The people who care

Tuesday, June 4, 2019

This 10-part series, a collaborative effort of the newspapers of Rust Publishing, NWIA, examines the myriad issues surrounding the mental health care crisis in Iowa. Reporters and editors from the Spencer Daily Reporter, Storm Lake Pilot-Tribune and Dickinson County News have contributed to the report.

Life as an Iowa mental health professional in 2019

Dr. Natalie Sandbulte, Dr. Rebecca McCrackin, and Marlee Christoffel stand inside Autumnís Center in Spencer.
Photo by Joseph Hopper

The core of any mental health care service is the basic interaction between a patient and the mental health professional providing care. They have many titles, such as psychologist, therapist or counselor, and without their contributions those suffering from mental illness would face a much more difficult road to recovery and normalcy.

In northwest Iowa, they can be found serving those in need from community health organizations like Plains Area Mental Health or Seasons Center for Behavioral Health which operate in multiple counties across northwest Iowa and in smaller, private practices like All Those Yesterdays located in downtown Spencer.

"It's the best job in the world," said Heidi Lohff, clinical supervisor at Plains Area Mental Health's Storm Lake office. "I don't know many people who get to say they impact someone's life at the end of the day. That's why we do this job."

Ryan Jensen, All Those Yesterdays mental health and substance abuse therapist, sits inside his new office which resides in Grand Avenue Community Outreach in Spencerís downtown district.
File photo

"I do this because somebody did this for me a long time ago and it saved my life," said Ryan Jensen, mental health and substance abuse therapist at All Those Yesterdays.

"Most in the field, they're there because they truly want to help," said Dr. Rebecca McCrackin, clinical psychologist and director of training and compliance at Seasons Center. "They see the need and are either part of the community or understand communities enough that they want to help people heal and be better, be the best they can be. But there's a lot of obstacles that can come up."

Despite the passion and enthusiasm within the mental health care profession, the local providers said there are several barriers to providing more effective care in the state of Iowa in 2019. Some of the most troublesome surround insurance companies, Iowa's Managed Care Organizations and funding in general. The region recently witnessed the effects of what can happen when an organization finds itself in a financial crisis with the collapse of Compass Pointe earlier in April. Jensen witnessed it firsthand as a former Compass Pointe employee. He said after being given seven days notice, "we were out of jobs, and all of our clients were out of counseling."

"Insurance companies run the world," Jensen said. "They run everything on our end, and that's where the system is very, very broken. It takes sometimes a few weeks, sometimes a month before we get paid for any of the services we make claims for. Without grants and without funding, stuff like that ... it can be hard to survive."

"It can be extremely frustrating because we are extremely limited by insurance companies, by funding sources," McCrackin said. "I would like to be able to give so much more. The best possible care is the ideal, but reality is, we can only give the best possible care for what we're allowed to give."

"Even if we think a certain thing is in the best interest of the client, we may not be able to do it because of those issues," said Dr. Natalie Sandbulte, clinical psychologist and vice president of clinical services at Seasons Center.

The lure of a career in Iowa's more developed urban areas has continued to attract professionals to Iowa's most populous cities. In stark contrast, rural Iowa is currently facing a shortage not only in attracting providers but in retaining them.

"It does come down to the fact the reimbursement rates are too low and people have to see a high number of clients and they can't," Sandbulte said. "They burn out. There's a workforce shortage and so we're getting these people who are really young, they're great people, but can't see that complex of cases and that many cases in a week. They need more support, but it's a vicious cycle. How do you get them the training and support they need while being financially stable?

She added, "We are constantly struggling with wait lists. We want to get people in, but we struggle attracting people here because it's rural Iowa. If you look under our careers tab on our web page, there's probably 30 open positions, and it's always like that. We just need more providers and it's hard to recruit them. If we do get lucky enough to have them, we hope they stay."

"For a psychologist here, we've had the same position open since 2013," McCrackin said. "Three people have applied and two of them backed out because they wanted more of a city mentality and style."

Attaining the correct education and certification for a career in Iowa as a provider can also be prohibitive for those trying to enter the market.

"With Medicaid, they put us through a very difficult process," Jensen said. "I've had my master's degree for over two years. I have been counseling for seven years and they made me do two years of more supervised experience before I could bill insurance for mental health counseling. It's like, how many hoops do we need to jump through to help people?"

"In the state of Iowa Medicare is very restricted on the credentialing they will let see their patients," Lohff said. "(Licensed independent social workers) are the only ones that can see Medicare and Tricare ó which is the military insurance ó that is very limiting. There are some offices that donít have an LISW, so the folks with Medicare who are 65 or older have no provider because LISW usually go to urban areas."

Sandbulte and her Seasons Center colleague Marlee Christoffel, licensed mental health counselor, said those who do manage to graduate school and enter the workforce can face an uphill battle in adjusting to financial regulations in the profession.

"School doesn't teach you about working with insurance," Sandbulte said. "You plop these 24-, 25-year-olds into this setting where they're meeting with these difficult clients, presenting them with complex cases like extreme trauma, generational illness, and then they're like "OK, go see 30 people a week. Good luck, because if you don't we canít pay for you to stay an employee here.' It's hard for them."

"It's that balance of, how do we take care of ourselves so we can take care of our clients but still get as many people served as need to be?" Christoffel said.

Despite the acknowledged challenges in the profession, the providers said they were grateful to treat patients in northwest Iowa and while doing so, have the understanding of others as the topic of mental health grows in importance at the state and national level.

"I think we are very, very lucky because we have organizations around us that are understanding or are at least willing to listen as to what the mental health needs are," McCrackin said. 'Whether it be law enforcement, hospitals, DHS, courts, anything like that. They're willing to listen and I think we have a huge benefit in the relationships we have. You don't always have that, and then it's even more of an uphill climb. We're lucky in that aspect that we have the relationships we do with some of the other systems we do."

With both Gov. Kim Reynolds and members of the Iowa Legislature acknowledging the need for mental health care and making changes to Iowa's mental health care system, the future of care in Iowa is currently unclear. However, as demonstrated in people like Jensen, whose prior organization collapsed and left him without a job, Iowa providers continue to follow their passion to help others.


Both Seasons and Plains Area offer crisis services for mental health emergencies in their service areas. Both Lohff and Sandbulte said the demand for crisis services has grown in the past year, with members of the crisis teams weathering stressful conditions to ensure proper care for patients in difficult situations.

"In the last couple of years it's really become a huge need," Lohff said. "At Plains Area we have our crisis line and a crisis home, we're trying to really get people services as a prevention but through these crisis services people are able to get the help they need right away."

Kimberly Silberstein, one of two full time staff members for Seasons Centerís 24/7 crisis line, agreed. Seasons' crisis team has grown to include a mobile crisis team which responds to law enforcement, hospitals, medical clinics and schools.

"We're 24/7," Silberstein said. "Someone will always answer the phone when it rings, even if itís midnight, 2 a.m., 4 a.m., whatever. Ö Even if an individual is not experiencing a crisis, maybe they need someone to talk to, bounce ideas off of, a behavior their child is having, something that happened at work and need someone to talk about it. Weíre just a general source of support for our clients or even anyone outside of our agencies.

She added, "A lot of the clients that do call, they just need a support system that doesn't have the biases that maybe other people in their life would have. So on my end, crisis services, I just try and be as much of a support for them as they need."

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