In her search for help, Walls encountered a psychiatrist who diagnosed her with . As a result, she sought out a therapist who specialized in trauma treatment, and that’s when she finally experienced relief.

“It was just like a world of difference,” Walls said.

Seeing herself as someone with PTSD was odd at first, Walls recalled. She isn’t a military veteran and thought PTSD was a diagnosis reserved for service members. But her psychologist, Lindsay Bira, explained that she likely developed the mental disorder from years of childhood abuse, neglect and poverty.

PTSD has members of the military who have gone through combat, and with first responders who may face trauma in their work. It’s also associated with survivors of sexual assault, car accidents and natural disasters. Researchers have also found that in adults who’ve experienced chronic childhood trauma — from physical, emotional or sexual abuse by caregivers, to neglect or other violations of safety.

Walls was fortunate to find a therapist trained to treat PTSD. Outside of military and veterans’ health facilities, finding knowledgeable help is often difficult.

Only a portion of the 423,000 mental health counselors, therapists, psychologists and psychiatrists in the U.S. are trained in two key therapies, called Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy. These are treatments recommended as part of a patient’s care by the and , which has studied treatments for PTSD since it affects many service members.

There is no definitive tally of people trained in these therapies, and neither the American Psychiatric Association nor the American Psychological Association tracks this data. A 2014 . found that only about a third of psychotherapists had the training. The VA says of its therapists have, although rosters for the and PE organizations list just a few hundred total practitioners.

Nonetheless, the wants to expand access to these treatments, and regional groups, including those in Texas, are following its lead. Texas has a need for more PTSD providers: It for its number of human-trafficking victims; it’s the leading state for refugee resettlement; it has the most unaccompanied child migrants of any state; and Texas is second only in the number of military service members — all factors that raise the risk of PTSD.

UT Health San Antonio, a research and academic center that is part of the University of Texas System, teaches community mental health providers how to provide the two PTSD therapies through its Strong Star Training Initiative. Funded by the Texas Veterans + Family Alliance grant program and the Bob Woodruff Foundation, it has trained 500 providers since it started in 2017. Most training takes place in San Antonio, and many of the mental health professionals who participate are Texas-based, though they also come from Florida, Illinois and other states.

In February, about 20 therapists gathered in a conference room at the medical school for instruction. Calleen Friedel, a San Antonio-based marriage and family therapist, was one of them. She said she is seeing more people with PTSD and often feels inept at helping them.

“I would just do what I know and do my own reading,” Friedel said. “And what I was taught in graduate school, which was, like, over 20 years ago.”

The group learned about one of the mainstream therapies, , which gradually exposes patients to trauma memories to help reduce PTSD symptoms. Strong Star also teaches , which involves helping the patients learn to reframe their thoughts about the trauma. But both therapies — often referred to as “evidence-based treatments” — have been among psychotherapists because they’re closely scripted and to mental health issues.

Edna Foa, who created PE, said in a 2013 journal article that many psychotherapists believe delving into a patient’s inner life and history is central to their work. By contrast, highly structured evidence-based treatments — with their pre- and post-session evaluations and their focus on symptom relief — can seem “narrow and boring,” she wrote.

Indeed, have complained that the treatments don’t work for everyone. But Foa and others argue the focused approach targets the brain’s mechanisms that cause PTSD symptoms, and symptom relief is what many living with PTSD .

Edwina Martin, a psychologist in Bonham, Texas, said treatments like the ones she’s learning at Strong Star weren’t mainstream when she finished school more than 10 years ago. She now is employed at a VA health center after working for a decade in prisons, and she said she wants these in her “tool bag.”

The push to expand the workforce coincides with a growing understanding of trauma’s effects. The National Council for Behavioral Health, a nonprofit organization of mental health care providers, calls trauma a “” for people with mental and behavioral health issues.

Because so many patients think that PTSD is mostly a military problem, Bira said, they encounter a roadblock to recovery.

“I get that all the time,” Bira said. “The beginning stages in treatment that I find with civilians are really about educating [them] about what PTSD is and who can develop it.”

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That unrelenting roller coaster, and the emotional and mental fallout, left her with little energy or resources to take charge of her overall health. Taylor, 53, has asthma and doctors told her she was at risk of developing diabetes.

“I wasn’t doing anything to help myself,” she said about her physical health.

Then an opportunity to get coordinated mental and physical health care services helped turn life around for Taylor, who also lives with bipolar and obsessive-compulsive disorders.

Until recently, health care professionals, in general, treated the mind and body separately and cared for them under different systems. That meant someone like Taylor, who relies on public transportation, had trouble getting to referrals for physical care at locations far away from her psychiatric appointments. That made follow-ups unlikely.

In 2012, Integral Care in Austin offered Taylor a holistic approach, with access to physical health care and a program to manage chronic disease, on top of her regular psychiatric care. Many of the services were available either at the clinic or in her home, and one case manager would help Taylor handle it all.

The seamless care made a big difference, Taylor said, because her recovery depends on addressing all aspects of her health, not just her mental state.

“With chronic-disease [management], resting well, good nutrition, that’s a full package right there,” Taylor said. “It has really built me up to be a better woman.”

Now she has her own efficiency apartment in south Austin and plans to volunteer for a local animal charity. She walks regularly with a chronic-disease case manager and has taken courses to learn how to cook healthful food on a budget.

Efforts to provide integrated care are spreading, especially in public health clinics.

It developed partly out of the realization that untreated mental health conditions negatively affect patients’ physical health, thus costing the system more money.

And in 2010, the Affordable Care Act established a to mental health services.

A desire to reduce costly emergency room visits also is driving the trend.

A conducted by the Agency for Healthcare Research and Quality indicated that 1 in 8 emergency room visits were related to a mental health or substance abuse diagnosis. Those patients were also more than twice as likely to be admitted to the hospital during that visit.

Over the past decade, the federal government has bet on integrated care to help relieve the problem. From 2009 to 2015, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded 187 grants worth over $162 million to implement integrated care models.

The Centers for Medicare & Medicaid Services also is investing in integrated care. A by SAMHSA found that Medicaid is the largest single payer for mental health services, and nearly a quarter of the inpatient hospital stays covered by the program were for mental health and substance abuse issues.

In Texas, 64 of the state’s 73 offer some mental health services, according to data from the Health Resources and Services Administration. That’s a jump from just 36 clinics over a decade ago.

Integrated health care is “fundamental” to achieving such as reducing suicide rates, lowering incarceration rates for people with mental health issues and developing a savvier mental health care workforce, according to the state’s behavioral health strategic plan.

Learning To Be Flexible And Multitask

Austin’s CommUnity Care is a federally qualified health care clinic that serves mostly low-income and uninsured patients in several locations around the city. Pediatrician Tracy Lama-Briseño sees the benefits and challenges of integrated care there every day.

She said the average person would be surprised to learn how many young children and teens deal with mental health issues.

“We do have some pretty young kids that start to present at an early age with symptoms of anxiety or sadness,” she said. “Parents separating … the loss of a loved one. All that can be pretty confusing to a young child.”

Lama-Briseño’s clinic sees about 23,000 medical patients per year, approximately 1,700 of whom use mental health services.

Sometimes the boundaries of responsibility can get blurred between mental and physical health care, she said. “I feel like I do a little bit more social work than I would like,” she said. “But in the end, it’s about taking care of the kids and the families.”

Addressing mental health in primary care gives access to people who might never seek it out, but it also opens the door to additional responsibilities for Lama-Briseño. For instance, CommUnity Care administers a two-question depression screening to every new patient older than 12 and repeats it for existing patients once a year. The results can prompt further action.

Lama-Briseño describes how her young patients can come in for one thing, like an earache, and then the visit turns into something completely different. She said it all happens quickly.

“You can’t say ‘OK, make another appointment,’” she added. “It has to be, you know, dealt with then and there. And so I definitely had to learn how to be flexible and sort of multitask.”

Lack Of Mental Health Specialists

One of the challenges for the integrated model is recruiting mental health professionals. statewide have a “serious mental illness,” according to the Texas Health and Human Services Commission, and more than 80 percent of Texas’ 254 counties don’t have enough mental health professionals to care for patients.

The that the majority of counties, especially in the western half of the state and in the Panhandle, have no practicing psychiatrists.

“My concern, actually, is that we don’t have a big enough pipeline to fill these jobs that are gonna be available,” said Neftali Serrano, executive director of the Collaborative Family Healthcare Association, an advocacy group for integrated care.

Serrano likened the problem to trying to build a plane while flying it. The health care system can’t just stop, so people need to be trained in this new way so that, as integrated care becomes more common, they’ll be ready to work, he said.

“This is not just about plopping a mental health professional in a primary care setting,” he said. “It takes … a certain kind of behavioral health professional, and well-trained physicians and nurse practitioners and [physician assistants] to do this work well.”

Buy-in from primary care doctors is another piece to the complicated puzzle of integrated care. While surveys show many support integrating mental health professionals with primary care, some lack the incentive to change their practices.

Dr. Ernest Buck is chief medical officer of Driscoll Health Plan, which serves mostly kids and families on Medicaid in a highly rural area that spans 26,000 square miles from south of San Antonio all the way down to Brownsville. Buck said most practices in his network aren’t willing to bring on a therapist.

“It’s hard to start a new model where a physician’s practice could be put at risk, particularly at Medicaid rates,” which tend to be lower than private insurance plan payments, he said.

Also, many primary care doctors simply weren’t trained to work this way — collaboratively, on a team with mental health professionals.

Bill Tierney, head of Population Health at the University of Texas-Austin’s Dell Medical School, said that when he was a practicing family doctor he rarely worked with mental health professionals.

“For 15 years, I practiced with no mental health support,” he said. “If I sent [patients] to the mental health clinic, I didn’t know whether they got there. They had a separate information system, I couldn’t see how they were being treated, and patients often didn’t want to go to see the shrink.”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).