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Women Pioneers Co-lead the West Haven Clinic

March 07, 2023
by Lucile Bruce

Imagine, for a moment:

You’re 20 years old and you have never known a stable home.

Your entire life, you’ve been in and out of state psychiatric hospitals—including the forensic hospital, where you were deemed “non-restorable.” When placed in group residential settings, you burn your bridges, get kicked out, and aren’t invited to return.

You have mental illness but don’t trust mental health providers—or anyone else, for that matter. You have a lifelong history of complex trauma, a hot temper, bad dreams.

Then one day, you arrive at a place where the promise is different. They say that no matter what you do, they will never turn their backs on you.

They are the staff of the West Haven Mental Health Clinic, a place that serves some of the most vulnerable children and young adults in Connecticut.

“Often, we are the only stable presence in our clients’ lives,” explains clinic co-director Michelle Comas, PhD, whose young adult client fits the above description.

“It is, I think, one of the biggest impacts we are able to provide, beyond the therapeutic work and the psychiatric care—just the stability of relationship, being able to repair the disrupted attachments,” she continued, “and helping clients heal from the rejection they have felt, including from systems of care that are supposed to help.”

West Haven’s flexible, dedicated approach to young people is rare in mental health care. And these days, the clinic is innovating in more ways than one.

When Dr. Comas and Adrienne Allen, PsyD took the reins as co-directors after the clinic’s longtime leader retired last year, West Haven became the first clinic within a sprawling service system to embrace a shared leadership model.

Structurally, the West Haven Mental Health Clinic, a satellite of Connecticut Mental Health Center, is a longstanding collaboration between the Connecticut Department of Mental Health and Addiction Services (DMHAS), Department of Children and Families (DCF), and the Yale Department of Psychiatry. Originally established in the late 1960s as a community “field station” in the basement of a church, today the clinic houses a Young Adult Services team, directed by Dr. Allen, for clients ages 18-25; and a smaller Child and Adolescent Services team, directed by Dr. Comas, serving children ages 3-18. In addition to directing Child and Adolescent Services, Dr. Comas serves as a clinician on the Young Adult Services team. Both psychologists attend each other’s team meetings and are knowledgeable about every young person who is being served. Both are faculty members in the Yale Department of Psychiatry.

Faced with new terrain—co-leadership—with no nearby models for how to do it, Allen and Comas have chosen a highly connected, integrated path they say works in part because of how much they enjoy working together, trust one another, and agree about approaches to clinical care.

Among their colleagues, co-leadership has caused some confusion, as the idea that two people can be in charge seems to have left some wondering, how will this work?

The question amuses Allen and Comas, who say it’s pretty simple: Dr. Allen directs the Young Adult Services (YAS) team, where Tara Spence, LCSW serves as team leader; Dr. Comas directs the Child and Adolescent Services team; and for issues to do with the physical building and overall workplace, they tag-team (send those questions to both of them; they’ll confer and one of them will respond).

Beneath the shared leadership structure, however, lives something more radical than a delegation of labor. Discontent with older models that foster competition and the pressure to succeed individually, Allen and Comas see their co-director role as rooted in mutual support.

“Yale has traditionally had a lot of white men in leadership roles,” Dr. Allen observed, referring to the Department of Psychiatry context. “We’ve heard from other women professionals that having two women step into this role has been very empowering for them, and we’re very proud of that.”

“We’re showing that there can be two people who lift each other up and support each other,” she added. “We want to be an example of how to succeed at this medical school, but also, how to help each other succeed.”

Donna LaPaglia, PsyD, director of CMHC’s Substance Abuse Treatment Unit and an associate professor who serves on the Department of Psychiatry's executive training committee, agreed. The appointment of Allen and Comas sends a strong signal about women’s capacity not only to lead, she noted, but to lead with confidence using their own style.

“They’re doing something right,” she said of Allen and Comas. It’s more than the clinic’s strong showing on internal audits of its services (“They’ve gotten their numbers up to a place where they’re chasing us now!” she laughed).

To run a clinic, the veteran LaPaglia explained, you have to get the entire team to “collaborate, communicate, and follow through.”

“I really believe that leadership exists in connection with others,” she elaborated. While it’s hard to generalize, she said, “I do think women have an eye for a more personal type of leadership. I think Michelle and Adrienne have an eye for people—for wanting the best for the people who work for them.”

Two of those people, Leslie Lemert, LCSW and Natasha Harris, APRN, said they deeply appreciated the leadership of Dr. Allen, Dr. Comas, and Tara Spence during what has been a very difficult time for clients and staff.

“In the middle of a pandemic, painful social unrest, and the retirement of the longstanding former leadership at West Haven, they bravely stepped into the breach to guide us into a new chapter,” the two wrote in a follow-up email. “We’re grateful to have the leadership of three strong women who’ve led by example with tenacity, grit and generosity of spirit.”

Dr. Comas, who grew up in Florida in a close-knit Cuban family that modeled steadfast care and commitment, said she has consciously sought out workplaces that prioritize connection and well-being. While completing her doctorate at the University of Notre Dame, she had an internship at the University of California-Davis Children’s Hospital where she worked with children who have been abused and neglected, and where she participated in forensic evaluations for the court and child welfare systems. “I really enjoyed that,” she recalled, and went on to accept a joint post-doctoral fellowship in Boston at Mass General Hospital and Harvard University, where she worked in a juvenile court clinic, completing in-depth evaluations designed to help inform the court about how best to support children and families. In 2018, Dr. Comas accepted a position in the West Haven Mental Health Clinic as a psychologist working across the child, adolescent, and young adult services.

She converged in West Haven with Dr. Allen, both early-career professionals (both said they were fortunate to be mentored by Tom McMahon, PhD before he retired). Dr. Allen, who grew up in New Jersey and earned her doctorate at the University of Hartford, had been at Yale before: she completed her pre-doctoral fellowship with the Yale Doctoral Internship in Clinical & Community Psychology program. She then completed a post-doctoral fellowship at the Institute of Living in Hartford, where she pursued her passion for working with people with psychotic disorders who have underlying trauma in their backgrounds.

Today, Dr. Allen and Dr. Comas serve as supervisors within the Clinical & Community Psychology training program. They said psychologists are highly valued and appreciated at Yale for the unique perspectives they bring to clinical care.

No question, their grit and tenacity have been tested since they took over at West Haven, as the Young Adult, Adolescent, and Child Services have seen the current youth mental health crisis up close.

“There is such a high demand for services now,” Dr. Comas said, and inpatient beds are scarce. “Across the state, outpatient teams like ours are shouldering a lot more acuity. Many kids are really struggling and are having to stay in our services”—even though, she noted, some of them should probably be in higher levels of care.

West Haven’s approach includes its comprehensive trauma assessment process, which Dr. Allen and Dr. Comas have developed alongside their colleagues.

“It is unique to our clinic,” Dr. Allen said, noting that she and Dr. Comas have recently presented at conferences on the methodology.

Many of their young adult clients, Dr. Allen explained, exhibit harmful behaviors, including harm to self or others; psycho-sexual risk; substance use; and non-participation in treatment.

“A lot of providers who work with them get very frustrated,” Dr. Allen said, adding that while the frustration is understandable, at its core, it shows a misunderstanding.

“You might hear someone say the client is ‘manipulative’ or ‘not trying,’ or other pejorative ways we hear people talk about these clients. But we know that so many of the presenting challenges are because of the complex traumas they’ve experienced in childhood and adolescence.”

The comprehensive trauma assessment involves a six-stage process. First, a thorough record review, combed for any indication of trauma. Next, a timeline of the client’s life, followed by interviews with anyone who might have knowledge of the trauma and who would be appropriate to talk to. Next, interviews and trauma surveys with the client.

“Then we look back at their behavior,” said Dr. Allen. “And we can say, this is where it came from. It is an adaptive behavior for them. It’s how they learned how to survive.”

Using all this knowledge, the West Haven team develops a detailed plan for the residential programs where many YAS clients live. Plans include concrete recommendations—what to say and not say, triggers to avoid, how to create a safe environment, and positive actions to help the client feel supported. Residential staff members come to understand the clients’ behaviors differently. Throughout, the West Haven team keeps coming back to support them in their work.

“We’ve had tremendous success with the approach,” Dr. Allen said. “It really humanizes our clients and changes their relationships.”

Today, the West Haven Mental Health Clinic is going through a period of growth and reflection, including diversity, equity, and inclusion work designed to raise awareness of the communities it serves. Dr. Comas hopes to be able to expand Child and Adolescent Services, which is mostly staffed by trainees under her supervision, so the team can serve more children and expand its community connections, including with local school and preschools.

Dr. Allen, who noted that the Young Adult Services team is rebuilding after staff turnover during the pandemic, said her primary goal is to expand care for underserved clients, including “through more community outreach, group programs, and bringing more evidence-based care to the work we do.”

Speaking of YAS clients—that young person who was once deemed non-restorable?

She recently reached her eight-month anniversary of being out of the hospital, a historic milestone in her life. She’s focused on getting to one year.

Talk about grit.

With so many strong, determined women behind her, who knows? She might just make it.

Submitted by Lucile Bruce on March 06, 2023