Why Mental Health Isn’t One-Size-Fits-All

Mar 24

Episode 39 with Beth Salcedo MD

In this episode of No Permission Necessary, Jill and Molly sit down with psychiatrist Beth Salcedo MD, to explore what it really means to support mental health in a system that often prioritizes quick fixes over long-term care.

Drawing from her experience leading a multi-location behavioral health practice, Beth shares insight into diagnosis, treatment, and the growing impact of social media on how people understand their mental health.

The conversation highlights the importance of therapy, lifestyle changes, and comprehensive care, while also addressing the challenges of navigating insurance and access to treatment.

Molly Bierman (00:00)
Beth I'm so excited to have you on I feel like for me knowing you knowing how much you've built your practices Knowing the population you treat. Why don't you just share a little bit about what you do in your day-to-day? that ⁓ You know has structured your passion for what you do in your psychiatric practice
Beth Salcedo (00:14)
Okay.
Okay, well, I think it's really important to note that even though I run these three offices, I do have a full clinical practice. So, you know, if I have a 40-hour week, 20 hours of it is devoted to my own patient care. And I think that's really important because, you know, things are always like, for example,
you know, this has been a rough year for the Washington DC area. And I'm experiencing that just like all my other clinicians are. And I think it's important that I know kind of what's going on in the clinical space versus just hearing about it from everybody else. Plus, you know, little things like, you know, prescription refills and the way things get handled in this practice, I need to experience it as if I were a clinician so I can make sure it's going the right way. So
I think that's a really important part of what I do. I know a lot of practice owners don't keep seeing patients, but I've really felt like it was important for me for that reason, but also for my own kind of professional satisfaction. I really enjoy the work that I do with my patients, as well as enjoy being an administrator of this big practice and, you know, helping support other clinicians in creating new service lines and bringing new things to the Ross Center. So I get a lot of...
enjoyment out of all of it.
Molly Bierman (01:39)
How many clients or patients do you guys see on average in your practices on a, I don't know how you quantify it, whether that's weekly or monthly.
Beth Salcedo (01:49)
Thousands. I can't tell you exactly the number, but ⁓ it's in the thousands on a monthly basis because we have 60 clinicians. ⁓ So there's a lot of patients being seen.
Molly Bierman (01:51)
Thousands. Okay.
Okay.
Jill Griffin (02:04)
Are they all prescribers?
Beth Salcedo (02:05)
No, no, probably like 30 % are prescribers and the rest are therapists of various disciplines. And everybody, you know, some people work 40, 50 hours a week, other people work six hours a week and everything in between.
Molly Bierman (02:13)
Okay. And so.
So take us back a little bit to the inception of the Ross Center. mean, we're looking at it at scale now. You have three locations, two in the mid Atlantic, one in New York City. And you are also seeing 20 hours of client facing work, which I think we'll get into a little bit later because Jill is also of the mindset running a group practice, knowing that keeping her pulse on patient care and client care is so, so important. But take us back a little bit to when you
Beth Salcedo (02:23)
Mm-hmm.
Yeah.
Right.
Molly Bierman (02:50)
Started the practice. What was the motivation behind the practice? Did you know how to Build a practice like where did you lean kind of tell us all the face down moment? Like what did that look like?
Beth Salcedo (03:00)
Yeah.
So actually the Ross Center existed before I came. It started in 1991 by a woman named Jerilyn Ross who was in the anxiety space. She had actually been a school teacher who had her own height phobia. And back in the seventies, wasn't, you know, CBT wasn't really a thing. It was starting to be a thing. But she met a couple of people who did some exposure at the time. It was
Molly Bierman (03:06)
Okay.
Beth Salcedo (03:27)
new to everybody, but now we know it as exposure therapy, helped her with her own anxiety disorder. So she went back and a master's in social work and started the outpatient practice that is now known as the Ross Center. It was actually called the Ross Center for anxiety and related disorders. And we don't really call it that anymore because it's really more, it's much more than that. So about five years into that is when I joined, I was a chief resident at GW and
You know, as such, had kind of a, it wasn't a cush situation, but it was a lot less work than I was used to. I didn't have to take call anymore. And someone that I met said that Jerilyn was looking for somebody to moonlight. And so I raised my hand and said I had huge student loans. So I, you know, needed to make some extra money ⁓ and started working with her. And it was just her and these three other women doing a very small amount of private practice, but all in the anxiety disorder space.
I brought the medication piece to the practice. ⁓ And then over time grew it because I had friends in the area who were interested in hearing more about what I was doing. Everybody was very interested in having a supportive place to work, but also a lot of autonomy. So
brought in several people and then some of the other therapists started to bring in people and it just kind of grew organically frankly. And Jerilyn got sick relatively shortly after that. I was still working part time and taking care of my kids and having kids and you know doing all that stuff but Jerilyn eventually got sick and left in her will that I could have the right of first refusal to buy the practice. So
you know, the last thing I wanted honestly was to lose what we had built because we had this really, it was a great community. And again, you you had all this support for, you know, when I went out on maternity leave, people supported me. ⁓ You know, if I was, anything that I needed, I had the support of the whole team, including an administrative team. So ⁓ I did everything I could to make that happen. And it took about a year, but it did eventually happen. And ⁓
⁓ I ended up selling half of the practice to another woman that worked here so that I would have a partner. And we just started growing it. And again, like it wasn't necessary. I hate to say this. I wish I could take a lot of credit for it, but it was not really our intention to grow it into these three offices. just, people would come and work with us and have a good experience and want to work more or, you know, then their friends might come. I mean, it really grew very organically. We haven't had to like,
advertise for people to join us. know, people call from the local residency programs when they're about to finish and they're interested in hearing about the Ross Center. And I think because, the people that run it have been, on both sides, so to speak, we were, you know, we worked here before we owned it. And so we knew kind of what made it a good experience for the clinician and we knew what would make it a bad experience for the clinician. So it's always been a really good place to work. So it's really grown on its own.
Jill Griffin (06:37)
you
Beth Salcedo (06:38)
Our
New York office opened up because we had a colleague that wanted to do what we're doing here in New York and our Virginia office the same way. So it wasn't some grand plan that we had, it just kind of happened organically. And I also think that when clinicians come to us and have an idea, we wanna support it, we wanna make it happen. The most recent thing we did is something called the single session consultation that I didn't know anything about frankly, but.
A couple of the therapists here had been following a woman named Jessica Schleider at Northwestern who is doing all this research on what can you do in one session? Like apparently if you look at insurance data, the most common thing as far as mental health appointments is that people just don't go. Most commonly you've had zero mental health appointments, but after that it's one.
Molly Bierman (07:28)
Yeah.
Beth Salcedo (07:31)
So many people go for one therapy session and never go back. So her thought was, if you got one chance, you gotta make it work. And so she's distilled some briefer types of therapy down into what can you do in one session to kind of, you know, get a really problem focused intervention and, you know, encourage, speak to the patient in a...
fairly routinized way to figure out what are their strengths and how can they move the needle on their problem just on a 10 point scale, just one point. And apparently, you know, and we've done several of them and they're actually quite fun to do as a clinician, but ⁓ it really makes people feel empowered and the outcome data even for like adolescents is really positive when you compare how they're doing versus their weightless controls. So, you know, we heard all of that from our
Molly Bierman (08:04)
Mm.
Beth Salcedo (08:25)
and their interest in that. And we were like, let's support this and try it. So we brought the training to the Ross Center and we've got 23, I think, clinicians who are offering this service and we've had really good feedback so far on it.
Molly Bierman (08:40)
the retention rate like on that? Like do people come back once you're trained in that way or the whole goal is that they're just coming in for one?
Beth Salcedo (08:48)
The whole goal is one session. it's, you know, the approach is if you want to have one session really problem focused, it's not about what's your medical history, what's your psychiatric history. It's you coming in and saying, you know, I'm struggling with my boss treating me poorly, something like that. A very specific problem and you speak for the session about the problem. You come up with an action plan and then you send them out the door. And if they want to come back,
Molly Bierman (09:02)
Yeah.
Beth Salcedo (09:17)
and do another single session, they can. They can do it with you. They can do it with whoever's available. If they decide that they wanna go to therapy, they can call and say, you know, what do you recommend? ⁓ But they get a chance to have one session of therapy with someone with a ton of experience without having to go through three or four sessions of the get to know you phase, you know? So it's a way of making therapy more accessible.
Molly Bierman (09:22)
somebody else. Okay.
Thanks
Beth Salcedo (09:42)
and also giving people one really good experience that then if they do need therapy, they're not gonna hesitate to get it, you know.
Molly Bierman (09:49)
Great,
great.
Jill Griffin (09:50)
And as you're saying that I'm just thinking of all the hoops we have to jump through with managed care. If you are billing insurance that like, they don't allow for you to just have that single session because of all the documentation. at this point in my day, I have jumped through hours of hoops of insurance issues. So that's probably why it's top of mind, but it's like, you know, part of the frustration, I don't know, maybe you can speak to this a little bit about.
Beth Salcedo (10:08)
Yeah.
Jill Griffin (10:18)
a twist, but the managed care system and what insurance asks us to do and Opposed to what the research is saying a lot of times, right? A lot of times, like you just mentioned, this woman has this research study. It shows we can have some, some effect, but yet the practices that most systems, there's some that are doing private pay and other services and we're all involved in that too. But most systems are insurance based. Most clients want to use their insurance. And so.
I don't know if you want to just speak on like a larger level with like how that affects our system of care and mental health and, you know, as a prescriber too, I'm sure you see that with refills, prescriptions, medication, all that stuff.
Beth Salcedo (10:56)
Yeah.
I mean, if we're honest, there's no company, there's no system in which the insurance companies are really looking out for our best interest, right? And all they're trying to do is maximize their profits. And so for a lot of them, the MO is delay, delay, delay, make it harder, make it less accessible. know, I mean, they...
They say that they're doing things like offering telemedicine, et cetera. But the reality is, if you're using your insurance, the system is really, really hard to use. And you're already in a very vulnerable position. So it makes it almost impossible. The single session is a consultation. There's no diagnosis. You don't do an assessment. So it has to be done outside of insurance because there's no, you don't
Jill Griffin (11:47)
Yeah.
Beth Salcedo (11:52)
come up with a diagnosis code at the end of it, you you're really focused on one very specific problem. So you can't bill insurance for that kind of thing. You should be able to because we've got these studies that show that it's good. There's good outcome data, but ⁓ you know, the insurance companies are not really interested in outcomes right now. They're interested in saving themselves money in the short term. Someone told me that the average person stays on their insurance plan.
And this you'd have to fact check, but the average person stays on their insurance plan for about six years. So the insurance company is really not interested in, know, if you're 40 now, you know, what's your bone density when you're 60? They're not interested in that. You know, they're interested in minimizing what they pay out on your behalf is really, that's the system that we have. And that needs to obviously shift 180 degrees.
Molly Bierman (12:32)
What's going to go at 50? Yeah.
Interesting.
Jill Griffin (12:45)
I think that's why there's lot of primary care coming online right now, because a lot of people are noticing, I'm not getting what I need from the primary care system. You see all these urgent cares popping up. People don't have relationships with primary care doctors anymore. And so I think there is a space and behavioral health is starting to see this with some more Concierge services popping up that like, they want somebody available to answer questions and navigating the system is very difficult.
Beth Salcedo (12:59)
Mm-hmm.
Yeah, it's really, really.
Jill Griffin (13:11)
especially when you're
struggling with your mental health.
Beth Salcedo (13:14)
Yeah, right, right. Yeah, it's impossible. The insurance company really makes it awful for everyone, for every reason. I mean, my husband recently had an orthopedic surgery and getting information about what was gonna be covered was impossible. So we basically went into the surgery thinking we could owe a copay or we could owe many thousands of dollars. We really had no idea. And he's a physician, you know? And he understands the insurance world. So if he couldn't do it,
Molly Bierman (13:29)
Okay.
Beth Salcedo (13:41)
You know, who can figure all that out?
Molly Bierman (13:43)
The average
consumer has no clue. I mean, just no clue. And honestly, I worked in insurance for a period of time and I still struggle to sometimes wrap my head around, you know, the different caveats to every plan. So.
Beth Salcedo (13:46)
Mm-mm. Mm-mm. Right.
Yeah. Well, and they change
Jill Griffin (13:58)
You never
will. Yeah.
Beth Salcedo (13:59)
a little something every year. So to keep you on your toes, I guess. Yeah.
Molly Bierman (14:01)
Yeah, yeah, exactly. And when you said
the average insurance plan was every six years of, you know, the average American changes their, you know, health insurance every six years, I feel like mine's changing every year. I mean, I don't know what's happening. Every year I have a new plan. So
Beth Salcedo (14:14)
Mine has a blade too. Yeah. Mm-hmm.
Jill Griffin (14:19)
I know is that
insurance premium I just got for my business and everyone's insurance premiums going up 11 % this year and ⁓ our reimbursement rates are not. So I just want to throw that out there that they are ready or making a profit off of us. Okay.
Beth Salcedo (14:26)
Lights.
Right, right, right. Exactly,
exactly, exactly.
Molly Bierman (14:35)
Yeah, it's
always, yeah, our freedoms are always going up and our margins are always going down.
Jill Griffin (14:38)
It's crazy. It's like we're a consumer
Beth Salcedo (14:40)
Yeah.
Jill Griffin (14:41)
and we're, it's like we're on both ends of it. We see what you're doing.
Beth Salcedo (14:44)
Right,
Molly Bierman (14:45)
Yeah.
Beth Salcedo (14:45)
right, exactly, exactly.
Jill Griffin (14:46)
And
so I guess this also segues into, we talk about medication, we talk about the distress of life. And I know I'm a clinician by trade, I'm an LCSW and a lot of times we are collaborating with prescribers around medication. And I think our society loves to throw a quick fix at a problem. Medication is one of those top things. We see it in all trends throughout the years.
Beth Salcedo (15:01)
and
Jill Griffin (15:13)
When we talk about studies, the studies show that medication works best when it's coupled with psychotherapy. ⁓ And a lot of things that I'm, if I'm recommending medication, it's because we can't access coping skills without it at this point. We've done all we can do in therapy and now we need something else. So I don't know if you wanna talk a little bit about what normal kind of distress and the stresses of life, we all have it.
Beth Salcedo (15:19)
Absolutely.
Mm-hmm.
Jill Griffin (15:38)
and when medication may be necessary or when you might want to consult with a medication provider and speak a little bit towards that.
Beth Salcedo (15:44)
Yeah, so I'm a huge fan of people starting with therapy as I think most people in behavioral health are. And if therapy is not working, I think people often think, well, maybe I need to think about medication. But sometimes therapy is not working because it's the wrong kind of therapy or it's not the right fit. So I think it's also important to think about a second opinion for therapy. But I would say what we see is that people's
their reactions to the stressors of life are outsized or they're reacting to that, you know, everything is great, but they're still depressed or they're still highly anxious, even though they aren't having, you know, multiple different kinds of triggers. And it's impacting their life in a multitude of ways. It's not just at work. It's also at home. It's, you know, more than one part of their life is impacted. ⁓
you know, they simply they can't sleep because they're so anxious and they're sleep deprived and therefore they're not functioning the way they need to the next day, et cetera. They're always angry with their spouse and irritable and that sort of thing. So it's really when the symptoms start impacting their functioning in one or more areas of their life that ⁓ if therapy is not enough to contain that medication can be added. ⁓
And you know, unfortunately, a lot of times people get the message then that you shouldn't be feeling X, Y or Z, you know, that no negative feeling is tolerable, right? And they'll often come in wanting medication when there's been a loss or when, you know, like ⁓ someone that I've seen recently is dealing with chronic anemia that has basically not been handled by her medical professionals and she's depressed for
Plenty of reasons, not the least of which is her hemoglobin is way too low and she can barely function. So I'm not going to medicate her. I'm going to send her back to those providers and say, we've got to fix this problem. It's been, she's been put off a little bit by them. So, you know, in her case, I think she was assuming that maybe this is depression and it needs to be treated with more medication. But I think this is depression secondary to a medical issue.
Jill Griffin (17:45)
Thank
Beth Salcedo (17:58)
and she's got to get that taken care of. You see that a lot in menopausal women, that they have a lot of emotional symptoms that come up around menopause and perimenopause. And, you know, rather than sticking them on an antidepressant or giving them sleep meds, you know, if you treat many of these women with hormone replacement therapy, their symptoms get incredibly better pretty quickly too, actually. So it's really important that the comprehensive medical history is part of any medication assessment for sure.
Jill Griffin (18:26)
One of the things we find in practice is that there is a subset of clients who really struggle with that message of no to a medication. They want the medication, they want that to be the quick fix because sometimes the other solutions are found in changing your diet, exercise.
Beth Salcedo (18:36)
Mm-hmm. Mm-hmm.
Right.
Jill Griffin (18:48)
⁓
you know, making some of these changes that are going to impact your hormones. We recommend sleep studies a lot to our clients because sleep apnea shows a lot of, you know, mental health symptoms if it's not treated properly. all, again, all of these things. And I guess as a clinician, you know, when we're ethically treating people, have to, you know, we talk about the risks and the benefits, but there's also this other part of it where it's like, we're not just going to throw
Beth Salcedo (18:54)
you
Yep.
Jill Griffin (19:16)
a treatment option at you when there's other lower risk options available. ⁓ But I think the whole concept is we have to be able to be uncomfortable and tolerate discomfort. And I think we've gotten so used to being comfortable. This is the topic that's come up in a lot of conversations this past week that in order to build resilience, we have go through discomfort. you're not going to learn how to.
Beth Salcedo (19:21)
Mm-hmm.
Jill Griffin (19:41)
to tolerate that and get through it if we're always kind of dampening the emotions or like taking the discomfort of it away.
Beth Salcedo (19:48)
You're absolutely right and I think we're seeing that in our kids because our kids are really struggling now with building resilience. The parents, the idea of a kid being sad or anxious is so uncomfortable for the parents that they do everything they can to fix that problem for the kid and the kid doesn't develop the skills that would make them resilient in those situations. So it's a huge problem all over the, certainly all over this country, but in every demographic, I think.
Molly Bierman (20:16)
How do you help navigate for parents? And you see children too in your center, right? Or you only see adults? But somebody does. Okay.
Beth Salcedo (20:21)
We do. I don't personally, but ⁓ yeah, we have
lots of different parenting programs. And there's more and more, again, evidence-based stuff coming out for parents. There's something called PCIT, which is about the interaction between the child and the parent and ⁓ a therapist observing that interaction and giving feedback to the parent, not having the kid in therapy, but having the parent in the therapy. ⁓
thing else called space, is it's supportive parenting for anxious childhood emotions. And it's fabulous because it's really all about the parents and explaining to the parents that what they say and do and how they interact with the child can either encourage the anxiety or it can help mitigate it. ⁓ And parents don't really understand that, you know, ⁓ it's not intuitive for everybody. So we are really pushing a lot of the parent coaching stuff. And hopefully that will be
preventive for some kids for, you know, development of anxiety disorders and mood disorders later on.
Jill Griffin (21:24)
Do you see pushback? Because I think we all see pushback. The parents accepting that they are part of the problem.
Beth Salcedo (21:28)
Yeah!
Right, right, so we try not to, we don't say immediately you're part of the problem. What we do say is, know, given your child's or with a child your age, your child's age, it's often best to work through the parents. You you sort of function as the therapist under our tutelage, sort of, you know? So we don't say you're the problem. And in fact, they're really, I mean, they're doing the best they can most of the time.
Jill Griffin (21:35)
Yeah.
Beth Salcedo (21:58)
Right? But a lot of times they do just want to bring the kid, drop the kid off and say, fix my kid. And that's never going to go well. I mean, no matter what's going on, the parents really need to be involved with what's going on for their child.
Molly Bierman (22:11)
Okay.
Jill Griffin (22:11)
Well,
you can't heal in the same environment that you got sick in, right? And we talk about that a lot too. Like we can't, the child can't come to us and we put all these coping skills in place and then they go right back to the same dysfunctional patterns. Everyone kind of needs to be on board with changing some behaviors.
Beth Salcedo (22:24)
Right. Yeah. ⁓
Yeah,
right. And the family definitely needs to change in sometimes in big ways, sometimes in small, but that's a huge part of process for any of these kids for sure.
Molly Bierman (22:40)
I think a lot of what we've been seeing too, I mean, I naturally see families post when they probably should have intervened, right, or gotten a second opinion, or they were hooked up with a prescriber from an early age. I see a lot of families that have children that were diagnosed with ADHD ranging from ages four to seven, put on medication usually as early as six. And so, and a lot of that happens in high performing overachieving.
Beth Salcedo (22:48)
Mm-hmm.
Molly Bierman (23:07)
⁓ wealthy socioeconomic environments, right? And so what has been your observation as you've navigated all different trends of prescribing different clinical interventions, you've been in practice for an extremely long time. And then also being a parent yourself, what would you say to the parent who may be struggling with different challenges with their child and are very quick to say,
you know, this doctor or that prescriber, you know, and I know that you don't necessarily treat, you know, adolescents, but knowing, you know, what you, the information you have in your practice, what would be some of the ways that are tangible for a family to start to explore other ways to support their family system, their child, even their own parenting style.
Beth Salcedo (23:41)
Hmm
Yeah.
I think a lot of times what needs to happen, especially if there's already been a kid, say, for three or four years has been on ADHD medicines and things are just not going well, sometimes what it takes is everybody stepping back, starting over, really doing a comprehensive assessment. A lot of times that might mean a full neuropsych assessment ⁓ and figuring out all of the pieces and doing ⁓ an evaluation of...
Molly Bierman (24:15)
Right.
Beth Salcedo (24:21)
the relationship between the parents, the relationship with parents and child, the family dynamics as a whole. All of that really needs to get looked at in order to figure out what's going on. So a lot of times it's really about, of course we pay attention to history and we find out what power providers have done. But if no one's ever really done a thorough assessment of the family system that the kid lives in day to day, then that needs to happen. ⁓
Molly Bierman (24:47)
Right.
Beth Salcedo (24:50)
can take a lot of time and energy and money, but it's really, really important. And so, you know, most of these parents want to do the right thing by their kids and they will, especially if they've been struggling, they will usually do whatever it is we recommend, you know, to really figure it out.
Molly Bierman (25:08)
I think part of the problem that I see and that I get really challenged with in a lot of ways, and it's not because I don't trust the medical system. I think there's a school of thought finding the right provider just like anything else, right? Searching out the people that you can trust that are transparent that you have a connection with. But I think where I get frustrated and challenged looking at systems that are coming to
to my firm primarily in crisis, okay? So they've kind of well surpassed the challenging phase. They're now more of the crisis phase. What is your recommendation, number one, to families who, or even clinicians who are stuck with a client, right? What are some of the things that you can help suggest that would deter someone from going to just their primary care doc?
to be treated with a psychotropic medication. There's some part of me there that is like, why am I going to my GP who's supposed to just kind of check my overall physical health for my mental health? It feels to me that there's a large disconnect and we're so quick to hear about individuals that are quickly prescribed a Lexapro or a Prozac or a, you know.
Beth Salcedo (26:21)
Yeah.
and they're given
a prescription that lasts for a year and nobody follows up. Yeah, yeah. And you know.
Molly Bierman (26:28)
And that's it. Yeah. So what would
you say to be more aware of when you're working with, you know, because that's a very common practice that is, you know, primary, you know, where you see individuals who struggle with anxiety or depression, where they are commonly getting their first prescription is through either their internist or their GP. And so, you know, what are some of the recommendations you would have for both adults and children? You know, I, you know, both alike.
Beth Salcedo (26:55)
Well, I think, you know, if at all possible, if you haven't been to a mental health professional who can provide a diagnosis and a treatment recommendation, then you should do that. I think the problem, like we alluded to earlier, is the system is really broken. You know, people look on their insurance website and they might call 10 or 15 different therapists and not get responses or half the responses are, you know, no longer take your insurance. I mean, it's a much bigger problem.
what you're talking about. If it weren't, then I would say to every internist out there, have a cadre of good therapists who again are good diagnosticians who you can send people to to get a really good evaluation and a treatment plan before I just hand them medication. Having said all that, sometimes some people are like, it's either medication or nothing. I'm not going to therapy and I'm having all these panic attacks and I'm about to lose my job.
You know, so the internist will say, okay, let me do something rather than nothing. And I think the mistake that they sometimes make is not saying we need to meet again in two weeks or three weeks or four weeks, whatever it is, people, think, can't be just left to their own devices in a situation like that. They really need follow-up and they need to make sure that what they're taking is working.
Molly Bierman (27:55)
nothing.
Beth Salcedo (28:11)
Or that they know what all the other options are, if what they're taking is not working or if they change their mind. And all of that takes time. And again, in our system, our insurance-based system, there is no time, right?
Molly Bierman (28:25)
I also think
that we live in a world of instant gratification. kind of going to one topic that I think is hot right now is just the amount of information people are digesting on social media about mental illness. And so back when I started my career in substance use disorder primarily first and then kind of brought into larger behavioral health issues, there was a lot of stigma around addiction.
Beth Salcedo (28:28)
Hmm.
Jill Griffin (28:44)
Thank
Beth Salcedo (28:52)
Mm-hmm.
Molly Bierman (28:52)
And
a lot of people didn't talk about it. A lot of people, even myself, early, I went to my first residential treatment program when I was 17. That story's for another day. But through that process, ⁓ I had loving parents who we were in a semi-affluent area in Connecticut where I grew up. And there was not a lot of exposure of where I was, who they could talk to.
And slowly over time, over the time that I've been sober now and in recovery is that the stigma of addiction has become less and less, right? There's been more recovering out loud, more, you know, access, more normalization, more ⁓ community, et cetera, right? It's just grown and grown and grown. But what we saw with that double edged sword, when the stigma started to lower,
was that families really started to hear more about fatalities, overdose. Obviously, overdoses started to increase. The risk of setting a boundary with your child, the risk of setting a boundary with their loved one. And so what we found was this kind of like double edged effect, right? On one hand for the people in recovery, it was extremely valuable, right? There was a lot more connection, less judgment, all those things.
Beth Salcedo (29:55)
Mm-hmm. Mm-hmm.
Yeah.
Molly Bierman (30:11)
But on the other hand, for a parent or someone who had a loved one who was still active, they were gripping to their loved one like, my God, if I let this person go,
they may not come back. Right. So all that to say with everything that has gone on with mental health also being destigmatized, there has been a rise in social media where people have been reporting or self diagnosing themselves.
Beth Salcedo (30:30)
Mm-hmm. Mm-hmm.
Mm-hmm.
Molly Bierman (30:39)
people's TikToks, Instagrams
or otherwise. So tell us a little bit about what that has looked like in your practice, in you have children, I don't know how old your children are, but you know, I'm sure you hear stories from them as well. Tell us a little bit like what has social media done to the Ross Center and you as a prescriber.
Beth Salcedo (31:00)
Well, I think one thing that it did do on the positive, and my husband thinks that social media is evil. He thinks that Steve Jobs is rolling in his grave, knowing that eight-year-olds are on a smartphone all the time, et cetera. So there's this idea that social media has been bad for kids overall. There's not a ton of data to support that.
Molly Bierman (31:04)
Okay.
Mm-hmm.
Beth Salcedo (31:25)
There is some data that suggests even that social media has been good for awareness of mental health issues in general, and I agree with that. I think that in some cases, social media has been helpful for someone who, is very depressed, maybe even suicidal. And if they've got some kind of connection, even if it's through social media, it pulls them up and keeps them safe maybe for another day, right? But in general,
you know, there's so much misinformation that's out there and there are so many people suggesting, you know, you must have ADHD because of X, Y, and Z. And so we are getting people coming in and saying, you know, I was on Twitter or I was on X or whatever it is. And I think I have ADHD because of X, Y, and Z. And, you know, we obviously do a thorough evaluation and let them know that it's not. And there's often a lot of disappointment because
Molly Bierman (32:15)
break.
Beth Salcedo (32:22)
They want to get the quick fix with the stimulant, which by the way, helps anyone. I would love to be on a stimulant. I would get so much more done if I was on a stimulant, right? So everybody kind of, not everybody wants one, but plenty of people do. Yeah, until you crash, ⁓ And so there's often a lot of disappointment because like you said, Jill, maybe it really is about, you know what? You're burning the midnight oil and you need to get some sleep and you don't eat enough. And you're not taking care of yourself and you're trying to...
Molly Bierman (32:29)
Let's see.
Jill Griffin (32:30)
same.
Until I crash.
Beth Salcedo (32:50)
run your business, but you're trying to work 18 hour days and that's just not gonna work. It's not ADHD, it's that you're burnout, you know? So people don't always wanna hear the harder answer. ⁓ But we definitely have seen a shift in what people are coming for. I think right now the hot bed topic is ⁓ autism spectrum disorder, right? ⁓ And people are thinking, ⁓ maybe that explains what's going on with me or maybe that sounds like me. ⁓
Molly Bierman (33:01)
on
Beth Salcedo (33:20)
plenty of people who are on the spectrum are getting some good answers, which is really lovely. But then there are people on the other hand who are looking for something to explain ⁓ something that they're doing or feeling or ⁓ some behavior of theirs that really has other explanations and they don't necessarily want to hear the reality. I think the overarching thing is more information is better and more awareness is better.
But we just have to shift a little bit how we approach these things with people.
Jill Griffin (33:52)
Well, I think I always try to remind clients too that the DSM and you look at these bullet points of all these symptoms at any given people can maybe hit on some of those symptoms, but there's a reason why we went to school for this to diagnose people, right? So it's not just you look in and, ⁓ I did that or I do this or I feel that and now I must have this. It's like, that's not, it's not really how it works.
Beth Salcedo (33:59)
the
Right, Yeah.
Jill Griffin (34:16)
⁓ go see a professional. But I also think that, ⁓ you know, the problem is with the misinformation is, I don't know, just going into these absolutes with all of this stuff and, and it's not just diagnosis, but treatment. And so what happens a lot of times is people come in almost this hope that I've, I figured it out. I have this diagnosis. I know what the treatment is and I've, I'm coming to you to get that.
And so there is this letdown when we're sitting on the other side and we're saying, Hey, yeah, I hear you. The assessment doesn't say that. And here's why. And here's the data points that we're looking at. And this is actually what I think you have. And this would be the solution. Because the reality is some of those changes you just talked about It feels out of reach and impossible to most people that I talk to. And that's, that's not even people that I feel like have.
Molly Bierman (34:52)
Thank you.
Beth Salcedo (35:02)
Yeah.
Jill Griffin (35:06)
a diagnosis, a mental health diagnosis. ⁓ That behavioral change is this really tough. So I'm wondering, you know, what maybe you tell your patients some of those, behavioral changes that need to be made and maybe some ways that you're, having those conversations.
Beth Salcedo (35:08)
Right, yeah, yeah, no, it's very true. Yeah.
I I usually try to break it down into something that's doable. So let's say somebody has like the worst sleep ever. They go to sleep too late, they wake up frequently, they never feel rested, et cetera. You know, take one little step. There's probably 10 different things they could do to make it better, but maybe you focus on just one step that feels doable. I had somebody once, ⁓ was a woman in her 50s, and I asked her to take the phone out of her bed.
and she started crying. Literally, she was crying when I said, just put it on the side table so that it's not so readily accessible. She couldn't do it. So we had to come up with something else that she could do to slowly start the process of change. I think for most people, and this is where the single session comes into play, for most people, it feels like this huge mountain. And if you break it down into tiny steps and they start to take the steps and see that they can actually do it, it makes a huge difference.
So, you for many people taking the phone out of the bed is easy, right? That's the first step and that's great. Get the electronics out of the bed, right? But for other people, it's not. So I think you have to really have an open mind walking into things with people and figure out, you know, what needs to change and what are they willing to do? What do they feel like they can do? Even if it's just the tiniest step, like changing your bedtime by 15 minutes, right? It sounds very easy for people who don't have problems sleeping, but for others, it's a big deal.
So that's.
Jill Griffin (36:53)
And the
plug for motivational interviewing, because if we think about motivational interviewing, it started in the medical field. It didn't start as a drug and alcohol intervention. So I think it's bringing it back to some of these behavioral changes. It's like, okay, well, how willing are you to do this? Because if the willingness is low, we got to start there.
Beth Salcedo (36:56)
Yes.
Mm-hmm.
Right, right.
Right, right. Don't even bother if there's not a willingness.
Jill Griffin (37:16)
You can be in as much pain as you want because of
your behavior and not like it, but if your willingness is low, we're not going to get anywhere. I keep throwing interventions at you.
Beth Salcedo (37:25)
Right, exactly, exactly. So you gotta meet people where they are and I think that does get lost sometimes, especially again, when there's not enough time to build the relationship and start to look at it as a collaborative thing that you're doing together.
Molly Bierman (37:38)
When you talk about, you know, having a collaborative effort and meeting people where they are, starting to build those foundational blocks, a lot of that plays into building a business and, you know, to kind of segue into what it's looked like as navigated your life. sounds like your husband also has a very as well, you know, being a physician, having children.
Beth Salcedo (37:53)
Mm-hmm.
Mm-hmm.
Molly Bierman (38:06)
taking over this practice, not really having to do much marketing, it growing organically. What were some of the things that either you questioned, feared, what were the moments where you you ever like, I can't do this, this feels too much. ⁓ You know, I think a lot of our listeners.
here on No Permission Necessary really get to a place where they want to take the risk to do something different. They want to build something bigger, right? They want to maybe get out of that nine to five grind and have a little bit more freedom. So maybe share with us a little bit about what that
Beth Salcedo (38:35)
Thank you.
Molly Bierman (38:43)
what that has been like, what have been the face down moments, what have been some of the scary times and how did you walk through that and take care of yourself to also be holding space still 20 clinical hours week, which I think we have to unpack at another time. I mean, that's still lot of clinical hours.
Beth Salcedo (39:00)
So I would say the first thing when we initially started all this, I was really scared because I didn't have a lot of financial resources, right? I was paying down my student loans. I bought this Ross Center and took on some debt with that. ⁓ So I was scared to do much. And in thinking about bringing new people on and contracts and things like that, was scared to death to like.
spend money for an attorney or spend money for administrative help, et cetera. And I made a couple of missteps for sure by trying to like, at the time we didn't even have AI or it wasn't like you could get a contract off the internet in the late, early 2000s. So we tried to do things sort of on the cheap with not using attorneys, not hiring the professionals that we needed to.
And nothing terrible happened, but it could have. ⁓ And at some point I was like, we got to do this the right way. So we got a good attorney. We had a fabulous accountant. And then I hired somebody to help run the operations piece of the practice and paid them a lot of money to do so because that was the only way that I could get all that stuff done and still hold onto my clinical practice and have that clinical connection with all the clinicians that worked with me. ⁓
And I would say that's the most important thing that we've done is pay people to help out in running all of this. Give people stipends if they take on running of a program. ⁓ This is not a business where you're gonna get rich. It's just, it's about time and ⁓ people's mental health. And you can make a living certainly and raise kids and send them to college and those kinds of things, but.
If you're trying to pinch every penny and you end up not having a well-run business, it's all kind of for naught. So I would say the most important thing we did is have good advisors and good people that we paid to do the work that we couldn't do ourselves or that we didn't know how to do because we're clinicians.
Molly Bierman (41:09)
Yeah. And I think that's like, Jules talks a lot about that, you know, how moving from a clinician to a business owner and what that really looks like is a pretty steep transition. And you really do need to call on people that have the organizational structure to be able to be your, COO or whatever that individual is called. how long has it now been since you took over the Ross Center? What year was that?
Beth Salcedo (41:26)
Yeah. Yeah.
It was 2010 that we took over. But on paper we took over in 2010, but it was probably more like 2006 because Jeroen was sick for a while. So it's been 20 years.
Molly Bierman (41:41)
Okay, and how old
Jill Griffin (41:42)
So 20 years.
Molly Bierman (41:44)
were your kids when you took over the practice?
Beth Salcedo (41:47)
My kids were like two, seven and nine.
Molly Bierman (41:50)
Okay. And was there ever a time, I mean, we talk a lot about this as well. I have much smaller kids than Jill and much smaller kids than you, but is there ever a time where you building a business where like, I feel spread thin, I feel like how am gonna manage all this between school activities and dance recital or a tennis lesson or whatever it was, know, how did you keep your center?
I mean, how did you keep going?
Beth Salcedo (42:16)
So I
would say, you know, I had a fabulous partner in my his one flaw was that he was an anesthesiologist and he took a lot of call. And sometimes that call meant he would come home at 11 o'clock at night, but sometimes it meant he would be there at three in the afternoon. So he could be around potentially to take the kids to soccer or whatever it was, but he was a little bit unreliable on the call days. So we agreed early on that we would have
a nanny who drove and rely on her for the days that I was working and he couldn't necessarily be around and that we would have someone help us around the house, you know? Because there's just only so much you can do. The one thing I always wanted to do though was cook for my kids. I didn't care who did their laundry or who cleaned up after them, but I wanted to be the one to cook for them and I'll never forget once my daughter saying, mom.
you make the best macaroni and cheese. And it was like a box of craft, right? But I had put it together, you know, and it was my way of taking care of her. And she felt like well cared for with that little craft mac and cheese, you know. So that was always really important to me. So again, I would say just like in the workplace, I got a lot of help. And if I started feeling like I was overwhelmed, I had to step back and say something has to go.
I can't do 18 million things. There's only so much room and to make sure too, to give myself a lot of grace in that. And no, I'm a human being. I need a certain amount of sleep and there's a finite amount of time in the day. And if I can't do it, either we don't do it or we hire someone else to do it.
Jill Griffin (43:38)
See you.
Molly Bierman (43:52)
Mm-hmm. Mm-hmm.
Yeah.
Jill Griffin (43:55)
And parenting role shifts, right? Eventually your kids don't want you as much, right? And so I've always really reflected back. I know I quit agency work when my children were five and two, maybe four and one. And part of the reason for that is I didn't want to miss their childhoods, being on call, they knew my work phone, ringtone, all this stuff, right? my schedule, I'm still
Beth Salcedo (43:59)
Absolutely.
Jill Griffin (44:22)
I work sometimes on the weekends or my schedule is different now that I'm a business owner, but when they have a field trip or when they have, I'm available for the things that they are going to remember me being there for, like their sports games and their practices and all that. And I'm so glad that you brought up cooking because I had this argument with my husband a couple of weeks ago where he's like, why, you know, why is the cooking thing such a big deal? It's like, that's the thing that I want to do. And last night, my son, my son goes,
My husband's complaining, every time you cook there's so much more dishes. And my son goes, bless his heart. He goes, that's because mommy's a better cook because there's more dishes because more people eat it because more people like it. I said, you know what? You're right, Beckett. That is exactly why. Thank you. Thank you. Thank you for pointing that out. Well, daddy does the dishes.
Beth Salcedo (45:02)
He deserves a reward, kid. Yeah.
Molly Bierman (45:10)
I also feel like there's some sort of therapeutic value in I also like to cook and I have developed that over the years, but I also remember my mom cooking a lot for us and it was like, yeah, we had carpools and we had.
you know, neighbors, and it was a team effort and all the things, right? But I do remember her cooking dinner and, you know, same as my grandmother. So I don't know. I think it's just like a tradition thing too. I mean, I definitely don't have the ability to cook for my kids every single night, but you know, there's always something available and, you know, I...
have found that when I do, it also is a therapeutic value to me. It's like unloading the day. Like I can only focus on what I'm doing right now because I'm not that good. Like I'm not a professional at this. So I have to really read the recipe. I have to be in the moment. Don't talk to me. I can't be distracted, you know? So I think it also gives me time to unwind. And I think it's a really helpful tool.
Beth Salcedo (45:48)
Yeah.
Yeah.
Yeah.
Yeah, and that doesn't have to be true for every woman, but I think it's important that they figure out what is the substitute for them. This thing, this cooking may work for us for different reasons, but everybody has their things, right? And I think you have to really respect that about yourself, right? What works for you.
Molly Bierman (46:21)
Yeah.
Yeah. And figure out what it is. Yeah, absolutely. So
how have you felt like you have maintained your clinical integrity as things have grown? You know, you have now a thousand plus encounters, it sounds like in your practice a month, which is a pretty large number across all three sites. So what is it that you do to keep your clinical integrity, the team's clinical integrity, and making sure you're not practicing out of scope?
Beth Salcedo (46:50)
I mean, the very first thing is to hire clinicians that have the same values as you. And as soon as you see that value shift, act in some way. ⁓ So that's the very first thing. One of the things that our administrative team does is make sure everybody is keeping up with their credentialing, getting all their continuing ed credits, et cetera. I pay a lot of attention to if
You know, if there's a peep about, one clinician from another clinician or from a patient or from a parent, you know, I follow up on everything about that. In fact, the admin team often is a great source of information. You know, this clinician is showing up late for the patients or not showing up at all or canceling too often. So, you know, I think there's some red flags that...
Molly Bierman (47:29)
Mm-hmm.
Beth Salcedo (47:39)
often mean that things are going awry for one reason or another. And so I pay a lot of attention to all of that. And again, I can't emphasize it's, is a huge team effort. It is not just me. It's so many other people. I wouldn't be doing this. I wouldn't be able to do this if I didn't have a team of incredible clinicians and administrative staff with me, you know.
Molly Bierman (48:02)
mean, truly impressive. and also level of humility that people walk with really shows in your team, know, essentially when you're in a place of humility and encouragement and connection to your team, it reflects naturally and organically. So I'm not surprised that you're
practice has grown in the way that it has because if that's the leadership quality that you lead with, then it naturally permeates through the team. So it becomes an easy place to work for. It doesn't mean that the work is easy, but it becomes less strenuous to come to work every day and work with clients and families that are really in, you know, some troubling times. So, ⁓ yeah, truly.
Beth Salcedo (48:42)
Thank you.
Well, and the one
other thing I'll say is that we are extremely collaborative here. ⁓ And that's an expectation. Like if you want to come work here, you better be somebody who calls every therapist that your patients are working with or calls every psychiatrist that your patients are working with and stays in touch. You don't have to be in touch all the time, especially when things are going really well. But that expectation needs to be put out there.
So we're like that internally with each other, but also I have plenty of therapists outside of here that I work with and usually update them when there's something going on or when I'm making a change and expect for them to do the same with me and want to keep the lines of communication open. And that keeps you on your toes. There's almost always somebody else involved in the process.
Molly Bierman (49:35)
Well, it also reflects in a healthy family system, right? So when you think about that, if that's the way you're operating with your clients, number one, you're reaching all parties that interface with that client, but then you're naturally doing that at the organizational level and you're starting to have those healthy communication patterns that happen within the internal system, then it permeates on both ends, right? And I think a lot of missteps happen, especially in ⁓ our space where things become siloed and ⁓ non-communicative.
Beth Salcedo (49:44)
Mm.
Molly Bierman (50:04)
you know, and so it becomes a bigger issue. So there's a couple of things that we do, Beth, in order to provide our listeners with some closure to our episodes. And if you haven't listened to one of our episodes all the way through, this will be a surprise to you. But we like to give a permission slip at the end of each episode, which really is a permission slip to our listeners, whatever you want them to take away from the episode or from your experience.
Beth Salcedo (50:04)
Mm-hmm.
Molly Bierman (50:31)
and there's no wrong answer. So what would be your permission to those that may be listening to this episode?
Beth Salcedo (50:38)
would probably say give yourself permission to ask for help even if you're not sure you need it. In any scenario, certainly with your mental health, it can hurt to ask for help. if you have too much help, you can always let it go. But sometimes you're in a position where you need help and you don't have it. And that's a little bit harder of a position to be in. And we had a situation here where
Molly Bierman (50:44)
Mm.
Yeah.
Beth Salcedo (51:03)
somebody felt that they weren't safe. And I said, you know, if you ever feel it, it doesn't hurt to call 911 if you feel unsafe, even if you don't have hard and fast evidence that you're unsafe. So I think we should all be willing to ask for help very quickly and, you know, turn it down later if it was unasked, if it was not necessary.
Molly Bierman (51:10)
Right.
Absolutely, absolutely. And I think that we will provide details for those that are listening to mental health service lines, if anyone were listening to this episode or were in any sort of crisis, the ways that you can ⁓ reach your local provider, obviously calling 911 if there were an emergency or go to your local emergency room. And Beth, if people are looking to learn more about you, where can they find you?
you know, where your location's based, tell them a little bit about where, yeah, where you're located.
Beth Salcedo (51:55)
Our website is Rosscenter.com, R-O-S-S-Center.com, and we are in the Friendship Heights neighborhood of D.C. We're in Vienna, Virginia, in the Northern Virginia suburbs, and then in Midtown Manhattan.
Molly Bierman (52:08)
Amazing. Thank you so much for taking the time with us. It was so, so helpful and Thank you so much.
Beth Salcedo (52:13)
Yeah, it was nice to talk to both of you.