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AHN’s Center for Traumatic Stress in Children and Adolescents is nationally recognized as a leader in its field.
Dr. Anthony Mannarino, chair of the Psychiatry and Behavioral Health Institute at Allegheny Health Network (AHN), uses a Maya Angelou quote to sum up the institute’s approach to growth and innovation: “Do the best you can until you know better. Then when you know better, do better.”
The institute’s evidence-based care services and support cover a continuum: preventive, community-wide services and education, digital self-help, sub-clinical and semi-professional care, outpatient care, intensive outpatient programs (IOP), partial hospitalization, and in-patient care. While serving some of the most vulnerable members of the community, there is also a movement to shift intervention to “the left on the continuum,” taking a more proactive approach to identifying and addressing problems before people decompensate or reach a crisis stage.
To learn more, I spoke with the institute’s leadership dyad, Dr. Mannarino and Dr. Doug Henry, vice president. We started our conversation by addressing the impact of the pandemic, then turned to discussing several of the institute's innovative programs and treatments.
Emily Laubham: In broad terms, how has the pandemic impacted society’s mental health?
Dr. Anthony Mannarino: One of the greatest causes of anxiety is uncertainty. Has there been anything in our lifetime that has caused more uncertainty that the pandemic?
Dr. Doug Henry: Data on the effects of the pandemic are still emerging, but it’s been striking. The pandemic has been like the boogie man — kids often describe it this way. The American Academy of Pediatrics has declared a mental health emergency among children in the U.S.
Anxiety disorders were on the rise even before the pandemic — anxiety spectrum disorder overtook depression as the most common diagnosis several years ago. Now, the number of people needing treatment for obsessive compulsive disorder (OCD), eating disorders, post-traumatic stress disorder (PTSD), and anxiety is increasing geometrically. On top of that enormous need, it’s extremely difficult in many cases to access services.
Emily Laubham: How has the pandemic impacted the institute?
Dr. Anthony Mannarino: It’s been all about the transformation from in-person, office-based care to telehealth. Pre-pandemic, we were beginning to move in that direction, but March 2020 began a dramatic pivot — from being mostly in-person to 95% telehealth. To this day, about 80% of our appointments continue to be telehealth.
Dr. Doug Henry: There had been a lot of hesitation about telehealth before the pandemic, from providers as well as patients. You know, would we miss something as subtle as a tear on the cheek or a hand tremor if we weren’t in person? It’s an understandable concern, but we’ve discovered that we can still see and hear just about everything. And 96% of our patients have given video service the highest satisfaction rating.
Telehealth options have been especially helpful for one of our most vulnerable groups, people on Medicaid. Think about all the costs and practical challenges associated with in-person mental health services — gas to get there, parking fees, time for the commute, finding a babysitter, etc. The option to meet via video can be life-changing for many folks.
Emily Laubham: Even with those high percentages of use and satisfaction, are there also instances when you recommend or require an in-person visit?
Dr. Doug Henry: Sure, for example, we want to do a face-to-face for initial evaluations with very young kids, and with someone who may be suicidal or potentially dangerous. In general, when it comes to providing ongoing video services to kids, I’m cautious. They’re already suffering from feelings of disconnectedness, and that was heightened by the pandemic. The last thing we want to do is contribute to that or miss an opportunity to reach them.
Emily Laubham: What’s the vision for how the Psychiatry and Behavioral Health Institute evolves in the future?
Dr. Doug Henry: In the last decade, part of the progression of mental health services in the U.S. has been about breaking down barriers between us, the providers, and the population of mental health care patients. Historically, we waited for them to come to us, sometimes through the emergency department or inpatient psychiatric units. The next phase for us is to become much more proactive instead of reactive.
Integration is another big theme. In a relatively short period, we have gone from one primary care practice at AHN integrated with behavioral health to now having 75 integrated access points with behavioral health and psychiatry professionals, licensed professional counselors, and licensed clinical social workers. We’re trying to capitalize on the trust people already have with their primary care physician (PCP), hoping they’ll extend it to us. Plus, that kind of integration means people don’t have to make separate trips to access care.
Emily Laubham: Dr. Mannarino, you are one of the developers of trauma-focused cognitive behavioral therapy (TF-CBT). Can you talk briefly about what that is and why it’s important?
Dr. Anthony Mannarino: We developed the TF-CBT model over 25 years ago, and it’s really the centerpiece of what we offer kids and families at the Center for Traumatic Stress in Children and Adolescents. TF-CBT is a highly effective, evidence-based treatment and typically is implemented over a course of about three to four months.
More than two-thirds of American youth have experienced at least one traumatic life event by age 16. Those are huge numbers. Fortunately, the majority of kids who experience trauma are incredibly resilient, recover, and do well in their lives. But about one-third of them do not. Instead, they experience a variety of psychiatric disorders, most notably PTSD. Without appropriate care and intervention, they’re at risk for developing late adolescence and adult psychiatric disorders.
If you look at the literature around what is now called Adverse Childhood Experiences (ACEs), they run mostly parallel to trauma. ACEs correlate with a variety of physical medical conditions in adulthood, including heart problems, cancer, and diabetes. If we don’t intervene when the person is young, then they’re at significant risk for those problems, too.
The Center for Traumatic Stress in Children and Adolescents is really all about getting to kids as soon as possible once they experience trauma and offering them evidence-based treatment to address their symptoms.
Emily Laubham: Is there a similar center or set of services for adults dealing with trauma?
Dr. Doug Henry: Yes, we’ve had the Center for Traumatic Stress in Children and Adolescents for more than two decades — we’re truly an industry leader in care for young people. But we were also finding such a high rate of trauma in our partial hospitalization program for adults that we saw the need to build out what we call our adult trauma care continuum.
The operation is characterized by evidence-based treatments including exposure and response prevention (ERP), prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing (EMDR). In some cases we combine individual treatment with group therapy each week, for example as part of our intensive day treatment program.Emily Laubham: I understand that the intensive day treatment program was one of the first of its kind. Can you talk about how this program helps people?
Dr. Doug Henry: Intensive day treatment and partial hospitalization programs provide a middle ground between inpatient care and outpatient therapy. Our intensive day treatment program generally involves between 12 and 29 hours of intensive, personalized treatment each week. Essentially, you’re getting a level of therapy similar to what an inpatient facility provides, but you’re able to live at home and go about the rest of your life.
There’s a burgeoning demand for this kind of intensive outpatient programming (IOP). We’re mid-way through our plan to build half a dozen regional outpatient and IOP centers for kids and adults. Each program can have a different emphasis. You can have effective IOP treatment for anything along the mood, thought, and anxiety spectrum.
IOP includes weekly individual therapy and medication management (as needed), but group therapy is an especially powerful additional component. People tend to make more progress in group therapy and at a faster rate. You can leverage the collective being and wisdom of the participants — it’s not just on the therapist. The work really comes to life in group.
Dr. Anthony Mannarino: It’s one thing for a therapist to say they understand, but it is so valuable for another group member to say, “I’ve been there, I know what you’re going through.” People at different points in their healing process can act as a model for other group members.
Emily Laubham: AHN has a Treatment Center for Adult Anxiety and Obsessive Compulsive Disorder. What’s the value of a specialized treatment center approach compared to someone just seeing an individual psychiatrist or psychologist?
Dr. Anthony Mannarino: Specialized clinics offer something the community can’t always get from private providers, which is a combination of treatments. Many adult patients with significant anxiety and OCD need a combination of psychotherapy and pharmacologic treatment. The literature supports that having one without the other isn’t as effective, especially for treatment-resistant OCD. Our approach helps connect different parts of the patient’s care.
Dr. Doug Henry: The center reflects a larger trend toward more specialty, boutique clinics set up for targeted populations. The model allows for clinicians to become more deeply trained, specialized experts on what they deliver. If you’re seeing and treating everything in the Diagnostic and Statistic Manual (DSM), it’s hard to develop the same level of expertise on any specific issue.
Emily Laubham: What are your most successful treatment options for anxiety and OCD?
Dr. Anthony Mannarino: Exposure and response prevention (ERP) is extremely effective. It’s been around for a while, but not everyone is well-trained in it. We consider it essential, and our staff are highly trained.
Dr. Doug Henry: With ERP, you expose the patient to the anxiety-inducing stimuli. The idea is to habituate their distress tolerance without them trying to avoid, escape, or participate in compulsive behaviors. You start gently and allow them to build up tolerance and strengthen their mental muscle. A lot of it is about proving to them that they can do it. In a relatively short time, you can have someone who was fairly disabled restored to good functioning.
There are a couple newer psychotherapeutic technologies as well. Transcranial magnetic stimulation (TMS) for OCD was just approved by the FDA about nine months ago, and insurance companies are slowly starting to reimburse. We also have a study at AHN on deep brain stimulation (DBS), where a lead is inserted into a certain area of the brain and activated to provide relief. While it’s been proven effective, a patient should have tried just about everything else before taking the risk of brain surgery.
Emily Laubham: We’ve talked about kids, adolescents, and adults, but what issues are being addressed in your infant/toddler mental health programming?
Dr. Doug Henry: It may seem counterintuitive that someone could have a mental health need so early on; however, infants and toddlers can be deemed at risk for mental health disorders by virtue of having an older sibling with an emotional disorder, or a parent with a major psychiatric disturbance. They may also be at risk due to adverse childhood experiences (ACEs), including being born positive for drug or alcohol exposure.
Our infant/toddler mental health program operates in conjunction with our postpartum depression program in the Women’s Behavioral Health Clinic at West Penn Hospital. Our programs are dyadic, with parent-child interactive therapy. They’re not targeting the infant, and they’re not targeting the mother — the client in this situation is the relationship between the child and mother.
It’s so important because we know that neuronal development in the first 24 months of life is radical. Every single day neurons are developing… or they’re not, and that “or not” could have scary longer-term consequences.
Emily Laubham: We’ve covered quite a bit of ground. Is there anything else you’d like to add?
Dr. Doug Henry: I would add that I hope the growing public awareness of mental health challenges leads to more equity on the business side of being a provider of mental health services. As we progress as a society in getting past stigma and recognizing the importance of mental health hygiene as an aspect of self-care, we need reimbursement and other parts of the U.S. health system to come along as well.
Dr. Anthony Mannarino: Despite all of our efforts and progress, there’s still significant stigma associated with mental health care. There’s a pervasive sense that people just need to “work harder” to overcome mental illness, and if they can’t, then they’re not motivated enough. In reality, mental illness is just like other medical disorders. Integrated care, digital care, the increased focus on prevention — these trends are all part of continuing progress, and progress also requires further advances in overcoming stigma.
Doug Henry, PhD, is a clinical psychologist licensed in Pennsylvania and California. From 2006 to 2017, he served as Clinical Administrator at Western Psychiatric Institute and Clinic of UPMC. He is now vice president of the AHN Psychiatry and Behavioral Health Institute, attracted by the integrated payer-provider model, and emphasis on patient-centered treatment at AHN.
Dr. Henry’s interests focus on providing broader access to the highest quality services for adults and families coping with mental illness and/or developmental challenges.
Anthony Mannarino, PhD, is chair of the AHN Psychiatry and Behavioral Health Institute, and is also Professor of Psychiatry at the Drexel University College of Medicine.
Dr. Mannarino has been a leader in the field of child traumatic stress for 25 years. He has been awarded numerous federal grants from the National Center on Child Abuse and Neglect and the National Institute of Mental Health to investigate the clinical course of traumatic stress symptoms in children and to develop effective treatment approaches for traumatized children and their families.
Dr. Mannarino has served as president of APSAC and president of the Section on Child Maltreatment, Division of Child and Family Policy and Practice, American Psychological Association. He is one of the co-developers of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT).
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