What would you do with $100 million dollars and the freedom to create your own youth mental health program from scratch? For Susan Swick, MD, executive director at Monterey, Calif.-based Ohana Center for Child and Adolescent Behavioral Health — part of Montage Health — that means tackling access issues, balancing service options, collaborating with the community and building a sustainable workforce.
Seven years ago, Dr. Swick was recruited from the suburbs of Boston to build the program with one stipulation: name the center Ohana, meaning “family” in Hawaiian, which Dr. Swick noted reflects its promise to be a welcoming place for children and families.
The project — largely funded from a $100 million gift from a single donor — reflects the needs and voices of the community and aims to tackle a major concern in child and adolescent psychiatry: access.
“As much as 75% of childhood psychiatric illnesses with the right diagnosis and evidence based treatment are curable. … That said, only about 1 in 5 kids who have a psychiatric illness ever see a mental health clinician. So 80% don’t,” Dr. Swick said.
While $100 million donations are rare, with so many pressing issues in child and adolescent psychiatry, it begs the question: How can systems maximize their funds to reach the largest number of people and make the greatest impact?
Throughout the design process, Dr. Swick sought to balance the full spectrum of care: crisis care, treatment and prevention. A vulnerable population’s first stop for care is crisis services such as emergency departments, which are the most accessible but also the most expensive, Dr. Swick said. Ohana aims to prepare for a time when prevention and crisis care are better proportioned.
“If we invested a little bit of our resources in prevention and the lion’s share of our resources in those evidence-based effective outpatient treatments that we know can get a young person to cure, then we can build crisis resources that are [at] a relatively lower volume, knowing that we’re eventually getting kids into the effective treatment that’s going to be curative,” she said.
Dr. Swick said child psychiatry is specifically challenging with issues such as lack of access to accurate diagnostic tests and providing long-term treatment services. But those investments are critical, especially for children, as 50% of all lifetime mental illnesses have shown up by the age of 15, Dr. Swick said.
“When you catch an illness early, it’s much easier to treat it and cure it than if it goes unrecognized or untreated for two or four or 10 years. It gets harder to treat, just like with medical illnesses, as they start to have some long-term sequela that gets a little more entrenched,” she said.
She aims to integrate prevention into every treatment to maintain “mental fitness” as she calls it, starting with whole-family care. The goal: equip the child’s natural immune system and give their go-to people power through knowledge with skills like the correct language to navigate conversations and support the individual. But, she clarifies, “We don’t want to make parents into therapists or doctors.”
“When parents can sort of be the right cheerleaders for their kids doing that work, their kids get better faster,” Dr. Swick said. “They have fewer relapses, lower need for medication, and you get kids back into being the hero of their story. Parents are already wanting to be supportive and helpful.”
Dr. Swick noted the most pivotal part of this project is the community. With over 200 volunteers — from social workers to business executives — stepping up to help however they can — this project has created a conversation. Dr. Swick said this community piece has turned out to be a “critical ingredient” in the well-being of children as there are layers of caring adults connected to these children — most indirectly, who they’ve never met.
“Being able to have a public conversation about young people and how to support their flourishing became a real shared conversation in this community. It’s made some things easier than I would have expected, because a lot of people show up to help out,” Dr. Swick said.
Like many behavioral health facilities across the country, Ohana has struggled with a shortage of clinicians, especially those trained in child psychiatry and psychotherapies. To that end, Dr. Swick said it was time for Ohana to pivot from place to work to a place to train.
Ohana started a postdoctoral program where psychologists can complete supervised clinical work in order to sit for the licensing exam. Training includes evidence-based treatments such as cognitive behavioral therapy and dives deeper into specialties such as family-based therapy for eating disorders.
“We now hire most of our therapists unlicensed, right out of social work school … and we are investing in training our unlicensed therapy team,” Dr. Swick said. “So becoming a training program sounds like a smart solution. … But building it from the ground up with the right infrastructure is definitely a big build.”
