Rose: Colorado Access limitations create Mental Health Redlining

Andrew Rose, LPC, Advocacy Director for COMBINE

Emotional health is an important part of self-care in every community.  While systemic obstacles and stigmas about mental illness continue to create barriers to treatment, and historical resources like family and the church or mosque offer coping strategies and support, the community faces anxiety, depression, and trauma impacts. These impacts are treatable, often without medicine, or supplemented with medicine. An important community resource to establish and maintain emotional health for the community is Medicaid. 

While we’re not using Medicaid anymore, my wife and I both weren’t making much money during and just after graduate school as we built our businesses.   We could not afford monthly premiums along with $10,000 deductibles. Medicaid paid for surgery on my shattered ankle, which would have bankrupted us at the time.  The assistance freed us up to create jobs.

Medicaid now covers over a million people in Colorado, since the expansion brought by the Affordable Care Act during Obama’s administration.  In Denver and Aurora, this program is managed by Colorado Access for behavioral health.  

Mental illness may evoke images of hard to treat and chronic conditions like persistent addiction or schizophrenia, and that’s actually not most of the work. Outpatient counseling is the front lines.  

People go to therapy when three things happen.  

First, they become aware that their capacity for managing the emotional world is overwhelmed.  Something is wrong.  Depression leads to apathy, low energy, less contact with others, isolation, and frustration.  Family members reach their limit of helpfulness. People can feel suicidal and even be surprised to notice they feel that way, which can be frightening.  Anxiety and panic attacks carry a toxic wash of adrenaline and cortisol, with long term health effects if not treated.

And then there’s trauma.  Psychological trauma has two elements: a threat to integrity or “wholeness” and an inability to escape.  Fighting and fleeing both allow the body to process the stew that’s churned up when danger is perceived.  Without the option to fight or flee, the body’s process to deal with the circumstance has lasting implications on memory, emotional regulation, cognition, and avoidance of life’s options.  Without treatment, an additional process called “kindling” causes traumatic reactions to a wider and more general set of perceptions over time. 

And physical threat is only one source of trauma.  We now know neglect, abandonment, and rejection have even more profound and long term effects than physical danger, particularly in formative times during infancy.  The brain can perceive rejection everywhere, like the sour looks of a teacher, manager, or co-worker, or racist micro-aggressions.  

When we have a history that includes abandonment, we are more susceptible to emotional upset in the present.  We are primed to be reactive.  The historical and current day impacts of living in a culture with a nonsensical racial hierarchy add on disparately to the emotional burden.

Second, therapy is available.  And third, the therapy is helpful.  When appointments are only available every three weeks, people abandon the work.  When counselors are overworked and burnt from the secondary trauma that’s an occupational hazard, they leave, reducing access.

I once treated an Afghan woman, a recent immigrant, who was impacted by sexualized behavior at her workplace, and demonstrated PTSD symptoms like avoidance of parts of the workplace, emotional disruptions, and memory problems.   I’m White, male, not Muslim, speak no Pashto or Dari, and her English was limited.  She was reticent to interact and appeared confused for several sessions.  We broached this and she surprised me in my ignorance and explained that she had never been alone in a room with a man before in her life and she wasn’t doing very well with that.  She didn’t feel safe, which is the primary requirement for successful treatment. 

This client deserved a therapist who understood her language and culture and could help her feel safe enough to process the disturbances she had experienced so she could meet her challenges from a constructive, creative, adult frame of mind rather than with regressed and frantic behaviors. 

We are clinic directors, social workers, and counselors with a front row view of how emotional wellness care is metered out in Colorado.   Our vision is for a diverse and sustainable counseling workforce, to meet the needs of the community.  The community deserves a “school-to-counseling-professional pipeline.”   Not everyone wants or needs a counselor that matches their gender, race, religion, and language, but it’s common sense that having a therapist with cultural knowledge will improve treatment. 

A pipeline has many parts, and a school-to-counseling-professional pipeline requires early exposure to the profession for students by professionals who look like them, access to higher education, opportunities to train and work with the community, and sustainable jobs that cultivate expertise to educate the next generation of professionals. 

Today we are concerned that Colorado Access limits access to counseling by not allowing pre-licensure counseling outside of large centers like MHCD.  Pre-licensure counselors are university interns and early career therapists who need thousands of hours of supervised work to attain a license.  They are eager, energetic, willing to learn, and successful at treating clients, according to research.  Smaller clinics where one supervisor could take on a few interns or supervise some pre-licensure therapists would open up job opportunities and more access. 

The policy choice must also be held in comparison to the rest of the state, where fewer immigrants and people of color live.  No other part of Colorado has this policy.  Boulder and Jefferson counties report three to four times as many providers per member as Denver and Aurora.  This is a mental health ‘redlining’ of Denver and Aurora that needs to stop.

We ask you to join us, or recommend our group, COMBINE, at combinebh.org, to diverse mental health professionals that navigate the Medicaid system.  We will be stronger and better informed by participation from all quarters.  

We also ask you to write the Colorado Democratic Latino Caucus and the Colorado Democratic Black Caucus or your own state Representative and Senator to support this change.  You can find your representative here https://leg.colorado.gov/find-my-legislator and write those groups at :  latinocaucusco@gmail.com and blackcaucusco@gmail.com