a third participant commenting that students also need to have conversations about culture, class, race, and ethnicity and about how these intersect and can affect a person’s self-care and self-advocacy as well as their care and advocacy for others.
Integrating Social Care
In September 2019 the National Academies released a consensus study report titled Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Darla Spence Coffey, president of the Council on Social Work Education, noted that the report contains a number of conclusions and recommendations that are relevant to educating health professionals to address the social determinants of mental
health, including a framework for how interprofessional teams can look beyond clinical interventions toward social needs. The framework included five “As” that are critical to this work. First, the team members must be aware of the impact of social determinants. Second, the team must know how to adjust care in order to accommodate or address social determinants. Third, the team should offer assistance by connecting patients with relevant resources. Fourth, the team should seek to align the system of social supports so that professionals are not working in siloes. Finally, team members should have the ability to advocate for changes on a broader scale that may affect their patients (NASEM, 2019).
Faculty for the Future and Closing Remarks
Whether a particular faculty member educates students on the role of health professionals in advocating for patients and communities may be influenced by the type of training that educator received himself or herself. This was Sheperis’s message as he reflected on a breakout session conversation that he had heard. From the discussion, he said, it appeared that some professions, such as counseling, psychology, and social work, embed advocacy and policy development as part of the training process and that faculty members view it as their ethical responsibility to teach students these concepts and skills. Faculty might take students to a state capitol or to Capitol Hill for advocacy days or train them in how to write letters to influence policy. Students are trained on how to know whom their representatives are and on how to use their “voice” in terms of policy development. In contrast, he said, other health professions with already crowded curricula, such as medicine and nursing, may have examples of such training but, overall, seem to place less of an emphasis on instructing learners on how to do advocacy. Sandra Crewe, dean of the Howard University School of Social Work, was quick to point out that including advocacy training in areas of the SDMH could do a dis-service to the importance of this area by offering inadequate or insufficient training. The challenge for educators is how to offer such training within a crowded educational program. One idea that Crewe suggested was to find ways of integrating advocacy training into already established competency training in order to avoid “spreading ourselves too thinly.”
Frost suggested taking an interprofessional approach to advocacy training. In this way, she said, different health professions can learn from each other and can leverage different professions’ expertise in offering advocacy training across curricula. Frost underscored the power of interprofessional advocacy as she described her recent experience briefing lawmakers on Capitol Hill who were captivated by NAP’s interprofessional approach to addressing challenges in health care. A representative from the Alliance of
Nurses for Healthy Environments talked about combining forces with a similarly motivated group from medicine, Physicians for Social Responsibility, which underscored Frost’s point about the power of speaking across professions with a unified voice. Bringing these sorts of experiences into the classroom can show (rather than teach) that everyone has a story to tell and that whether it is at the federal, state, or local level, learners can see how “our voice counts,” the participant said. Learning from other professions who were trained in how to do advocacy may also be a way of providing informal faculty development. With that thought, Carter moved to close the workshop, but not before Sheperis reminded the participants to think about their own commitments to learning and how, by developing an education contract with oneself, each health professional and educator can influence colleagues and leaners well after this workshop ends.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2019. Integrating social care into the delivery of health care: Moving upstream to improve the nation’s health. Washington, DC: The National Academies Press.
Phillips, C. 2019. Four years in the making, mental health center opens in south San Antonio school district. Texas Public Radio. https://www.tpr.org/post/four-years-making-mental-health-center-opens-south-san-antonio-school-district (accessed January 23, 2020).