Two Sundays later I found myself back at the Shalom free clinic. I was unusually punctual and keen to explore what had been referred to by many on my previous visit as 'the other side'. I'm pretty sure that sending patients to the other side is generally discouraged in most health systems but at Shalom it simply referred to the part of the service that focused on mental health and psychological complaints.
The behavioural health clinic is situated in a church hall across the road from the main building and this, according to the founder, is the first of many necessary but negative changes that have occurred in recent years.
As she said when we spoke, "the separation between the two aspects of healthcare is the one thing she would change about the clinic; it goes against the philosophy behind its conception."
She also told me early on in our conversation that her desire when forming the clinic was to facilitate a space where patients would be treated like family. This was perhaps an easy thing to say in passing but I was interested to see how it would actually translate on the ground.
On entering the church hall, I was greeted by a very large pot of steaming bolognese.
A hot meal is offered every week to those attending the clinic and I'd been told that the reasoning behind it, apart from obviously providing sustenance, was to encourage people to stay and talk. It was strange to think of a healthcare facility that could and wanted to actively encourage patients to stay longer and this feeling was echoed by the founder's statement that "the clinic was originally set up so people told their stories five times".
I was fascinated to explore this comment more and in doing so came to understand how, at least in the past, the clinic had been set up to meet a variety of needs, many not medical in nature, through the availability of a variety of professionals. There had been the GP, as there is now, a nurse checking patients in as well as a social worker, an attorney and a member of the community offering spiritual/pastoral support. I wasn't surprised to hear that this ' one-stop shop' model had worked extremely well, especially for this population, many of whom were struggling with other life issues. However, I was equally not surprised to hear that it had been hard to sustain as patient numbers grew and professional support and time dwindled. It is worth noting that some relief came with the introduction of Obama care in the States and at the time of my visit (immediately post election) the repeal of this act was a huge concern for the clinic in terms of how they would cope.
As staff numbers have dropped, increasing responsibility has fallen on the board members who hold the service together. It is not unusual to find them there late into the evening as patients continue to turn up requesting to be seen.
When I met with the founder of the clinic we talked a lot about this sense of responsibility, how it affected her own life and how she felt it related to the community and American society as a whole. It was one of the many conversations I had during my stay in the States that concluded with the acknowledgement that the 'American dream', a concept that promises the opportunity for prosperity and success, and an upward social mobility for the family and children through hard work has led in many ways to a very individualistic culture where personal achievements and success are highly valued. Whilst great things have come from this, some would argue that certain areas of life, such as health, have suffered. Some would argue that convincing many Americans of the need to take responsibility for the health of the rest of the population would be a hard task, simply because it is not an idea that many have grown up with or experienced. Many of the healthcare professionals I spoke to see this as one of the main barriers to making changes to the current system.
One of the clinic workers who believed this and who I was privileged to spend time with worked primarily on the mental health side of the clinic. Her story was quite staggering; trained as a psychologist and social worker she had started out with her own private practice. Through the necessity of having to bill patients she found she was not accessing, in entirety, those who she felt would most benefit from her services. Many were limited by their insurance plans and, like we often see in the UK, care was restricted to six or fewer sessions. It was interesting to hear a psychologist's perspective on this as it is a frustration that I have felt myself whilst working in General practice but have only ever seen from the referring point of view. This particular psychologist talked of the impossibility of making an attachment in such a short time and the difficulty she had therefore experienced making real progress with patients. For her, it became 'too much about the money' and she could not cope with the feeling that she was 'exploiting mental health'.
She quit her private practice and began to volunteer for the Shalom clinic as well as a drug and alcohol assessment team in Chico. In order to live she teaches when she can at the local university. It is clearly sometimes a struggle and perhaps not how she would have imagined her life to be but she takes comfort in feeling that she can, to a certain extent, practice in the way she wants to.
I asked her to meet me for a coffee the week after we met at the clinic to talk more about her work. As we chatted over the best hot chocolate in town, I felt simultaneously in awe of and troubled by her weekly schedule. She understood that her choice of practice was unusual, remarking a few times how many of her colleagues had called her 'mad', and as a consequence of her dedication to her work in the clinic her patient load was high. She respected colleagues who worked along side her on the mental health side but where the majority of them (other social workers and psychiatrists) managed to keep to their hours and appointment numbers, she found her work often running over to an extreme degree. Through a struggle in getting people seen by secondary care who she feels are at risk, she often carries the responsibility of caring for some very complex patients single-handedly making
leaving her work in the office challenging; she spoke of spending multiple evenings during the week assessing patients at home and answering phone calls from people in distress.
I had so much admiration for her commitment to her patients but at the same time couldn't help but worry about her own emotional resilience and how long she could sustain this working life. I know she worried about it too but at the same time felt that some of the strengths of her own practice and that of the wider clinic lay in its uniqueness. She described Shalom as 'working on the edge'; necessary regulations were adhered to but boundaries were pushed and aspects of care were prioritised differently in comparison to other places. I think she summed it up well with the phrase, 'there's sometimes not a lot of privacy but there is a lot of embracing'.
I wanted to know what help there was available to her in managing some of her cases, was there a crisis team of some sort who could offer support in the community? She replied that they were 'trying to put one together' which answered the question fairly well: not as of yet. Her frustrations in the lack of support from other healthcare facilities in the area in addressing this need was evident but, like the founder of the clinic had told me the previous week, she did see a real desire to help from the community itself; 'the community really seems to want to do something, they just don't know what'.
Indeed it is often through community connections that people in need find their way to the clinic. I saw a good example of this in the case of a young woman who had attended the clinic the Sunday before; she had suffered with episodes of psychosis for a number of years and after a bad experience at the local hospital had become a recluse in her flat, refusing help. It was the hairdresser of one of the clinic workers who suggested to the patient's mother during a cut and colour session that she come to Shalom for help; she had now been seeing the social worker for over a year and was making good progress.
The behavioural health side of the clinic functions slightly differently to the physical health side. Most of the patients seen have booked appointments and are able to spend up to an hour with either a psychiatrist or social worker. There are, however, still 'walk-ins' and unsurprisingly it is the spontaneous presentations of problems of this nature that can be the most challenging to manage.
I experienced this first-hand during my second Sunday at the clinic as I sat in on a consultation with the social worker and a young man who had turned up fairly late in the day. He had moved to the States alone from Yemen three years ago and described a long-standing history of severe anxiety symptoms dating back to witnessing traumatic events in his childhood. Things had escalated to the point where he was now struggling to work and was in danger of losing his accommodation. I sat with the social worker and the patient for over half an hour as she began to very superficially touch on some of his experiences and the understandable anxiety he suffered as a consequence.
We talked about options for him, how she might be able to fit him in regularly to talk and, as he was keen to explore using a medication to help in the interim, we then sent him across the road to one of the GPs to assess him and prescribe if appropriate.
After he'd left I debriefed with the social worker and admitted that I even felt overwhelmed in hearing his story. There were so many issues to be dealt with, so many areas in which he needed help. I'd been witness to an amazing half hour with her in which I'd seen him experience a conversation that was clearly a first for him and a starting point to the rest of his journey. Yet I knew the pressure that the clinic was under and indeed the already full diary of this social worker alone. She shared my concerns and my frustration in the knowledge that she would be unable to give this man exactly what he needed but the point she made very clearly was that she would give him something, 'the best I can hope for is to give him some tools and go from there; all you can do is start the conversation'.
I saw so much value in that one half hour of conversation and coupled with the food, the care, the time and the medicine that made up the rest of the clinic, a real example of holistic care in its truest form. It's not perfect; providing such a service requires sacrifices from both staff and patients, but my experiences at the Shalom free clinic have made me look at the model of care we offer in a whole new light and consider what we could achieve by perhaps thinking a little more outside the box...