Is Mental Health Working for Hispanics?

hands“This is not working for me,” the man muttered in my direction as he stormed out of the large banquet room. It was November 19, 2012, and the mood at the Goldwater Institute annual dinner was somber after Mitt Romney’s clock had been cleaned by President Obama just days earlier.

Today, I’m the CEO and President of a non-partisan, not for profit 501c3 Community Mental Health Center, RI International, but at the time I was an executive with a publically traded, for profit health plan. Several of our leadership were in attendance for the event, which was sponsored by the organization named after Arizona-based Barry Goldwater and which describes itself as a “watchdog for conservative ideals.”

Governor of Oklahoma Mary Fallin was the first keynote, and she explained to the audience that every single elected congressional official in her reddest of states was a Republican. She asked what the party should learn from the loss to Obama, and concluded… nothing. We should double-down on our values and keep up the good fight, she encouraged the audience.

Next up was Fox News conservative pundit Tucker Carlson. He echoed Fallin’s conclusion… nothing to learn.

Then, he paused. “Well, maybe one thing,” he added. “Maybe we should make sure Hispanics don’t think we hate them.” Carlson was clearly trying to add some humor to the subject of changing US demographics and their impact on presidential elections, but the man who protested by walking out was not humored.

There have been discussions for many years about changing demographics. Four years ago, Carlson targeted political leadership and challenged them it was vital that they pay attention to this key demographic and bring Latino voters into the fold. No more talk. Time for action. He described the significant growth in the Hispanic population, which reached 57 million in 2015, or approximately 17% of our country’s total.

But, what about behavioral healthcare?

Have we done any better in bringing Latinos into the fold?

Is mental health working for Hispanics? Or, are we the ones walking out on the demographic realities?

changing demographics in US population

Changing demographics in US population

When community mental health was launched in the 1960s, Hispanics made up a mere 4% of the population. Today, Hispanics comprise more than 30% of individuals residing in Arizona, California, New Mexico and Texas. Other key states include Colorado, Florida, Georgia, Illinois, Nevada, New Jersey and New York.

And, the shift continues. In many western states, the majority of children in Kindergarten through 6th grade are Hispanic.

Historically, a discussion of race and ethnicity has prompted behavioral health leaders to point to our efforts to strengthen “cultural competency.” Check mark. We’ve done our part, right?

My boss at Magellan Health used to say that simply was not enough. When I worked for Richard Clarke, he always insisted that our behavioral health leadership team also use the words “race and equity.” He came out of an education background where the culture was strongly focused on active ownership, and not simply passive acknowledgement.

Richard formed a regular breakfast think tank group, in collaboration with local community and behavioral health leaders focused on change. The meetings included leaders of organizations that had specialized in meeting the needs of Latinos with mental health needs and whose client base was more than 50% non-white. Chicanos Por La Causa, Ebony House, Native American Connections, People of Color Network and Valle del Sol.

We borrowed from the educational/institutional model in our discussions:

  • Confront individual bias and racism
  • Transform institutional policies and practices
  • Accelerate systemic change

But, two questions were key then, and it seems they are still the appropriate ones now.

First, dis-aggregate your data by race/ethnicity.

Match up the racial/ethnic background of the individuals for whom you are funded to deliver care and cross-walk those penetration rates to the actual percentages in the population. If you find strong mismatches, start a tough discussion of why.

We found our system was serving many Latinos, but not nearly as many as the Arizona population data would suggest existed within our covered lives.

One of the key actions that resulted was outreaching and engaging the community promotoras, lay Hispanic community members who have received specialized training to provide basic health education to others in the community. We learned promotoras were not professional healthcare workers, generally women and extremely effective in sharing and connecting individuals who needed services.

Second, review the composition of your top leadership.

Several years ago, when I was serving on the Board of Directors for the National Council for Behavioral Health, the trade association for community mental health centers, we engaged an external firm to help develop a strategic plan.

The board reflected the composition of the leadership of the nation’s nearly 2,500 non-profit CMHCs, which meant that the majority were white males, and there were only one or two people of color. The suggestion: Focus on racial and ethnic diversity within leadership activities, developing collaborative relationships with organizations that represent diverse ethnic members.

The answers to the above questions are pretty similar across the majority of mental health, both at the plan and retail levels. Whether state authorities, health plans or provider organizations, we haven’t delivered the kind of care that connects with Hispanics in the same way as the rest of the population. The service penetration data says we must do better.

And, we’ve not recruited and hired the executive leadership to help us make the breakthroughs necessary.

Third, evaluate your cultural delivery and sensitivity.

It’s common for anyone to want to say, “My family member does not have any mental health problems,” but this may occur more frequently with the cultural stigma among the Hispanic community.

Do we more closely align with Carlson’s plea to engage and include, and ask how our services are working for Hispanics? Or… do we more closely align with the frustrations of the individual who walked out because change was too frustrating?

Maybe instead of an annual dinner, it’s time for a regular behavioral health race and equity think tank breakfast in your community.

Peer Supports: Where’s the Evidence?

peer supports panelIt was the late 1990s, and there was little published evidence on the efficacy of peer supports. Georgia’s Wendy Tiegreen had grown up in behavioral health… literally. Her father led a non-profit community mental health center, and she had seen the volunteer corps of people in recovery firsthand. These individuals understood the level of pain others were experiencing and were frequently providing informal supports. Wendy had heard of a couple of pockets of similar programs in New York, but that was about it.

Five years earlier, Bill Anthony and the psychiatric rehabilitation movement had declared the 1990s “the decade of recovery.” But, unfortunately, the concepts of “what’s strong, not what’s wrong” and peer supports had simply not made any material headway into mainstream mental health. In over 2,000 community mental health centers across the country, “recovery” was a word seldom used and peer support staff did not exist.

At the time, Wendy was one of the program leaders at the Department of Behavioral Health & Developmental Disabilities (DBHDD) which occupied the middle floors of the 2 Peachtree Street high rise in downtown Atlanta. Larry Fricks’ office was just down the hall. He was the director of the Office of Consumer Relations and Recovery and had helped co-found the Georgia Mental Health Consumer Network (GMHCN), which beginning in 1992 had since hosted one of the largest statewide annual conventions in the nation of people receiving mental health services.

From the beginning, GMHCN had surveyed its membership of “consumers” and publicized their annual top five objectives, with increased employment opportunities continuously holding the top spot. One of their most acclaimed successes nationally was supporting nearly 3,000 individuals in finding meaningful work in Georgia communities by the August 1999 convention.

Peer support panel

Former US Surgeon General Dr. David Satcher with Dr. Jerry Reed and Representative Patrick Kennedy

It was also in 1999 that the Surgeon General’s Report on Mental Health was published. Another Georgia connection, Dr. David Satcher was also US Secretary of Health at the time and a founding director and senior advisor to the Morehouse School of Medicine in Atlanta. This key report was important for many reasons, but in particular, it introduced “self-help groups” and peer supports as an emerging evidence based practice and chronicled the history of the recovery movement.

Satcher and company described in detail the consumer movement of the 1970s and its protest of the indignities and abuses experienced in psychiatric inpatient facilities. They trace the history back to former patients Clifford Beers and Judi Chamberlin. In 1908, Beers wrote “A Mind That Found Itself” and ignited the first reform movement. In the 1960s, Chamberlin, with a similar asylum experience and motivated by the civil rights movement, became one of the primary leaders forming liberation organizations to advocate for increased self-determination and basic rights.

Judi Chamberlin, 1978

Judi Chamberlin, “On Our Own” (1978)

In 1978, Chamberlin wrote “On Our Own,” which the Surgeon General’s report referred to as a “benchmark in the history of the consumer movement.” It led to much more widespread understanding of the extra difficulties of experiencing mental health challenges and what services were really like. Over the next 20 plus years, Chamberlin was successful in raising the bar, with this inclusion in the 2000 report from the National Council on Disability, “Patient privileges, such as the ability to wear their own clothes, leave the confines of psychiatric facility, or receive visitors, should instead be regarded as basic rights.”

In the late 1990s, it would be several more years before SAMHSA would recognized peer support services and Consumer operated programs as evidence based practices, which they later did in 2002 and 2009, respectively. Meta Services was beginning to hire peers in Phoenix, Arizona and formulate key concepts around a recovery organization, but it would be a few years before the impact was known outside the Southwest, and the Company would not change its name to Recovery Innovations until 2005.

Wendy Tiegreen and Larry Fricks

Georgia’s Wendy Tiegreen and Larry Fricks

In this context, with the timing just right, Wendy Tiegreen and Larry Fricks joined forces with a mission to advance peer supports and recovery in Georgia. In 1999, they achieved a striking breakthrough, and successfully brokered with CMS (federal Medicaid) the first statewide provision of billable Peer Support Services. Their crystal clear and yet audacious goal was to build out the lived experience voice and in so doing to also expand and transform the thoughts and minds of administrators and policy makers, while creating a new employment niche for peer providers.

These Georgia innovators quickly realized that their victory would be short-lived without the necessary infrastructure, and over the course of the next 18 months, they led the construction of the curriculum and credentialing required for success. In December 2001, 35 individuals gradated in the first class of Certified Peer Specialists. Throughout this system redesign, the DBHDD team focused not only on peer supports but on what creates recovery and how to build environments conducive to recovery, as they saw these elements as crucial to a successful implementation.

15 years later, Georgia is a national leader with $20 million per year in utilization of services provided by Certified Peer Supports. They have continued to expand the model outside the original core focus, and these services now include peer respite, drop-in centers, wellness centers, and peer supported warm lines. Certified Peer Specialists also serve in administrative roles in addition to the traditional direct services roles. In 2009, Sherry Jenkins Tucker, the Executive Director of GMHCN, was awarded the Mental Health America Clifford Beers award, designated for a “mental health consumer whose service and leadership best… improve conditions for and attitudes toward people with mental health conditions.”

Today, Wendy Tiegreen is the “Medicaid expert for Peer Support” guru, having consulted with 37 states to adopt and implement peer supports as a Medicaid billable service. She has provided technical assistance through CMS, SAMHSA, NASMPHD and the National Association of State Legislators, and averages two to three state visits per year. And… she is not resting on her laurels. Georgia is continuing to expand the application of peer support, with young adult, formal addiction, co-occurring disorders and trauma informed care tracks. Now, she’s turning her attention to extra credentials for health coaching and prevention, as peer supports becomes approved for a whole health approach.

See Link: Georgia’s Community Behavioral Health Provider Manual which, within, defines the state’s various Peer Support services.

After their success in Georgia, Larry Fricks partnered with Ike Powell and launched the Appalachian Consulting Group (ACG), received a SAMHSA Lifetime Achievement Voice Award and became an integrated care and recovery leader with the National Council for Behavioral Health, appearing on the Today Show in 2008 after his story was included in the book “Strong in the Broken Places.” Last month, Larry gave the keynote at the 25 year celebration of the GMHCN annual conference and reviewed the success, from grassroots to national innovation and from pioneering certified peer specialists to documentation of reduced hospital admissions and crisis costs.

See Link: SAMHSA-HRSA Center for Integrated Health Solutions, operated by the National Council for Beahvioral Health (Larry Fricks is the Deputy Director)

Almost 20 years later, the published evidence of peer supports has grown but we still have a long way to go in building the rigorous research required to take the program to scale.

To be fair though, I would argue that the same could be said for traditional mental health programs (counseling, case management, medical management, etc.) During the recession, from 2010 to 2012, my team at a large health plan closely tracked 6,000 individuals with serious mental illness who lost access to the core services described above and the vast majority experienced little change or fared slightly better in their two year absence (the algorithm included over 15 key indicators including community outcomes and costs).

If we used the world happiness scale as our index instead, the existing infrastructure of traditional mental health services would be strongly challenged on every core metric:

  1. Income per person
  2. Social supports and connectedness
  3. Health life expectancy
  4. Freedom to make life choices

80 to 85% of those with serious mental illness are unemployed. A significant number live alone, and don’t have someone to talk to about their problems or go out to dinner with on a Friday night. The years of potential life lost as a result of heart disease, diabetes, COPD, suicide and accidental deaths puts them on par with individuals in lower income countries. And, finally, we are seeing a call for increased assisted outpatient treatment (AOT), a euphemism for court-ordered and mandated outpatient care.

By contrast, it’s self-evident that hiring people with lived experience and providing them training as Certified Peer Supports would positively impact several of the happiness core metrics.

So, again, where are we with the evidence on peer support?

Wendy and I had a conversation with leadership from the National Institute of Mental Health recently to review the work completed to date and request funding be targeted at more rigorous outcomes research going forward.

Over the last 20 years, Wendy has compiled and maintained a quick guide to peer supports outcomes and credibility, and she believes much of this work has been very good, but we need more work and that is very challenging when the resources to date have required stringing together funding from occasional grants.

I was working in the Georgia behavioral health system in the late 1990s and remember what it felt like as these dynamics came together. Like today, there was resistance and many naysayers, but Wendy, Larry and countless others made tremendous breakthroughs, in large part because of the pioneers before them who had made it possible.

It just feels similar now in that we as a nation are poised to make the same kind of full scale advances to peer supports and recovery that Georgia and Arizona did in the late 1990s and early 2000s. When the White House takes notice, I think maybe something special is occurring.

Earlier this year, Symplur participated in a White House workshop which was focused on engaging participants as partners in research. Symplur is an analytics and big data company interested in the intersection of social media and healthcare. After discussions with Obama administration officials, they went back and began “building on the effort of many to strengthen the voices in healthcare that are too often ignored.”

Stakeholder Mix at Healthcare Conferences

For those of us in behavioral healthcare, the word “patients” is off-putting, but the essence of Symplur’s findings are that healthcare conferences don’t value the input of individuals who receive services. Only 1 in 100 influencers is a patient, and the depressing statistic has been stagnant since 2013. On the question of evidence for the approach, the Symplur team concludes, “The inherent value and profit of partnering with patients for healthcare conferences should at this point be self-evident.”

Last Thursday was a watershed moment at the White House, which has been the host of upteen mental health summits. This one was the last in a series on Making Health Care Better, with previous sessions addressing diabetes and heart disease, and this one focused on suicide prevention. And, for the first time, a panel was explicitly brought together to focus on the value of lived experience (see picture at beginning of blog).

Dr. John Draper moderated the discussion and introduced pioneers who came out of the closet even prior to the late 1990s when Wendy and Larry began their work . These leaders included Heidi Bryan, Leah Harris and DeQuincy Lezine, the latter a psychologist who leads the newly founded lived experience division for the American Association of Suicidology.

He concluded his opening remarks with the question, “Looking for evidence?”

And, as he scanned the panel of peer leaders, his answer, “Look here.”

Download: Quick Guide to Peer Supports Research/Outcomes

Yes, I can! What if We All Embraced Recovery?

disability rights are civil rights

In his 1965 “If I Ruled the World” album, Sammy Davis Jr. sang,

Yes, I can, suddenly

Yes, I can

Gee I’m afraid to go on, has turn into

Yes, I can

Wind me up then watch me fly

A regular sort of sunburned Superman I

Are you ready, I can climb Everest

Yes, I can

I can fight here all night and never rest

Yes I can

In fact, one of three lead members of the Rat Pack and so successful in the industry he was called Mr. Show Business, Sammy Davis, Jr. was nonetheless much more familiar with a jarring repetition of “No… you can’t.”

That’s a phrase that some in our society have heard much more frequently than others.

We tend to think of being held back only in terms of success, but it’s much more fundamental than that. Our American family has evolved to the sophistication that our lives are extraordinarily interdependent. Our daily lives depend on the contributions of millions of people, who provide the goods, services, infrastructure, government and joint defense we rely upon.

Humans find meaning and purpose in determining their niche and pitching in their own unique impact. And, when this is thwarted, we’re like ants with no role in the colony.

All of us have occasionally heard “No, you can’t.” We’re told we’re not smart enough. Not persistent enough. We don’t have the resources for the preparation. But, the message is shouted from society at people with serious mental illness over and over.

This past year a blogger wrote in the Huffington Post that it was time to discontinue the use of the word recovery for mental health. She suggested such a concept doesn’t exist for people with more serious challenges. Legislative reform efforts highlight recovery from addiction but decrease self direction for individuals with mental health challenges.

A top healthcare policy maker called for “Bring[ing] Back the Asylums,” and shared his belief that there are a million Americans currently living in communities who are in fact so permanently disabled with serious mental illness they should instead be confined to institutions.

Just three years ago, the CEO for one of America’s largest Community Mental Health Centers talked of hiring 200 peers, individuals with lived experience of serious mental health challenges, but explained that their roles would be limited to janitorial and administrative functions.

Repeated. No. You can’t.

It is time to change the narrative. It is time we all embraced recovery. Time for a different answer to three questions.

Question one. What if I don’t move to the back of the bus?

In 1955, a seamstress and activist in Montgomery, Alabama boarded a bus and sat in the first row behind the front section dedicated to white riders. When those seats were filled, she refused the order to move to the back of the bus.

Her protest was a powerful symbol in inspiring other African Americans and a catalyst of the civil rights movement, which would help pave the hard road to the Civil Rights Act of 1964, that outlawed discrimination based on race, color, religion, sex, or national origin.

Society stood up to the institutional barriers that prevented African Americans from full participation, with such key rights as electing public officials. In Selma, Alabama, African Americans were legally entitled to vote, except…

No, you can’t, without a sponsor who has previously voted.

No, you can’t, without passing the literacy test.

No, you can’t, without paying the voter’s fee.

After hearing these kinds of messages over and over and over, Rosa Parks refused to move to the back of the bus.

Question two. What would I do if I was not afraid?

What contribution would I make? If I didn’t fear looking foolish. Didn’t fear failing. Wasn’t concerned about not staying “in my place.”

Sheryl Sandberg, the Chief Operating Officer for Facebook, asked a group of Harvard MBA students to stand if they had previously considered leading their company, their industry, their field. It concerned her that too few female students did so. Equal or more intelligent, articulate, capable, but lacking the ambition of their male counterparts.

They too have heard messages. We have the highest number of female CEOs ever a recent article stated… at 5% compared with male CEOs at its lowest level… or 95%. No, you can’t.

But, Sheryl turned herself straight against the wind and wrote Lean In, inspiring women to support one another, and to consider the hopes and dreams of what they would accomplish… if they were not afraid.

Question three. What if my answer is… Yes, I can.

Recently, a group promoting the 2016 Rio Paralympic Games created the most bombastic, spectacularly positive and frame-breaking video of the year, We’re the Superhumans, which used as its theme song Sammy Davis Jr.’s Yes, I can.

It certainly wasn’t the first time that the disability community has borrowed from the African American struggle for civil rights. Last year marked the 25th anniversary of the Americans with Disabilities Act. Social services are no longer a matter of the charity of “do-gooders,” but the requirement of a civil right. Our constitution now demands an end to institutionalizing and/or segregating people with disabilities as the answer. And, it calls for an end to discrimination in hiring for competitive employment.

The first efforts to obtain dignity and equal opportunity for people with disabilities were much like our mental health promotion. Flyers and bumper stickers included the following:

  • Think Inclusively! School, Work, Play, Community, Life
  • Assume Competence
  • Label Jars… Not People
  • Not Being Able to Speak is Not the Same as Not Having Anything to Say
  • Celebrate Community
  • If you… Thought the… Wheel… Was a good idea… You’re going to love the ramp.
  • Don’t Think That We Don’t Think
  • Raging Against the Dying of the Light: Institutions Are Not the Solutions

The movement has been adamant about the power of language. “Sticks and stones can break my bones, but names will really hurt me.” I visited the remarkable Disability Empowerment Center in Phoenix recently and noticed that it has been powerfully renamed Ability 360.

Helen Keller emerged as a champion of the disability rights movement, determined to break the hold of discrimination, and the language of “childlike,” “dependent,” and “disabled.”

Yes, I can.

injustice is a threat to justice everywhereBut, society refused to yield. Material change just did not result from the most thoughtful and persuasive plea. And, so people with disabilities continued modeling the Civil Rights Movement. The iconic photo at right includes the Martin Luther King, Jr. quote on a banner, “Injustice Anywhere is a Threat to Justice Everywhere.”

In the 1980s, the activist national network ADAPT encouraged nonviolent civil disobedience to demand changes in policies that excluded people with disabilities from full community participation. They were strongly focused on public transportation, including handcuffing themselves to buses that were not accessible to people in wheelchairs. One of their flyers stated, “Power concedes nothing without a demand.”

Our Declaration of Independence set all these expectations in motion 240 years ago. “All men are created equal… with certain unalienable rights… whenever any form of government becomes destructive of these ends, it is the right of the people to alter or to abolish it.”

It was the capitol crawl that finally pushed the passage of the Americans with Disabilities Act across the finish line and the signing by President George H.W. Bush. After an interminable delay with the House of Representatives, at a large rally, 60 activists abandoned their wheel chairs to climb up the 83 stone steps to access the U.S. Capitol Building.

And, this brings us back to the most remarkable re-frame. “We’re the Superhumans” is a delicious, toe-tapping celebration of the indomitable human spirit and the power of “Yes, I can!” The Guardian described it:

“[Superhumans] shows exactly how much excitement you can generate if you cram the talent of 140 athletes, musicians and ordinary people with disabilities into three minutes of television. From a pilot steering a plane with her feet to a blind pianist, it’s a celebration of an extraordinary range of talent.”

I just cannot get singer Tony Dee’s version of Sammy Davis, Jr. out of my head or stop thinking about wheelchair stuntman Aaron Fotheringham’s death-defying flight. It’s “Yes, I can” sung in the shower at the top of your lungs.

African Americans. Females. People with disabilities. LGBT. Different differences. Same challenges.

How Does Any of this Relate to Mental Health?

But, the three questions. What if… I don’t move to the back of the bus? What if… I’m not afraid? What if… my answer is Yes, I can.

People with disabilities, like those in a wheelchair, Deaf, blind or with an intellectual and/or developmental disability, still have an unacceptably high unemployment rate. But put another way it’s clear they’ve had much more success than we’ve had in mental health. Nearly 40% of these individuals have competitive employment compared with about 15% for those with serious mental illness.

The strong focus of the disability community has been on the law, on their abilities, and on society’s obligation to provide the reasonable accommodations and supports for them to play meaningful roles, to fully contribute and connect in their families, neighborhoods, and larger communities.

But mental health is very different, right?

The ADA doesn’t apply to mental health, does it?

“We’re now on the cusp of expanding what we understand to be a disability to include those invisible disabilities, the ones we can’t necessarily accommodate with a curb cut.” These are the words of Representative Patrick Kennedy, a front runner in leadership characterized by sharing his own mental health lived experience.

If we weren’t crystal clear in 1990 that the ADA also applied to mental health, the Olmstead Supreme Court ruling eliminated any doubts. Actually, I’m going to start instead naming this watershed ruling for its plaintiff, the Lois Curtis decision, after her Georgia lawsuit that went to the highest court (Olmstead was the state health commissioner and defendant).

On June 22, 1999, the US Supreme Court held that unjustified segregation of persons with disabilities constitutes discrimination in violation of the Americans with Disabilities Act and stated that people with psychiatric disabilities are legally entitled to live in communities of their choosing.

If you are a person with Schizophrenia, Bipolar Disorder, or Major Depression, a history of trauma or debilitating anxiety, a diagnosis of Borderline Personality Disorder, or other serious mental illness challenge, I’ve got three questions for you.

  • What if… I don’t move to the back of the bus? What if I reject society’s expectations of disability and dependency?
  • What if… I’m not afraid? What if I dare think of hopes and aspirations? What am I good at? How might I contribute?
  • What if… my answer is Yes, I can.

There will be challenges. Recovery doesn’t mean society suddenly accepted Sammy Davis, Jr. It doesn’t mean a Hillary Clinton presidency would dramatically change the proportion of female CEOs. It doesn’t mean a person in a wheelchair can suddenly walk.

It means we dream. And, we take actions to achieve our goals. We connect. We contribute. We participate fully in this incredible American family. We chart a course for others to gain courage and follow.

I am still moved by Representative Kennedy’s assertion that it’s time to end mental health promotion and shift our efforts to enforcing the law. “We stand on the doorstep to make momentous progress in advancing the cause of this new civil rights struggle started by the work of President Kennedy over 50 years ago.”

Yesterday, North Carolina-based Trillium Health Resources hosted a Recovery Summit in partnership with RI International (formerly Recovery Innovations). RI employs more than 500 peers, many of whom also have experience with addiction and/or homelessness in addition to mental health challenges.

They work as peer supports, wellness coaches, crisis navigators and make a difference in the lives of countless others.

And, today, I had the privilege to participate in a White House afternoon forum on Better Healthcare, which for the first time included a panel of peer leaders, and the discussion was about strengths and abilities instead of deficits and problems, and “lived expertise.”

It all depends on how we collectively answer the three questions. This is just another day, September 30 and the last day of recovery month. Or… it’s time everyone embrace recovery for mental health.

Something that sings in my blood

Is telling me

Yes, I can

#RecoveryNow

22 Days: How Many Push-ups for Veterans and Suicide?

stars stripes heart handsWith co-author – Dr. Sally Spencer-Thomas

In the span of 22 days, Iceland went from being an off-the-beaten-path, exotic vacation destination to THE place to visit. Hard to imagine it was ever considered “fringe,” given the stunning and unique untouched nature that results from the island’s combination of ice and fire near the Arctic Circle, with immense glaciers and over 100 volcanoes.

Most simply didn’t know enough about this small Nordic island country to “immerse [themselves] in ethereal panoramic landscapes and breathe in the pure mountain air of this unspoiled land,” as the Visit Iceland website suggests. But the small population and infrequent sightseers knew its treasures, from adorable puffins to dazzling Northern Lights to exhilarating waterfalls. The value was largely missed by the rest of the world.

Until it came to the surface in the form of an erupting volcano.

volcanoEyjafjallajökull, which belched to life in April 2010, ejected so much volcanic ash into the atmosphere that it created the largest shut-down of commercial air traffic in Europe since the Second World War. Much of Northern Europe was grounded continuously for over a week, but sporadic disruptions meant the story was front and center in the news… every day… for 22 days.

In hindsight, there could not have been a more effective means of getting the word out about Iceland. In the five years following, the number of international visitors to that tiny country has nearly tripled and tourism now grows at a rate of 20% per year.

Iceland was once a fringe destination, but now it seems everyone knows someone who has been there recently. And they’re telling their friends. Word is spreading. The critical mass has created a movement.

Suicide and veterans

22to0Last September, Magellan Health spearheaded a suicide prevention month campaign to bring attention to veterans’ suicide and called it 22 to 0, based upon the estimate that had been circulated for many years that approximately 22 veterans die across the nation each day (more on the right number later).

Senior VP Michael Braham stated using social media was important to focus on reducing the number, “because anything greater than zero is too many.” Mike was an officer in the Marine Corps and flew combat missions during the Gulf War, but he’s also a passionate suicide prevention advocate.

One evening, after an event in Washington, DC, Mike came upon a man standing on the far side of the rail of a downtown bridge, threatening to jump off. Some in the crowds jeered for the man to go ahead, but Mike engaged the man, who nevertheless let go of the rail. As he tumbled toward the water, Mike lunged and grabbed his arm…and held on. The man couldn’t swim and would likely have perished if it weren’t for Mike’s rescue.

Unfortunately, a committed few who stand against the crowd cannot change our world. Change takes everyone, and 22 to 0 was an effort to engage beyond the faithful few.

A Worldwide Phenomenon

A few weeks ago, Sally and I received a challenge from Greg Dicharry, who also hails from Magellan Health and who leads their national youth empowerment programs, including the innovative MY LIFE program in partnership with outstanding youth leaders.

Greg challenged us to the 22 Push-up Challenge. When Sally and I looked into it, we discovered a global phenomenon that was reaching masses of people. This week, an NBC Nightly News story reported that celebrities from Dwayne “The Rock” Johnson to Snoop Dog have been posting videos showing their support, adding to the collective millions of push-ups already performed since the movement went viral.

Akin to the ice-bucket challenge that raised millions for ALS, NBC reported that the push-ups are not raising cash, but awareness, calling them not a show of strength, but an act of compassion. And the masses have showed up, full of passion and determination. Finally, our conversation is moving beyond the mental health and public health experts, and just like the breast cancer movement, people of all backgrounds can do something to help muster the political will our cause has been lacking.

On a fairly regular basis, the suicide prevention and grief support community bemoans being largely ignored, underfunded, and marginalized. However, with this incredible social media movement, we are front and center on almost everyone’s radar. Our colleagues, college friends, children – even pets – are joining in solidarity all over the globe; the new and needed voices for the movement are arriving by the thousands. This moment gives us an opportunity to shape the conversation by meeting people where they are.

For some who have participated, they have found parallels that create connection to this cause. Those in less than ideal fitness wrestled with fears of being challenged, embarrassed, of looking weak, or receiving backlash from our own community.

Sound familiar?

These are the same fears many Veterans face when deciding whether or not to reach out for support. Whether or not to speak up about their pain. The truth is that each of us who faced our fears and exposed our vulnerabilities gained from this experience. We started new conversations where conversations did not exist before. We helped shift the dialogue from suicide statistics to resources and recovery.

What’s the Right Number?

Some veteran’s support groups have raised concerns over the lack of context and research accuracy with the number 22, which was based on a sample from 21 states from 1999 to 2011. They express concern that those who hear about 22 push-ups assume that these deaths are primarily from those who served in Iraq and Afghanistan, when veteran suicide also strikes those who are much older and perhaps never saw combat duty.

Last year, the Washington Post Fact Checker gave the idea “two Pinocchios” and concluded, “The actual number of veteran suicides a day might be higher than 22 for a given population of veterans facing certain risk factors, and lower for another group.” Some have suggested a campaign that varies between 18 and 22, which was the original conclusion of the original VA’s 2012 Suicide Data Report.

But other experts have raised concern that push-ups that only represent veterans miss the point. According to the American Foundation for Suicide Prevention (AFSP), there are 117 suicide per day in the US. I was contacted early on by a national expert who suggested we do 117 push-ups per day instead of just 22.

Others have proposed that any focus on those who have died is the wrong message. Instead, we should highlight the millions who currently struggle or who have in the past, but found a way to survive. We should offer hope, healing, and help. Changing the conversation will strengthen our entire society and begin to truly reduce suicide as individuals realize they are not alone, and that others have found a way through the pain.

Ken Norton, Executive Director for NAMI New Hampshire, began doing 30 push-ups daily to focus on the average number of daily active rescues for those who engaged the Veterans Crisis Line and/or the National Suicide Prevention Lifeline.

What’s the right number? The 22pushups website that launched this incredibly successful social movement poses the question and answers:

“Every pushup counts so don’t be shy to show your support for our veterans. You can do as many or few pushups as you can or choose. Whether it’s 1 or 100 in a row, we will accept them however they come. They can be assisted (on your knees), incline (on a desk/wall), or if you physically are unable to do any, we’ll even take air pushups.”

Bottom-line… they all count. Do what you can.

22 Days Is the Difference

Some have asked if the extraordinarily short news cycle in 2016 will continue to shorten or whether we have reached bottom. We seldom see the public hold its attention on any news item for more than a few days. And, it’s exceedingly rare that a story keeps our attention for nearly three weeks, for 22 straight days.

But, when it does, magic happens and the world changes. Some have criticized the 22 pushup challenge because it seems to lack a specific ask. Is social media dissemination the means or the end? Well, Eyjafjallajökull had no other end than bringing attention to a small island towards the top of the earth, and the crowds are now filling Reykjavik.

Here’s what we do know. Without this challenge, we wouldn’t have seen the pictures at the bottom of this post:

  • Ursula Whiteside getting down on the floor alongside football great Herschel Walker and talk about veterans, suicide and peer support (Ursula is a clinical psychologist and her website www.nowmattersnow.org incorporates her own lived experience)
  • Ken Norton inspiring us with his humor, guns and his focus on life, and the encouragement and reality that survivors survive (Ken is Executive Director of the New Hampshire National Alliance On Mental Illness affiliate and led the development of the CONNECT program)
  • Shelby Rowe’s courageous and vulnerable posts (who interrupted a date to video and post her push-ups)! (Shelby is manager of education and prevention for the American Foundation for Suicide Prevention and a suicide attempt survivor.)
  • Taryn Aiken’s “Lean on me” and tears in a post viewed 1,600 times (Taryn is a founding member of the Utah AFSP chapter and has seen suicide from all angles.)

Today is World Suicide Prevention Day and we’ve been watching an amazing international conversation. For those of us who confronted our fears of shame and rejection by engaging in this 22 day effort, we now have greater strength and empathy. We realize our daily ritual, which honors the suffering and strength that comes with suicidal thoughts and behavior, is a burden we can all help carry. It’s a dialogue that includes everyone.

On this last day, we did the right number. So, how many push-ups did we do today?

All we could muster.

And…

Not enough.

Join the movement.

 

Please note:

Confidential help is available now for Veterans and their families by caring responders at the Veterans Crisis Line. Call 1-800-273-8255 and press “1” to engage with specially trained and experienced individuals helping Veterans of all ages and circumstances. Many are Veterans themselves and understand the life and challenges faced by Veterans of all ages and service eras.

Since its launch in 2007, the Veterans Crisis Line has answered 2.5 million calls and provided emergency rescues more than 60,000 times. The Veterans Crisis Line also has anonymous online chat and text services. Visit www.veteranscrisisline.net chat or text 838255.

Dr. Caitlin Thompson, the Executive Director for Suicide Prevention at the Veterans Administration, is behind September’s Suicide Prevention Month #BeThere campaign. In addition to professional resources, she says everyone can do something to help prevent suicide. “You don’t have to be a trained professional to support someone who may be going through a difficult time. We want to let people know that things they do every day, like calling an old friend or checking in with a neighbor, are strong preventive factors for suicide because they help people feel less alone. That’s what this campaign is about – encouraging people to be there for each other.”

pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets pushups for vets

Mental Health Policy Action We Can All Get Behind: Crisis Line Investment

mental health worker taking callWith co-author – Dr. Michael Hogan

We are in a rare time when national action to improve mental health services seems possible—even likely. However, the downside of this positive opportunity is that reforms that emerge may be more defined by what can be agreed upon—and probably, inexpensive—rather than what is needed. We write to propose a limited but exceedingly important policy initiative that has already been advanced.

 

But first, a little background:

  • In our view, it’s essential that reform addresses real problems. Creating new national roles (e.g. Assistant Secretary of DHHS for Mental Health) and supporting actions that have already occurred (such as Medicaid’s targeted and limited support for weakening the IMD exclusion) do not count as actions worthy of “the mental health crisis.”
  • National Suicide Prevention LifelineWe believe that a central problem in mental health care is that the US has no national approach or investment in crisis care. While the suicide rate in America continues to rise, the federal government (SAMHSA) spends less than $10M annually to support the effective but under-resourced National Suicide Prevention Lifeline. Yet crisis care is pivotal. Crisis lines and crisis systems are on the front lines of suicide prevention, with proven effectiveness but an inadequate infrastructure. With better support in the face of rising call volume, the Lifeline’s network could become a stronger public health safety net for communities across the country. And good crisis care assures that people get what they need and prefer, at a time when they desperately need it. It speeds access and reduces overreliance on institutional care when it is not needed.
  • We were privileged to co-chair the Crisis Care Task Force of the National Action Alliance for Suicide Prevention. The Task Force included many of the nation’s leaders in delivering excellent and responsive crisis care—despite the lack of federal support. The Task Force’s Report analyzes the problem and makes the case for change. The report is at http://crisisnow.com.
  • To date, modest investments to improve crisis care are almost completely missing from the national debate. One exception is the strong provisions for crisis care in the CCBHC demonstration project—recognizing that CCBHC crisis services would be embedded within funded demonstration projects, and not regional or statewide in scope. A second (modest) proposal in the President’s 2017 budget is for $10M in the SAMHSA budget to improve crisis care. This is a good but insufficient start, and because of politics it is unlikely to get a fair hearing.

What strong proposal to improve suicide prevention and crisis care is on the table? Hundreds of advocates with the American Foundation for Suicide Prevention made improved crisis care a core aspect of their national Advocacy Forum just a month ago.Their specific proposal, following recommendations of the Crisis Task Force, is the investment of $55M annually to strengthen crisis lines answering Lifeline calls in all the states. The AFSP action can be viewed on their advocacy page at:http://bit.ly/SupportMHReform.

We urge your personal and organizational support for this investment, which is small enough to be feasible but big enough to be transformational. This request is aligned with policy initiatives (e.g. recent investments in the VA to improve the Veteran’s Crisis Line, and the Crisis Task Force) well-focused on real problems in care, and complimentary to other reform efforts such as those you support, rather than competitive.

We view this policy action as one effort that the often-fractured mental health community can get behind. An investment in crisis lines—preferable housed within comprehensive crisis centers that facilitate access to care, deploy mobile crisis teams and operate crisis residential alternatives—would be the first national leadership in this most urgent sphere of action.

Please contact us if you have questions, concerns or suggestions. We need Crisis Care Now!

David W. Covington, LPC, MBA                                                Michael F. Hogan, PhD


 

Crisis Care Now: Delaware Leads with Recovery Response Center Grand Opening

What People Think vs What We DoOn Tuesday, August 2, 2016, Delaware Governor Jack Markell and several other state and county representatives plan to attend the grand opening of the new crisis stabilization center funded by the Delaware Department of Substance Abuse and Mental Health (DSAMH).  The new Recovery Response Center (RRC) is the latest accomplishment in his state’s effort to build more robust mental health services.

“This new facility demonstrates the commitment we have made in Delaware to create a robust community-based mental health system,” Markell said. “Individuals experiencing a mental health or addiction crisis need immediate and appropriate evaluation and care. The Recovery Response Center in Newark provides that important first step in getting people in crisis the care they deserve.”

DSAMH Director Michael Barbieri said the crisis staff is broad-based and specifically trained. “Delaware residents in crisis will be met by trained clinicians and peers with lived experience. Under the medical leadership of onsite psychiatric providers, these staff will work quickly to help people rest and de-escalate and take the first steps towards recovery.”

The Newark location just outside Wilmington is RI International’s second crisis center to be opened in the state of Delaware, with a similar program in Ellendale since 2012. By the end of 2016, the Company will operate ten Recovery Response Centers across five states, all modeled after the Peoria, Arizona RRC, established in 1996.

Newark, Delaware Recovery Response Center (2016)

Newark, Delaware Recovery Response Center (2016)

Peoria, AZ Recovery Response Center

Peoria, Arizona Recovery Response Center (1996) funded by Aetna-affiliated Mercy Maricopa Integrated Care

In the Crisis Now: Transforming Services is Within Our Reach report, Crisis Stabilization Program facilities are described as a core component of a full service continuum. “Crisis residential facilities are usually small (e.g., 6 to 16 beds), and often more home-like than institutional. They are staffed with a mix of professionals and paraprofessionals. They may operate as part of a community mental health center or in affiliation with a hospital.”

When these crisis programs employ the Peoria RRC “Living Room” model, the focus is on a welcoming and healing environment, and certified peers operate as integral members of the team emphasizing hope and empowerment. “Individuals in crisis are admitted as ‘guests’ into a pleasant, home-like environment designed to promote a sense of safety and privacy.” [Click below for a detailed look.]

Timeline of RRC

Timeline of RRC “Living Room” Model Adoption

Last week, I toured the Company’s west coast crisis facilities. The Fife, Washington State RRC, was launched in 2009 by now Optum Health Pierce County Regional Service Network CEO Bea Dixon and manager Jodie Leer (who now serves as the program’s Regional Service Administrator). Following the 2015 supreme court ruling on “psychiatric boarding,” RI International launched a 16 bed Evaluation and Treatment program (E&T), which like the Fife RRC, got its start in a wing of Western State Hospital.

Washington State RRC

Fife, Washington State Recovery Response Center (2009)

From Washington State, I traveled to Southern California to visit the two new 24 hour crisis programs funded by the Riverside County Mental Health Board. While housed in a temporary structure awaiting the completion of construction on a brand new facility, the Riverside RRC team led by LCSW Peggy Wiley has already served more than 800 people. The Palm Springs location will open later this year.

RRC Riverside CA

Riverside, California Crisis Service Center (2016)

Last month, Leon Boyko, RI International’s Chief Administrative Officer, and I visited the Durham Recovery Response Center funded by Alliance Behavioral Healthcare. Site administrator Joy Brunson-Nsubuga, LMFT, LCAS, shared with us the Durham outcomes dashboard and the high safety survey score that reflects staff perception of the program.

This intersection of both a recovery and safety environment is critical as Recovery Response Center teams support individuals in highest need. Best practice medical, clinical and recovery interventions and supports are immediately engaged.

Why so important?

All of the RI International Recovery Response Center facilities receive direct drop-off by trained law enforcement teams, with a handoff and turn-around time that generally runs 10 minutes or less. This critical practice can avoid both criminalization of crisis-induced behavior and the costs and potential trauma associated with hospitalization. If it is determined a guest continues to pose a safety threat to self or others, he or she may be transferred to a more intensive level of care.

Durham NC RRC

Durham, North Carolina Recovery Response Center (2015)

The conclusion of the Crisis Now: Transforming Services is Within Our Reach report on Crisis Stabilization Programs: “Many communities have only two basic options available to those in crisis, and they represent the lowest and highest end of the continuum. But for those individuals whose crisis represents the middle of the ladder, outpatient services are not intensive enough to meet their needs, and acute care inpatient services are unnecessary. Crisis stabilization facilities offer an alternative that is less costly, less intrusive, and more easily designed to feel like home.”

The US Healthcare system spends billions on acute care psychiatric inpatient hospitalization and lengthy stays in hospital emergency departments where persons with mental health and addiction issues languish.

But, the solutions are right in front of us. And, more and more states, like Delaware, are saying “Crisis Care Now!”

DE RRC Grand Opening DE RRC Grand Opening DE RRC Grand Opening DE RRC Grand Opening DE RRC Grand Opening DE RRC Grand Opening

 

High Rates Rise and Fall: Japanese Leadership Makes Strides with Suicide Countermeasures

tokyoIn May, the International Association for Suicide Prevention held its regional conference in Tokyo, and it was my first visit to the bustling capital of nearly 14 million people. Lonely Planet calls it a “cultural Galápagos where a unique civilization blossomed.” Imagine sacred Tibetan temples colliding with flashing neon of the Las Vegas strip, and Star Trek robotic technology swarming through the fused results. At times serene, then frenetic.

The contrasts are rich. One million people cross the street everyday at Shibuya Tokyo, but follow an orderly queue. The jam-packed, ultra-modern transit system is eerily quiet. There’s no loud talking or phone conversations. And individuals with a cold or the flu wear a cotton mask to prevent passing the sickness on to others.

I found the people warm and respectful. A little shy. Hard-working. More likely to be in a group.

And the suicide rate in Japan is one of the highest among high-income countries in the world, nearly three times higher than in the United Kingdom.

“The Rise and Fall of the Great Powers” predicted that Japan would become the next world superpower, succeeding America, but that didn’t happen. Instead, the late 1990s saw a serious banking crisis that led to decades of economic stagnation and downturn.

“In few other countries does joblessness trigger suicide so easily as in Japan,” says Yasuyuki Shimizu, “where being part of a corporate organization is seen as essential to one’s survival.” Shimizu runs Lifelink, a non-profit suicide prevention organization. The perception that one is contributing to the collective whole is important everywhere, but in the unique communal culture of Japan, layoffs and salary reductions in 1998 fueled a dramatic surge in suicide deaths among middle-aged men. Major financial institutions simply failed, including the bankruptcies of Yamaichi Securities Co., Hokkaido Takushoku Bank, and Sanyo Securities, and tens of thousands of jobs were lost in the aftermath. The steep 35% suicide increase in 1998 would be sustained for a decade.

One of the reasons I wanted to visit Tokyo was to learn more about the leadership in Japan in stepping up suicide prevention. The World Health Organization (WHO) reported that the still-high statistics in 2016 mask significant gains that have been achieved since 2006. Strong efforts to change have helped drive year-over-year declines in the death rates beginning in 2010 that have nearly brought the country back down to pre-1998 levels.

yasuyuki shimizu

Yasuyuki Shimizu, Honorable Takemi-san and Professor Motohashi

I first made acquaintance with Yasuyuki Shimizu at a prior international conference when he presented on Japan’s efforts, and he participated in the 2015 Zero Suicide in Healthcare summit in Atlanta. While in Tokyo, we visited the National Diet, which is Japan’s legislature, and Shimizu and I sat down with key leadership to discuss the successful progress of the program. Honorable Keizo Takemi-san was Vice Minister of Health, Labour and Welfare in 2006, and Honorable Mitsuyoshi Yanagisawa-san had been elected to the House of Councilors in 2004 and would later become Vice Minister of Economy, Trade and Industry in 2012.

yanagisawa san

Honorable Yanagisawa-san

According to the WHO, “In the late 1990s, suicide was a socially taboo topic in Japan, rarely discussed in the public sphere.” These leaders realized the scope of the challenge and worked together to enact the 2006 Basic Law on Suicide Countermeasures. Their goal was a society where no one is driven to suicide. The comprehensive strategy included a partnership with the national government and local public entities, as well as supports for those bereaved by suicide, and included intensive public awareness campaigns.

The expression “suicide prevention” was seen by many families who had been bereaved to suggest blame, and thus the terminology was changed to “suicide countermeasures.” There was also a strong focus on the non-medical, social determinants of health and their impact upon suicide deaths, as opposed to a preventive medicine approach.

Professor Yutaka Motohashi, the Director of the Japan Support Center for Suicide Countermeasures, led pilot studies in rural communities such as Akita Prefecture to measure the impact of the new approach, and there were strong reductions, especially among the older population. Within three to four years, reductions ranging from 23% to 47% were observed while the rates in comparable control areas remained relatively unchanged.

In March, Shimizu led a revision of the decade-old act, with a focus on shifting from national declaration to local action (which is also the theme for our upcoming 2017 Sydney Zero Suicide in Healthcare summit). “I believe this is a landmark amendment and huge step forward,” said Shimizu. Local governments will be responsible across the country for implementing concrete action plans. The new law will mandate funding for key projects in each municipality and include research analysis (see “Landmark new law”).

Breakthrough Technologies… For Good

robot battlesThere were so many amazing memories of my time in Tokyo. The blur of the enormous robot battles in a Shinjuku basement. Browsing through the center of the geek universe in Akihabara Electric Town. Whizzing along at 200 miles per hour on the Shinkansen bullet train. Japan is a temple of high tech.

So, I was naturally drawn to a very small presentation at the conference titled, “Joint Symposium with IT Companies,” which included professors from the University of Tokyo, two Japanese IT companies, and Mazda Motors.

When I was delivering mental health counseling services back in 1996, I gave the individual with depression a Montgomery–Åsberg rating scale to track our progress together, but it was dependent on the reliability of self-report. A decade later, researchers working for Dr. Madelyn Gould at Columbia University were listening in on crisis calls and making their own determinations about the level of distress and improvements from the time of the call to the conclusion, with a follow-up two weeks later.

Professor Tokuno Shinichi and his team at the University of Tokyo have developed software to evaluate distress by synthesizing in real-time 200 distinct variables in an emotional analysis of their voice. They are finding the early versions of the system are already nearly as reliable as a 30-item General Health Questionnaire and they believe they can eliminate the bias of self-reporting to identify individuals with depression.

These types of technologies are already being employed in other industries for “honesty maintenance” and to keep an eye on employees and screen out job applicants, but many of them are not real-time. In the recent movie “Ex Machina,” the main character Caleb comes to realize he should not answer any question from the beautiful Ava robot, as she can readily determine his truthfulness from a combination of biometric and voice analysis (Wall Street Journal, “App Tells You How You Feel”).

Professor Tokuno’s team has created an algorithm that generates feedback in real-time, and they are focused on how to use the technology to support better identification and treatment of mental health and suicide risk. I’ll be tracking this important work.

Georgia Crisis & Access Line 10 Years Later

georgia crisis and access lineIt was late 2005. Inspired by the Single Point of Entry model and Behavioral Health Link’s work in Atlanta, Georgia’s behavioral health authority, or DMHDDAD as it was called at the time, put out a statewide bid for an access and crisis hotline and web-based internet service. Four national managed care companies showed up at the bidders’ conference. The BHL team was determined to take their good work to the next level and create the best crisis and access call system ever. But, they also realized the company’s continued existence depended on it!

georgia crisis and access line staffSo, the BHL team set about to replace and upgrade simply everything! All of the telephony systems, all the hardware including shifting to dual monitors for increased efficiency. They dramatically expanded their physical space by moving additional workstations into the training area that had been the base of operations for the recent Hurricane Katrina FEMA-funded crisis counseling war-room. They also quadrupled the size of the team. But, because of a protest by one of the competitor companies after the award, BHL had only a few short weeks to implement what was designed to take three months.

replicating the georgia crisis and access line modelI remember vividly sketching out the first prototype of a new call center electronic record interface on a train ride to see family and my wife Jeannine peering over my shoulder to offer friendly advice (her background is supply chain management software design). The development team performed seventeen miracles to get the new Call Center Information Database (CCID) system ready but it was rolled out for testing only days prior to the launch. The team was forced to skip the usual four to six week process of quality testing and training but the adoption of the new “live-fire” environment created a faster-paced team and fostered a culture of aggressive innovation that continues at BHL today.

air traffic control model

The Georgia Crisis & Access Line (GCAL) received 21,500 calls during July 2006. Crisis calls started pouring in at midnight June 30, 2006 with the immediate transfer of nearly 20 different legacy hotlines from across the state and the very first calls on what would become the central statewide Georgia Crisis & Access Line 1-800-715-4225, as company CEO & President Gregg Graham flew a small plane back and forth across the state like he was mowing the lawn and airdropping millions of GCAL cards (well, it certainly seemed like that’s what he was doing)!

At the end of the day, it was the people answering the phones who made GCAL a success that very first month. The team was truly building the plane they were already flying in July 2006. Their expertise in the new protocols and systems was just emerging, but their care to engage, collaborate, problem-solve, support and advocate with callers, their family and friends and the social services and first responders who support them that made all the difference. Still does.

innovation highlights/awards

See detailed timeline.

And, huge thanks to my business partner Gregg for his leadership and vision. He and I sat together at a table in Durango’s Steakhouse across Peachtree street from the current BHL office in the summer of 2002, and he painted a picture of a statewide service that would revolutionize crisis intervention and access to care. It sounded impossible, but I liked it.

Thanks to each of those individuals who helped launch this big dream in 2006 and make it happen and the team at BHL that continues the work today! The individuals below are still with the Company in some capacity and supported the Georgia Crisis & Access Line launch ten years ago:

  • Bruce Albert
  • Crystal Bass
  • Mimi Etienne
  • CEO Wendy Farmer (Schneider)
  • President Gregg Graham
  • Jim Frank
  • Darcel Gentry
  • John Grady
  • Angela Hammond
  • Felicia Hilton
  • Nicole Bartell
  • Anthony Swift
  • Allison Trammell
  • Dr. Mahaveer Vakharia
  • Adam Williams
  • Kathy Wheelin
  • Emeka Wolfe-Norman

***

Special recognition to the pioneering leaders at Georgia DBHDD and BHL’s new partnership with Beacon Health Options that is taking the system to new heights of integration with the Georgia Collaborative ASO.

 

The Woman Card… Politics and Suicide Means in the US and China

US and ChinaIn April, both candidates in the race for President of the United States talked about the “woman card.” Donald said the Democrats were playing it. Hillary replied passionately, “Deal me in.” The ensuing discussion ranged on important topics from equal pay to health care, but we must now add one more.

The tragic CNN headline appeared the same week of the events above: “Suicide rates up,
especially among women.” The story was repeated frequently after a new report from the Centers for Disease Control and Prevention (CDC) reported that the age-adjusted rate in the United States was 24% higher in 2014 than in 1999, with the increase among non-Hispanic white females up by a confounding 60%.

We see every other disease going the other way, with significant declines in mortality for HIV/AIDS, heart disease and breast cancer over the last decades. This only makes the heartbreak more difficult that our efforts have not generated the same kinds of outcomes with suicide. Leaders in the field publically questioned to what degree more accurate reporting is a factor, as we struggle to comprehend.

Major Suicide Reductions in China

It’s a little uncanny, but we are living the exact opposite story from five years ago in China. It was 2011, and I was headed to Beijing for the World Congress of the International Association for Suicide Prevention (IASP). And, I was questioning whether their data could be real.

The headline at the time: “China’s Suicide Rate Has Declined Drastically.” In the early 1990s, 30 out of 100,000 individuals died of suicide in China annually, compared to 15 in 2009. Instead of 25% increased as in the US, China was reporting suicide was down 50%! And, again, central to the story and the primary driver in the reduction: a significant change related to women.

The 2010 Daily Beast blog “China’s Female Suicide Mystery,” explained the hardship on women in rural farmlands, and their strength and pride in withstanding suffering, sadness and stress, to “eat bitterness,” as they call it. “But every woman has her breaking point,” the author concluded in describing the only country in the world where the female rate of suicide was higher than their male counterparts (25% higher in the late 1990s).

I’ve written on the myth of suicide as a choice. People die of suicide when their supports, strength, resources, and hope utterly and completely fail. However, this idea has little meaning divorced from the concept of “acquired capability.” It’s been a little over a decade since Thomas Joiner’s Interpersonal Model of Suicide cracked and broke the foundation of what we used to believe about the causes of suicide. Essentially, “acquired capability” suggests that extraordinary intrapsychic emotional pain is insufficient. Dying of suicide requires that the person also has help.

The most powerful allies in suicide prevention are our own bodies and minds. Put simply, it’s extraordinarily difficult to harm one’s self because it requires breaching the human innate self-preservation security system. It protects us from threats, both external and internal. Our brain’s amygdala sends us frightening messages to warn us away from sources of pain and death. Our blood clots to stop leaks. Our body will even shut down and reboot, with unconsciousness as a way to restore breathing if required.

The difference in the US and China was the method and the means to short-circuit these natural defenses.

In the United States, a typical presentation during the late 1990s for a young woman in desperate emotional pain was an overdose and self-poisoning, with the most common substances being benzodiazepines, antidepressants, or paracetamol. After the attempt, the brain’s survival mechanism regains control and the person experiences ambivalence. Outreaching emergency medical services results in 98% of individuals being saved.

However, in the rural countryside of China during the late 1990s, a young woman experiencing a similar emotional hell had access to something much more deadly: a jar of organophosphate pesticide with product banned in many other parts of the world. Within a couple of hours of ingesting half a cup of toxic pesticide the individual dies, and there is no opportunity for reversing the course.

New and Unusual Partnerships

forefront memorial at washington state capitol

Forefront memorial at Washington state capitol with markers showing the impact of guns and overdose on suicide (photo credit Katie M. Simmons)

There was no getting around the obvious: a suicide prevention plan that did not incorporate a critical strategy for pesticides was not going to be effective. It was involved in 60% of Chinese suicide deaths according to the World Health Organization.

So, leading researchers in suicide prevention approached large companies that manufacture pesticides, like Syngenta. The ask was that they play an active role in reducing access, as opposed to blame and claiming they were directly responsible given the misuse of their product. The goal was partnership and material change.

The recent World Health Organization report “Preventing Suicide: A Global Imperative” was in part sponsored by Syngenta, who has also funded projects to increase the safe-storage of pesticides so that they would be unavailable to those in distress, and assess the toxicity of new formulations of paraquat, a widely used herbicide.

Three significant shifts have reduced the level of access to these deadly means. There have been governmental actions to prohibit certain types of pesticides that are the most deadly in several Asian nations, including China and Sri Lanka. And, a migration away from rural farm life to the large metropolitan areas has also meant that many women in emotional distress no longer have access. But, part of the success must be attributed to the pesticide companies who are funding and partnering on creating new solutions.

I traveled to China skeptical of the data around a drastic reduction in suicide death, and I returned from this nation of 1.4 billion people convinced that they had answers the United States should replicate. Hundreds of thousands of lives are being saved annually because individuals in enormous distress do not have access to a jar of deadly pesticide.

The Analogue for the United States

Half of suicide deaths in the United States are the result of firearms. Guns are clearly our pesticide. But, I’ve not been aware of any tangible efforts to replicate China’s success partnering with the manufacturers of the means. We’ve cast stones at times, but true efforts at partnership to date have centered on small gun shops or local firing ranges, and nothing has been taken to scale. Yet.

It’s just beginning.

In February, I spoke at a Zero Suicide in Healthcare summit in Washington State and had the privilege to spend a few minutes with the indomitable Jennifer Stuber. She is an associate professor of public policy at the University of Washington and co-founder ofForefront: Innovations in Suicide Prevention.

In her April Washington Post opinion piece, she described her initial awkward call to the National Rifle Association after her husband died of suicide. To her surprise, “they were not just willing to talk but also willing to listen.” These are individuals who have also been touched by suicide, and they had been like others in our society, including healthcare- they assumed suicide was inevitable for someone who “chooses” to die.

Jennifer describes an active year-long conversation with the NRA and the Second Amendment Foundation about saving lives in Washington State. And, they did what Syngenta and the World Health Organization did in 2007 to address pesticide and suicide. They convened a working group led by Rep. Tina Orwall (D) comprised of gun rights advocates and suicide prevention leaders.

The first result of this new partnership is a law signed by Governor Jay Inslee last month designed to reduce suicide deaths by firearm and overdose. Rather than mandating changes, the law focused on encouraging industry participation through incentives and will focus on gun dealers, shooting ranges, gun shows, pharmacies and drug stores. “There was strong backing by legislators on both sides of the political aisle,” Jennifer wrote.

Challenging the Status Quo

In China, reductions in the access to deadly pesticides meant that women were much less likely to die of suicide. In the United States, we are seeing a significant increase in suicide deaths, and firearms are increasingly involved with women. But, the new partnership in Washington State is extremely encouraging that our society is taking serious actions to reverse the disturbing trend.

The status quo is well known. “In the US, we cannot have a meaningful dialogue about guns and suicide.” We’ve said it again and again, but Jennifer Stuber and the NRA have proved us wrong in Washington State. “There’s too much self-interest for large manufacturers.” Today, Syngenta is cited as a key partner in the World Health Organization’s seminal report on suicide prevention, and they are creating better solutions that will save lives and have enormous potential to do so at a societal level.

Means matter, and we too in the United States can reverse our upward trend of suicide as we take bold steps and engage in new partnerships. Jennifer writes that the Washington state law “marks the beginning of a different way of talking about gun violence in America.” Staking out our common ground is hard work, but leaders in Washington State are simply getting started and moving forward.

The Future Is Already Here… Family Health Center of Harlem

IMG_3748Blimey! This was the initial one word response when the United Kingdom’s Norman Lamb and I toured the Institute for Family Health (IFH) Harlem Center in north Manhattan. A long-time member of parliament and prior Minister of Health, MP Norman Lamb is not easily impressed. His Liberal Democrats have pressed for the future in mental health, calling for parity since 2010, with the campaign, “No health without mental health.” The party also inspired a nationwide UK “Zero Suicide in Healthcare” dialogue in early 2015.

But, as Senior Vice-President Virna Little and her team showcased their integrated services, it was impossible not to conclude that we were seeing the third revolution in behavioral healthcare. Three key innovations stood out: collaborative care management, patient-centered technologies and a central focus on suicide care.

Collaborative Care Model

IMG_3778There’s no disputing the evidence. In 2002, Jürgen Unützer’s randomized clinical trial in JAMA showed collaborative care was twice as effective for treating depression, improving physical functioning, and reducing healthcare cost as compared with care as usual. IFH was one of the first in the country to utilize the approach beginning in 2003, and over 80 RCTs have since confirmed the effectiveness of the model.

The experience shows. The transdisciplinary care team-based approach goes far beyond integration, with dentistry, community outreach, and population health all baked into one. My jaw dropped as we toured the first floor and saw 14 dental chairs with services that include cosmetic care.

IMG_3759Exploring the five floors above revealed a remarkable example of near seamless behavioral health and primary care integration. IFH has found this approach essential to combating major chronic illnesses like depression and diabetes, where behavioral health provider staff are elevated to equal contributors alongside primary care physicians, nurses, nutrition, care managers, dental and community health.

There’s a remarkable focus on outcomes with the utilization of tools like the Patient Health Questionnaire 9 (PHQ9) and General Anxiety Disorder 7 (GAD7). Mental health has tended to avoid quantitative measurement altogether or utilize lengthy and burdensome tools that made integration across care silos impractical. These brief and evidence-based best practices have united care teams around a common language and process.

Treatment at IFH is open-access and fast paced, more akin to the primary care culture than traditional long-term mental health care. Appointments are typically between 20 and 30 minutes and the duration is between 8 and 16 weeks. It’s less about a full and complete history and more about the current presentation, utilizing brief and solution oriented therapies or behavioral activation. While this may look very different than where we’ve been, it’s not only more effective but better aligned with compliance audits where documentation of medical necessity is required.

Epic Technology

IMG_3776 (1)

With MP Norman Lamb in front of kiosks in the Harlem Center lobby

Herculean! The name of this electronic health record (EHR) is fitting, both in terms of market size and ease of use/ functionality. In May 2015, Epic was the top EHR as measured by the most providers nationwide who attested to meaningful use, the certification standards of the Centers for Medicare and Medicaid Services (CMS) to improve care coordination and population health.

IFH’s approximate 100,000 patients are among 190 million worldwide reported to have a current electronic health record in Epic, and these patients have had access to their own records via MyChart MyHealth since 2007. One-third are active users of the portal which supports the following functions:

  • Communicating with their physician or other staff
  • Scheduling and/or changing appointments
  • Reviewing lab results, health information, their problem list and treatment plan
  • Viewing an audit of their chart (who has viewed their information and why)

The collaborative care model is activated by the shared treatment planning, community collaboration and patient engagement that is core functionality of the Epic platform. In addition, the IFH medical leadership has developed and customized within the software clinical pathways and automated work-flows which are creating a learning environment for consistent practice and focused outcomes.

Going for Zero Suicides

In 2010, CEO Dr. Neil Calman challenged the leadership to develop a Zero Suicide initiative to save lives for those most at risk within the IFH community. Virna Little and her team did what they do every day- they brought their robust technology platform and transdisciplinary care teams to the task. They also incorporated key evidence based practices like collaborative safety plans to reduce access to lethal means and introduced training to better equip all staff (like LivingWorks safeTALK).

In December, Epic released clinical program guidelines “Preventing Suicides in Primary Care Settings,” based upon IFH’s pioneering work. It included the specifications for screening for risk, and the decision support tools, workflows and SmartForms required to replicate their program. For example, the header banner turns red on every page of the record for an individual with “suicidal thoughts” in their master problem list.

The document also includes implementation guidance, securing buy-in from senior management and physician providers and determining the scope of the program.

Social Justice and the Future of Care

In 2015, the Americans with Disabilities Act (ADA) turned 25 years old. This landmark civil rights legislation determined that confining “persons with disabilities in institutions constitutes unnecessary and illegal segregation.” The 1999 Supreme Court Olmstead ruling verified that individuals with mental health diagnoses were also included under the protections of the ADA and could not be held in asylums simply because the state had not invested the appropriate resources in alternatives.

Since the 1960s, the emergence of the second revolution in behavioral healthcare, the Community Mental Health Construction Act, created a system of outpatient services that seemed substantially improved over the largely state-run institutions that preceded them. However, segregation of individuals with serious mental illness away from the larger primary healthcare system has persisted in very significant ways.

The third wave of behavioral healthcare is full and equal integration. It is empowered by technology. Suicide care is a central focus. And, the future is already here. The saying goes that it’s just not widely distributed. Well, stay tuned. The pioneers at the IFH Family Health Center of Harlem have shown us our future destination, and they have also shared the road map for getting there.

 

MENU