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.


Hanging On One More Moment: Lessons from Fear Factor

shutterstock_357336836Some things go without saying. Some things are so obvious. They are just the plain truth.

For example, I look in the mirror every morning and see a full, healthy head of hair.

From my one person vantage point, it seems true. Occasionally, I’ll be in an elevator and catch a glimpse in a mirror looking down from above, and I’m like – hey, who’s that guy?!

Another example of what appears to be obvious. The earth is flat.

Earlier this year, a hip hop star called B.o.B. made the headlines. If you didn’t already know him from his hit songs like “Magic” and “Airplanes,” you may have heard about his epic Twitter feud with astrophysicist Neil deGrasse Tyson.

It started here at Stone Mountain overlooking metro Atlanta all the way up to Sandy Springs.

2016-04-08_20-57-15B.o.b. (what’s hip hop etiquette? Can we call him Bob?) tweeted, “There are 16 miles between the cities in the background, but no curve.” Please explain this.

Look it – it’s obvious the earth is flat. Imagine if you will that we didn’t have our modern science. We didn’t have super cool astrophysicists like Neil deGrasse Tyson. Going back a thousand years, the earth would in fact have looked downright flat to everyone of us.

From the every-man perspective, with a limited view, it kind of goes without saying. B.o.B. probably sings his famous song about airplanes while traveling the world in his private airplane and peering out his airplane window at 30,000 feet. Still pretty flat, the high flying view would not dissuade what appeared to be obvious for thousands of years.

Of course, there have always been signs that our limited view as humans was… well… limited. First clue, in every lunar eclipse, we see the shadow of the earth cast against the moon. And, we see a circle.

2016-04-08_21-07-56If the earth were actually flat, we might instead see something like the picture to the right. My youngest son saw me working on this presentation and from his vantage point, “Dad, look- it’s Pac-Man.”

And, I replied, “That doesn’t look anything at all like Pac-Man!”

In their online rap battle (not making this up), Neil deGrasse Tyson explained to B.o.B. that a combination of the Foucault (pronounced Foo-Coe) pendulum (2nd clue) and the shadow of the earth on the moon during an eclipse together prove the earth is a sphere.

The lunar eclipse proves the earth is round. And, the Foucault pendulum demonstrates that the earth rotates. These clues could have been put together (and were) long before satellites or space travel. The conclusion: the world must be a ball!

Apparently, this was way too much looking through a glass darkly and didn’t persuade B.o.B. He believes the pictures of the round earth are the CGI creations of a conspiracy, and in reality, most humans have not seen this view with their own eyes.

However, if we could change his perspective. Instead of 16 miles across, let’s go one more mile. Let’s make it 17 miles… but straight up. Now, the curvature of the great, great big planet begins to emerge. The ah-hah moment!

In life, we don’t always get the 17 mile perspective. Sometimes we fall one mile short. What seems obvious could not be more wrong, and sometimes unlike B.o.B. tweets there are in fact consequences.

Suicide is a Choice?

Let’s talk about another obvious truth. Suicide is a choice. It’s unlike cancer. People with cancer don’t make a conscious choice. They don’t take a deliberate action. But, people commit suicide.

Two beloved actors died over the last two years. We offered genuine respect and love to Alan Rickman who was said to have succumbed to cancer. He lost his battle the headlines read.

By contrast, our response to Robin Williams was much less clear. He “committed” suicide. Many headlines added that he hanged himself.

Many in the suicide prevention community have discontinued the use of the word “commit,” but many have not. I mean it kind of works, right? This isn’t the year 1800- we don’t think of suicide as a sin or crime any more. But, we do think of it as a choice, as a deliberate action.

This is an obvious and self-evident truth, we believe. We don’t need research or science to prove it. We just know it. Isn’t that right?

I wish we could zip up 17 miles to see the true perspective, but it’s going to take some faith. Let’s look at the clues, what doesn’t fit, that nagging circle shadow of the earth on the moon.

2016-04-08_21-40-18First clue, falling is not a choice

A few years ago, I participated in Fear Factor. In the first act, I was hanging from an upside-down Y-shaped bar 40 feet high above the ground.

I’m pretty competitive, and I chose to outlast the five others, to be the last one hanging on… no matter what it took, no matter how hard it was.

And, that all sounded really good… until the exact moment the platform holding my weight dropped away underneath me. I was immediately slipping on the bar, struggling to hold on, my hands sweaty. I double-downed my grip! But, quickly, my muscles began to ache with intense pain and my forearms ballooned like Pop-eye. The pain only intensified as the seconds passed.

I’m a clinician. I can handle this, I told myself. I relaxed my breathing, went to my happy place, a beach in my mind with gentle waves lapping- that strategy was good for a couple seconds and then NOT WORKING!

Finally, I was simply repeating to myself “hold on one more second… one more second.”

It was a long ways to fall. I desperately wanted to hang on. That was the only choice in my head, and yet, I still could not. Gravity, fatigue, and I was forced to succumb to the pain. If falling was a choice, I would still be there hanging on!

Watch my embarrassing fall as my legs fight to resist the inevitable (YouTube Video).

Second clue, pain is not a choice

Let’s talk about the pain. I mean, we believe we get it, right? The every-man perspective around suicide is that we can get a sense of the pain. We don’t understand the choice, but we have all had sadness and disappointment. Griefs and losses. The normal ups and downs of being human. These experiences have given us an insight into the pain behind suicide, haven’t they?

One of America’s top novelists William Styron said not a chance. His book “A Darkness Visible” about his own debilitating and suicidal depression is titled after John Milton’s description of Hell in “Paradise Lost.”

No light; but rather darkness visible

Where peace and rest can never dwell, hope never comes

That comes to all, but torture without end

One of our most talented writers ever, Styron said his depression was so mysteriously painful and elusive as to verge close to being beyond description. “It thus remains nearly incomprehensible to those who haven’t experienced extreme mode.”

If you haven’t experienced this kind of darkness, anguish, the clinical phrase “psychic distress” probably doesn’t help much. Styron offers the metaphor of physical pain to help us grasp what it’s like. But, frankly, many with lived experience say they would definitely prefer physical pain to this anguish.

Putting the Clues Together

So, some of you are thinking, I get everything you are saying but my loved one didn’t fall passively… I’m sure they were in pain, but they took a deliberate action. They pulled a trigger. They ingested a poison.  So, let’s put these two clues together, but reverse the order. The pain. And, the response.

After multiple trips down the hall, I dumped the last bucket of ice into the bathtub, then topped it off with cold water. Just a couple hours earlier, I had completed my first marathon in New York’s Central Park. My legs cramped badly in the last half-mile, and after returning to our hotel, my friend Michael and I thought it would be a good idea to do what the professionals do to expedite recovery: take an ice bath.

You might have already sensed that we skipped the instructions. With his teasing encouragement to go first, I stepped into the tub and quickly sat down, immersing my body in the ice and water up to my neck… Geez Louise- I won’t ever forget that moment!

The physical pain I encountered upon entering the tub was instant and unbearable beyond words. I don’t really recall the specific nature of the pain, but the core memory is vivid. I was filled with an all-consuming terror that I would not be able to get out of the water fast enough. In the next moment, I was thrashing in the water, like an animal desperate to escape the acute pain I was experiencing.

That type of reaction is hard-wired in all of us. Our immediate response to acute pain is physiological: our pupils dilate and eyelids widen, our heart rate and blood pressure spike, our breathing quickens. It is part of our body’s built-in defense system, and in a micro-second we are into fight-or-flight mode. I didn’t choose whether to exit the ice bath; my primal reaction was to simply GET OUT.

I didn’t passively fall like Fear Factor. I was rising up! Yet, deliberate action?

Here’s what didn’t happen. I didn’t ask Michael to roll in a white board so that we could business plan the benefits and drawbacks of leaving the tub. I didn’t sit in the tub 20 minutes with no idea what to do until Michael administered the Exit the Bath Survey and suddenly gave me an idea that had never occurred to me.

Deliberate action? No, like any animal in pain, I instinctively bolted away from the source of it. I was propelled. Exiting the tub filled every neural pathway of my mind, and my hands and body flailed as if completely disconnected from my conscious decision making process.2016-04-08_20-55-16My example references an acute pain, but extend that into a chronic day-over-day anguish that blinds the person to the possibility of a better day. Perhaps people do not choose suicide so much as they finally succumb because they just don’t have the supports, resources, hope, etc. to hold on any longer. Their strength is extinguished and utterly fails.

The every-man perspective is suicide is a choice- Robin Williams committed suicide. And, it’s the hand of the taker that is completely responsible for the choice and deliberate action.

It seems so obvious. But, it’s the limited 16 mile perspective, the one we all have, and it is one mile short of the truth.

Someday we’ll have the space station view. And, with it the solutions to create Zero Suicide.

But, for now, it’s time we study the signs and trust the clues, and be brave to stand behind them. Here’s a different headline:

Robin Williams lost his battle. Tragically, he succumbed and died of suicide.

Loving, respectful, truth.

When you can’t hang on any longer, you can’t hang on

I want to draw your attention to the actual picture of me falling. Even after my left hand fails and forces my fall, you can see it looks like my right hand is still holding on to an invisible bar. I never, ever stopped choosing to hang on.

When I presented this blog as a TED-style Talk in Chicago recently, I wore the Live Through This t-shirt (Thank you Dese’Rae Stage). Its simple message: Stay. Suicide is not a choice. Just one more moment of holding on can be all the difference.

Believe the signs. Change your perspective. Use your voice. Let’s change that great big beautiful round planet we live on, and let’s do it together by double-downing our efforts to help others hold on.


Note: The YouTube link to the 2016 American Association of Suicidology TED-style Talk on this topic will be posted soon!


Originally posted by

INSIDE OUT: A Model for BH Leadership

2016-03-10_22-56-50I am a behavioral health care executive. I know because of my socks.

Many years ago I was sitting in an Atlanta office interviewing with one of the industry’s largest companies for an executive role, and the question on the table was this: how could they be sure this counselor had converted and was now executive-worthy?

Like many of you, I started my career as a clinician. And, when I started, I had everything I needed. On my wall, my LPC and diploma. On my desk, my Zen Garden with its tiny rake. I wore my black dress crew socks every day. And while I didn’t know the meaning of “P&L,” I was very excited about making a difference in mental health.

But years later, here I sat…very nervous. How could I persuade the interviewer I had shed any excessive sentimentality and taken on the full mantle of executive responsibility?

What Does a Mental Health Executive Look Like?

As my interviewer and I talked, I realized that his actual litmus test for whether one was ready for the executive suites was whether or not one’s socks came over the calf (I am not making this up). After I picked my jaw up off the floor, I explained to him that I had obtained my MBA. I pointed to the pinstripe suite and power tie. Nope. These superficial external trappings would be totally betrayed by the presence of crew socks underneath!

I was forced into a corner. I had no choice but to prove my mettle. I lifted my pant leg… and POOF! I was bonafide. My sock went above my calf.

Superficial? Of course. And, a little odd. Some have since joked that he just wanted to see my calves. However, I think the actual question he was trying to get to was crucial.

Many of us among the 25,000+ behavioral health care executives started our careers as counselors, social workers, nurses and psychiatrists. But today, we work in the C-suites of Community Mental Health Centers, lead behavioral health in hospitals and health centers, and administrate in health plans and state authorities.

Our education and professional orientation began with Skinner, Freud, and Rogers. So, interviewers want to know, and we want to know with our own teams, are those the only voices in our head?

INSIDE OUT: What’s Our Model?

Last year, Pixar returned to greatness with a movie about an 11-year-old named Riley whose family was moving to the big city. INSIDE OUT provided us with an up-close and personal look inside the HEAD-quarters of her mind with the personification of five emotions: joy, sadness, anger, disgust, and fear.

We too need a mental model for the voices INSIDE OUT the HEAD-quarters of the BH executive. The old saying is models are a dime a dozen… but you have to have one.

I’m going to propose we need five critical voices. The model I’m sharing is adapted from Reframing Organizations, but it’s fueled and ignited by my own experience with five amazing mentors.

I’ve been really, really fortunate as these five mentors are real champions in the field, and they are my heroes. They have become the voices in my head.

1. FINANCE: “Net”

2016-03-10_23-15-39The first voice is the one that interviewer was trying to locate with his sock test! We’ll call him “Net.” He’s the finance guy.

By the time I met my new boss Richard, I was still wearing the pin stripe and right socks. I knew the difference in a balance sheet and cash flow statement, and I could sniff out BS (baloney and stuff). BUT… my finance voice wasn’t an equal in my command center. Richard was at Magellan Health and leading one of the largest health plan contracts in the country and we were neck deep in the worst economic downturn in our lifetimes.

Richard’s not a CPA, but he had a saying about driving results… “Gentle pressure, relentlessly applied.”

It was late 2009 when I came rushing into the Phoenix conference room for the morning budget meeting. I had been up late and had finally found THE answer. To my team, “Thank goodness everyone, we don’t have to cut Marvin and his program after all (I know it’s not been productive and the outcomes have been poor but Marvin’s really near retirement.) I’ve got an alternative. Instead… if we tweak our travel policy, change our cell phone provider, and save our quarters, we can get the same savings but a different way.”

Richard’s response is the telltale sign that Net’s voice is active and being heard. “These are always difficult decisions, but we’re the stewards of these funds,” Richard replied. “and we need to do ALL these ideas, eliminate Marvin’s program, and get double the savings we were originally seeking! It’s our job.”

It was these actions repeated over and over that dramatically mitigated the actual impact of severe budget reductions upon people receiving vital services. Increasingly, we are in a marketplace. INSIDE OUT the mind of the BH executive: “Net,” the finance voice, must be fully engaged and integrated into all our decisions and actions.

2. FAMILY: “People”

2016-03-10_23-12-16“Net” may on occasion bicker with her, but her name is “People,” and she is constantly thinking about the organization using the mental frame of a family.

I first met Linda in Las Vegas at the MGM Grand at the 2007 National Council for Behaivoral Health conference, and it’s a true success story how she has since grown her national association of community mental health centers and partners into a big tent of inclusion and national influence and accomplishment.

Five years after we met, she and I were participating in a steering committee meeting in a first floor conference room of SAMHSA headquarters in Rockville. She came over and encouraged me to consider pursuing a seat on her board of directors. It was the way she did it that I remember most closely, inspiring me to become part of a group that would put a dent in the universe.

More than ever before, this new generation of workers looks for meaning and purpose in their work. And, the “People” voice is asking some key questions about employees (excerpted from First Break All the Rules):

  1. Do they have a best friend at work?
  2. Do they believe their work matters?
  3. Do they believe a supervisor or someone at work cares about them?
  4. Do they get to do what they do best every day?

“People” suggests that we conduct an annual employee survey to assess their autonomy, engagement, and voice. She asks us to expand the ways in which we invest in our employees with skills and professional development. She is constantly looking to expand the diversity of our workforce.

I recall a corporate executive who chided in an all-employee meeting that the first commitment was to the Company, and he wasn’t interested in those whose identification was first with a professional orientation. “People” reminds us that our staff want to engage in a big dream, in a glorious purpose, and they will commit to a Company that supports them in that endeavor.

3. FACTORY (Clinical/Medical/Recovery): “Soul”

2016-03-10_23-13-13Let’s not run from the third voice. Far from it. Instead, let’s embrace “Soul.”

Underneath the pin stripes and power tie, we clinicians are still clinicians.

“Soul” speaks for what we actually do in our business. In our factory, we deliver services and programs, and the content is clinical, medical, and recovery.

The inspiration is my second mentor named Richard, who leads suicide prevention efforts as SAMHSA Branch Chief and with whom I’ve worked closely since 2005. He’s an architect of policy and national standards, but he always keeps the experience of individuals and the clinical people who serve them front and center, and his work has shifted the tectonic plates in terms of real social change.

There is a sea-change with people with lived experience involved in the leadership and design of programs, and he was leading that charge a decade ago with one of the first national committees for “consumers” and survivors.

However, it was in a cramped meeting room at the Hilton Garden next to BWI airport where I most remember his clinical soul. We were thinking about suicide care in the national community mental health system, and he said the following:

“When I think back over the decades, individual clinicians working under our leadership… they’ve made heroic efforts to save lives, but we administrators, the leaders of systems of care, we’ve done very little.”

This statement was a key driver in launching an international movement to equip clinicians to do what they love better, and to have the confidence to support and engage those at risk so that we together might aspire for something called “Zero Suicide.”

Yes, many of us are clinicians and social workers by background. But it’s not about converting from this disposition. Far from it. Own it. The voice of Clinical Soul must be strong inside all BH executives.

4. INTEGRITY: “Risk”

2016-03-10_23-14-47For us to be successful over time, we need to depend heavily on the voice of “Risk.” And we’re not simply talking about an external analysis, but the core backbone of integrity.

For me, this voice is that of my friend and mentor Sue, who leads a think tank and consulting firm, Crestline Advisors, and has been a corporate executive at the former Value Options and with Tricare.

Over the last several years, I’ve worked closely with Sue and her team on developing a strong compliance program, using the Marguerite Casey Foundation Organizational Assessment Tool for non-profits to establish a baseline, creating an organizational strategy and vision, and creating a road map for a world class program, with Chief Compliance Officer reporting directly to the Board, external and confidential ethics complaint line marketed to employees, stronger compliance education for all board members and staff, etc.

In the short term, it was beyond nerve-wracking. It’s been a couple years ago when Sue and I approached the leadership with the new approach and the investment required, and it seemed quite a contrast from the industry status quo. The memory is extremely vivid as four of us stood around a small round table in my office, perspiring bullets, and waiting for the thumbs up or thumbs down, but Sue emboldened me to take the long term view.

At the end of the day, “Risk” is the voice that presents the core of integrity, of honest and straight dealings, and of acting to protect the organization over the course of time.

5. JUNGLE (Strategic/Symbolic): “Vision”

2016-03-10_23-14-00The last voice is that of the jungle. His name is “Vision.”

One of the highlights of my career is working with Mike. For 30 years he led mental health authorities Connecticut, Ohio and New York, working for multiple governors. And he has been extremely effective in extraordinarily complex environments.

Whenever we talk about a political frame, lots of negatives come to mind. Our jaundiced view only increases if we use the word “power.” But politics is the realistic process of getting things done, of making decisions and allocating resources when interests diverge and resources are scarce.

From Mike, I’ve learned practical insights on how things get done (or not):

  • Research shows that of those in an action group, about 30% are focused on the task at hand (the remainder are focused elsewhere, asking questions like, “what’s my role in this group?” and “is this still a formal group or not?”)
  • And, why do CEOs adopt some new ideas/programs that come across their desk and not others? Research shows there is a bias towards solutions for problems being contemplated at that moment, solutions that fit their preconceptions and ideas that are easy to implement.

These are the dynamics of politics and strategy, of the jungle.

One of my favorite stories is when Mike was chairing the landmark “President’s New Freedom Commission Report on Mental Health.” To my surprise, then President George W. Bush actually spent several hours with the team in a conference room in Albuquerque.

Having never met, the President strided into the room, made his way through a dozen folks and straight up to Mike, taking his hands and shaking them and saying “Michael, thank you for taking this on!” Mike replied, “I hope we’ll do work worthy of your trust Mr. President.” “I have no worries about that.” He then went on to thank the other members of the group by name.

The “Vision” voice knows that we rely too much on reason and too little on relationships. And, there’s simply some horse-trading as part of successful coalition building. Think about all that President #43 communicated that day, both with memorizing the names and faces beforehand and sharing the gift of his time.

Setting the agenda is an important first key strategic step in navigating the maze, but establishing a Big Hairy Audacious Dream is even better.

One more thing. The jungle is not just strategy. There’s an important component that’s part temple/part theater. Call it symbolism.

“Vision” will provide you with metaphors, ceremony, and rituals. Our organizations each have a culture, and these are powerful ways to influence and motivate. Think about the symbolism of the actual title of the President’s New Freedom Commission Report. It was “Achieving the Promise.”

Decisions that get made in the HEAD-quarters of BH Executive minds are tactical, financial, clinical, and strategic… but they are all observed by the employees, partners, funders and customers and they all carry significant symbolic weight.

Reframing Leadership: They Are All Right

You can find a great book on most any of the five frames above in your local Barnes and Noble, and each will explain they have the ONE secret to leadership. My experiences with these five heroes of behavioral health suggests they may all be right. It’s also the message of the book Reframing Leadership.

“Net” “People” “Risk” “Soul” “Vision”
Capacity, Productivity, Value, Cash & Margin Aligning Company & Human Needs Strong Compliance & Risk Mgmt. Foundation Clinical, Medical and Recovery Practices Strategic, Political and Symbolic
Architect Empower Protect Advocate Inspire
Excellence Love Truth Hope Significance


The authors state,

“Explosive technology and social change have produced a world that is far more interconnected, frantic, and complicated.”

In order to succeed, we need a mental model: five voices at the command center in our HEAD-quarters. It’s not about exchanging a clinical soul for finance. It’s about ensuring an equal say by all five voices. We cannot afford to keep even one in a closet, not for a moment. And, we don’t have the luxury to focus on one at a time. This isn’t juggling.

The lesson of the kids’ movie INSIDE OUT. Perky Joy is determined to find the happiness in every moment and keep sadness and other emotions at bay. In the end, she learns that all the voices play a critical role.

We’re all really good at one of these voices, and are all probably lacking in at least one, giving us an Achilles Heel. We need to develop competence incorporating all five. This doesn’t mean we won’t still make mistakes, but it’s essential to our success. Integrating all five is our task and what we must do to succeed.

Like 11 year-old Riley, we’re not in small-town Minnesota any longer, and the world… well, it just keeps a’ changing. But as BH executives, we’re up to it.

I should know. I’ve got the socks.


Note: The YouTube link to the 2016 National Council TED-style Talk on this topic will be posted soon! If you are interested in improving your competency in any of the frames above, check out a few of my favorite references:

  • OVERALL – Reframing Organizations: Artistry, Choice & Leadership by Bolman (1991)
  • FINANCE – Good to Great by Collins (2001)
  • FAMILY – First, Break All the Rules by Coffman (1999)
  • CLINICAL – The Skilled Helper by Egan (1974), and Why People Die by Suicide by Joiner (2005)
  • INTEGRITY – How to Deliver Accountable Care by Lloyd (2002)
  • STRATEGY/SYMBOLISM – What Got You Here Won’t Get You There by Goldsmith (2007)

Also, I would like to credit my friend Dr. John Santopietro from Carolinas Healthcare who used the phrase “clinical soul” when I was visiting Charlotte programs in 2015.

Originally posted on by davidwcovington

Pursuing an Ambitious New Zero Target in the UK

IMG_2554Clean, clear blue sky. I snapped this picture of the iconic London skyscraper known as the Shard last week, a rare one as it lacks the ubiquitous jam of black taxis, big red buses and cars crawling through the streets. But, it evokes what might be.

What would the UK capital look like if it ran on 100% clean energy? Recently, it became clear that London will in fact miss its first target for incremental improvement. The think-tank IPPR challenged mayoral candidates that it was time to get serious:

“We call on the next mayor of London to pick up the pace – and provide a plan for how they could pursue an ambitious new target, for London to be a zero-carbon city by 2050.

Hard to imagine and totally impractical given the infrastructure that exists today? Maybe, but instead of conceding smaller targets IPPR went the other way. They urged Londoners to imagine the ultimate goal and pursue it with earnest. If you guessed that the candidates balked, you would be wrong (see Mayor Candidates Commit to Zero).

We humans aspire to the heights. We tackle wicked problems. And, when we stretch and dream of the vision we desire, despite it seeming impossibly out of reach, we galvanize resources, we break through with new ideas, and we achieve amazing things.

Aspiring for Zero Suicide in London

The venue for the picture above was the Hotel Novotel. I was there to participate in a forum of the three major UK Zero Suicide pilots hosted by Public Health England. The inspiring day was led and facilitated by Director Wellbeing and Mental Health Gregor Henderson and Public Mental Health and Wellbeing Manager Helen Garnham.

It was my privilege to kick off the morning with a reflection on the current state of Zero Suicide (see my presentation PowerPoint). I started with the concept of the BHAG, a Big Hairy Audacious Goal, and reviewed the history of El Capitans that healthcare has already ascended or begun to climb (see “Is Your BHAG as Humbling as El Capitan?”).

2016-02-15_14-37-53Gregor referred to Zero Suicide as a “movement,” and it is officially an international one with growing pilots in the US, the UK and the Netherlands. The early adopters are strong missionaries carrying the flame to others. The clinical soul is deep and rich- the movement has its heart.

The evidence burned bright in three moving presentations of the UK pilots:

  • South West Strategic Clinical Network– Dr. Adrian James, Chair, challenged the group that changing the clinical approach to suicide will have cascading benefits for the overall care. The South West vision is based upon a mindset, a methodology and markers.
  • Mersey Care NHS Trust– Dr. David Fearnley, Medical Director, on the partnership with Mersey and Cheshire Suicide Reduction Network Strategic Partnership Board, “Suicides are not inevitable.” Safe and effective care and treatment exists already, but a competent and skilled workforce must be equipped.
  • East of England Strategic Clinical Network– Dr. Caroline Dollery, Clinical Director, shared key characteristics including relevant training, local community champions and creating attitudinal change.

Three different programmes, but the Henry Ford Health System focus on robust performance improvement was clearly in the DNA of each. None of them claimed any magic formula or pioneering innovation. Instead, they each believe there are tried and tested methodologies that healthcare must employ with rigour.


Rapid Cycle Quality Improvement at Mersey Care NHS Trust

And, we are seeing the first strong steps towards strengthening the science. Andy Bell presented on the Centre for Mental Health evaluation of the East of England Zero Suicide programme. In the US, the National Institute for Mental Health has recently released RFA-MH-16-800 seeking Applied Research toward Zero Suicide Healthcare Systems.

Ann John closed out the day encouraging the group to move forward with further evaluation. As part of Public Health Wales, Ann is national lead for suicide prevention and chairs the national advisory group to Welsh Government on suicide and self harm prevention.

Alys Cole King (Connecting People) presented on training clinical professionals and Joy Hibbins (Suicide Crisis Centre) talked about her lived experience and the respite program that her team has since created to meet the needs of those at risk.

West Yorkshire Vanguard Zero Suicide

A day earlier I was in Bradford, UK, three hours north of London by train, where more than 150 clinicians, law enforcement, community stakeholders, persons with lived experience and others gathered for a summit at the Bradford City Football Stadium, “Building Resilience and Wellbeing: Zero Suicide.”

2016-02-15_9-56-55Simon Large is chief executive of the Bradford District Care NHS Foundation Trust, which operates the centre in the grounds of Airedale Hospital. He shared, “We are fully committed to the ‘zero approach’ and have been inspired by hearing the experience of others who have adopted this aspiration.” Dr. Mike Doyle is leading the local efforts, and working to develop a consistent model across West Yorkshire (see local news coverage).

Whereas in London I spoke about the outcomes and evaluation components of Zero Suicide, in Bradford my message was the clinical underpinning. Including people with lived experience (think about this experience as “lived expertise”) in the design and leadership of these programmes alongside other stakeholders creates something different. And, rejecting the myths about the inevitability of suicide for some people are key ingredients of Zero Suicide (see my presentation PowerPoint).

International expert Professor Nav Kapur provided a keynote address on the UK wide perspective from the National Confidential Inquiry. His presentation buttressed the systems approach with the 2012 findings regarding mental health services that had implemented 24 hour crisis teams, dual diagnosis policies and/or multi-disciplinary reviews. Overall, their study concluded that systemic changes save 200 to 300 lives per year (see Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006).

An Inconvenient Truth

In December 2015, the United Nations convened in Paris a climate change conference attended by most of the countries in the world. The discussion centered on incremental improvement, and whether setting a goal of limiting global warming to less than 2 degrees Celsius (°C) compared to pre-industrial levels was enough.

By contrast, Londoners are dreaming of a city that is a global leader in climate change. Zero Carbon, they are calling it.

And, beginning in March, 2016, a group from 13 nations will release “Zero Suicide: An International Declaration for Better Healthcare” (see advance Final Draft). Zero Suicide is equal parts aspiration, social movement and culture change. It represents a new mindset to harness enthusiasm and create action.

The London event quoted Australian businessman and former politician John Brogden, “It’s the national emergency we can no longer ignore.”

So, the status report on Zero Suicide after a quick trip to the UK: We have climbers in three countries who have surveyed the wall, identified the summit, and… begun to climb. As more healthcare leaders join, let’s all make progress together.



“History has shown that action by organizations can, eventually, make a large and life-saving difference, even for issues that at first together seem intractable. Stroke, AIDS and heart disease have dropped dramatically. However: not for suicide. Yet.”

Zero Suicide: An International Declaration for Better Healthcare (Final Draft)

If you are interested in supporting the global dissemination beginning March 6, 2016, please contact us to become a Zero Suicide Ambassador. 


Originally posted on by

A-10 Thunderbolts and Crisis: What Happens With Precision and Focus?

2016-01-28_20-32-08“Hey, look! It’s a pair of A-10 Thunderbolts!” The distinctive buzzing hum of the planes’ turbofan blades distinguished them as “Warthogs” well before I could make them out. The four of us stood in the parking lot of ConnectionsAZ Crisis Response Center and admired these marvels as they lined up in the sky above us for landing at Tucson’s nearby Davis-Monthan Air Force Base.

Hours later, during our return drive to Phoenix we reflected on our tour and the striking success that can be achieved when a group knows exactly what they want to do… and then just does that and little else.

The A-10 has one mission only: destroy tanks. Period. Its front landing gear offset from center, the plane was literally designed around the 30 mm Gatling rotary cannon, which sprays depleted uranium armor-piercing shells at rates of nearly 4,000 rounds per minute.

Targeting small, slow-moving targets is difficult for fast jets. The A-10 flies low and slow to accomplish its singular mission and this means absorbing significant amounts of damage. In order to stay focused on its mission, the A-10 engines and pilot are wrapped in 1,200 pounds of protective titanium armor. All so that it can… destroy… more… tanks. That’s it.

In Good to Great, business visionary Jim Collins describes the magic that occurs when a team crystallizes their reason for being and refuses to be distracted by anything else. He contrasts the fox, which is good at many things, and the hedgehog which is the master of one thing. Like the A-10.

Tucson’s Crisis Response Center

Dr. Margie Balfour is Chief Clinical Officer at the Crisis Response Center in Tucson and also serves as Vice-President for Clinical Innovation and Quality at ConnectionsAZ. Dr. Balfour graciously facilitated a tour of this state of the art facility which was opened in 2011.

The result of a $50 million community bond, the Crisis Response Center facility housed crisis stabilization, with 23 hour observation and sub-acute residential beds, and separate units for adults and children. A secure “sally port” facilitated transfers from law enforcement, and a covered walk-way connected the facility to Banner University Medical Center South Campus, which includes an emergency room and acute care psychiatric inpatient unit next door. In addition, a crisis call center and peer warm line was co-located in this fully integrated and coordinated model.

IMG_1677In the original approach all these different services were subcontracted through a single vendor, an approach that might be described as “foxy,” to borrow again from Jim Collins.

On April 1, 2014, ConnectionsAZ began operating the crisis stabilization programs inside the Crisis Response Center, and Dr. Balfour relocated from Texas to Tucson to provide the medical leadership. A circuitous career path that started off as a scientist prior to developing a passion for clinical in public sector behavioral health established a foundation for a new kind of precision and focus.

If the A-10 singular mission is dispatching tanks, what is it for crisis?

It seems self-evident that crisis services should be about getting the best care to people experiencing a psychiatric emergency… FAST. It’s an emergency, and the response should match. When the call comes in, the firefighters proverbially slide down the pole and roll the trucks. Remember the opening theme to the long running NBC hit ER… everyone is running! Lives depend on it.

Yet, the reality of crisis services is often the exact opposite. It can take hours or even days in an Emergency Department to be “medically cleared” before entrance is granted to many of the nation’s crisis stabilization programs. Law enforcement and first responders are expected to take the person in crisis to the hospital first, not the crisis unit.

The experience of the over 13,000 individuals that utilized the services of the Crisis Response Center each year had been uneven. There were often long delays in the clinical triage area while the patient awaited a decision on whether they would be admitted or discharged. Frustration abounded, which was compounded because the same questions were repeated several times during the process.

The result was a decrease in safety and increase in injuries and assaults. Individuals in crisis were sometimes left unattended for long periods of time and staff were spread thin between the crisis programs and interview areas. Security was frequently involved.

Lean Six Sigma in Action

There was a significant need to improve and speed the triage process, but there was a lack of agreement on the mission of the facility. Dr. Balfour and the ConnectionsAZ team met with the leadership and front line staff in a series of town-hall meetings, conducted rounds in the facility to interview patients and staff, and worked shifts providing clinical care to view the experience up close and personal.

2016-01-31_23-20-54The result of this process was an A-10-level singular mission: Meet the immediate needs of those in behavioral health crisis in a safe and supportive environment.

In order to reengineer the Crisis Response Center for this new mission, Dr. Balfour and team utilized Lean Six Sigma. Motorola and Toyota both revolutionized process improvement, by eliminating waste and improving the flow of manufacturing, and by building upon the pioneering work of Edwards Deming in the 1950s (think Plan-Do-Study-Act). Healthcare has been slow to catch the vision, and crisis care for behavioral health has been characterized by waiting in lines, for both the patients and the various internal and external agencies with whom these programs collaborate.

The team began by establishing some assumptions. They would achieve gains with the existing resources and staffing by standardizing the process and eliminating waste and inefficient practices. They also introduced a number of interventions, including improved dashboard tracking tools.

Next, they analyzed wasted time and function. What were the tasks that added value? What were the tasks that added little value but were nevertheless required (by licensure, contract, etc.)? And, finally, what were the tasks that were waste?

The value analysis found that the old process required almost 11 hours, and that nearly 40% of this time was simply unnecessary and non-value added. Wasted time. For individuals and family members dealing with a behavioral health crisis. Idly sitting in the waiting room was a significant portion of this time, but there were also inefficiencies in some of the other tasks that needed to be improved.

The Results

The outcomes were Thunderbolt! They decreased the “door to door dwell times.” The average time spent in the triage clinic decreased from seven hours to two hours, and the time in the 23 hour unit decreased 30%, improving not only the patient experience but also the capacity through improved through-put.

Even if you haven’t been in a psychiatric crisis, most everyone has been to the Emergency Room, and the key metric we all remember… how long did it take us to see the doctor? Dr. Balfour’s team reduced the waiting time by nearly 80%. These significant gains had other cascading benefits. For example, the facility reduced dramatically the time it spent on diversion so that it could better serve the needs of those in crisis in greater Tucson. Assaults to staff and calls to security were also dramatically reduced, and the changes in process yielded additional space. The building was remodeled to take advantage of these improvements and the capacity of the temporary observation unit was increased by 36%.

Dr. Balfour believes there were several key ingredients in their success. They engaged everyone from top leadership to the line staff. They kept compliance and quality functions separate, and obtained Lean Six Sigma green belt certification for quality staff. And, they built the IT and data system necessary to track and report accurately on the performance.

When I think of the A-10 level focus of the ConnectionsAZ culture, the metric that comes to mind most readily is law enforcement drop-off turnaround time. First responders don’t take people in crisis to the emergency room first. They drive straight to crisis facilities in Phoenix or Tucson where they spend between five and ten minutes before returning to their patrol.

Precision and focus. Business is changing healthcare, and lean six sigma has come to psychiatric crisis services. The results are in, and it’s time for us to re-model our own A-10 Thunderbolts.

We can measure our performance and progress through the levels below.

Levels of Accomplishment

Level 1 Everyone in the organization/department knows what the unit’s core processes are.
Level 2 Each core process is fundamentally documented.
Level 3 The primary customer requirements of each process are documented and conformance to spec is tracked.
Level 4 The primary control factors that drive desired performance for each process are documented and tracked.
Level 5 Each process can be documented to be behaving as intended (e.g., is “in control”).
Level 6 Each process is completely standardized, in control, and has an on-going continuous improvement plan.


Note: Dr. Margie Balfour will be one of the presenters at the National Council for Behavioral Health conference in Las Vegas on March 7 – 9. Also, check out her article: “Crisis Reliability Indicators Supporting Emergency Services (CRISES): A Framework for Developing Performance Measures for Behavioral Health Crisis and Psychiatric Emergency Programs,” Community Mental Health Journal, 2015 (download here), which includes the outcomes model below. 


Originally posted on by

Defend the Alamo: Crisis Mental Health Care Must Be Transformed

shutterstock_9835540Vastly outnumbered. Ill equipped. Foraging for resources. The nation’s Emergency Departments are the Alamo of mental health access and care.

The recent headline was not surprising: “8 in 10 ER Docs Say Mental Health System Is Not Working for Patients.” The survey by the American College of Emergency Physicians (ACEP) of 32,000 physicians, residents and medical students working in hospital emergency departments concluded that “boarding” wait times for psychiatric inpatient needed to be reduced and more training and education of staff about psychiatric emergencies was required.

Sheree Kruckenberg is Vice President Behavioral Health for the California Hospital Association, which represents 400 hospitals and health systems. Her April 2015 open letter drew similar conclusions:

“The increasing dependence on… hospital EDs to provide behavioral evaluation and treatment is not appropriate, not safe, and not an efficient use of dwindling community emergency resources. This includes not only hospitals, but emergency transportation providers and law enforcement. More importantly, it impacts the patient, the patient’s family, other patients and their families, and of course the hospital staff.”

The Emergency Nurses Association (ENA) has reported similar challenges with a shortage of tailored education and training. According to the National Alliance on Mental Illness (NAMI), many patients and families are displeased with their experience in the ED because of wait times and a lack of respect.

Everyone seems to agree with the problem.

The solution doesn’t seem as clear. ACEP is leading a response with a larger group of partners to form the Coalition on Psychiatric Emergencies, also known as “COPE,” with the goal of improving mental health and addiction care in EDs.

History would suggest those reinforcements aren’t coming in the numbers necessary. By the time the mental health crisis reaches the Alamo, the battle is already lost.


Our country’s approach to crisis mental health care must be transformed. It is the time, and we have the tools to prevent tragedies like these:

  • Unspeakable family pain: In November 2013, Virginia State Senator Creigh Deeds told CNN that he was alive for just one reason: to work for change in mental health. Just a week earlier, his son “Guss” stabbed him 10 times and then ended his own life by suicide. This happened only hours after a mental health evaluation determined that Guss needed more intensive services, but unfortunately, he had to be released from custody before the appropriate services could be found.
  • Psychiatric “boarding”: The month prior, the Seattle Times concluded their investigation of the experience for individuals with mental health needs in Emergency Departments. “The patients wait on average three days [emphasis mine] — and in some cases months — in chaotic hospital EDs and ill-equipped medical rooms. They are frequently parked in hallways or bound to beds, usually given medication, but otherwise no psychiatric care.” In 2014, the state supreme court ruled the practice of “psychiatric boarding” unconstitutional.
  • The wrong care, in the wrong place, compromising other medical urgent care: In April 2014, California approved $75 million for residential and crisis stabilization and mobile support teams. This investment was based on the belief that 3 out of 4 visits to hospital emergency departments for mental health and addiction issues could be avoided with adequate community based care.
  • Thousands of Americans dying alone and in desperation from suicide: And, in 2015, the National Action Alliance for Suicide Prevention launched the Crisis Task Force, with the goal to provide stronger 24/7 supports to the 9 million Americans at risk each year. Over 115 people per day in the US die alone and in despair.

Four different compelling reasons. Public safety. Civil rights. Extraordinary and impactable waste of public funds. And, the opportunity to address one of our most intractable human problems. The time is now, and the burning platform is clear.

It does not have to be this way. In a few states and communities across the U.S., solutions are in place. But until now we do not have the vision or will to approach crisis care with national resolve and energy.

Three examples highlight what can be done differently.

  • Power of Data and Technology. The Georgia Crisis and Access Line utilizes technology and secure web interfaces to provide a kind of “air traffic control” that brings big data to crisis care and coordination in real time.
  • Power of Peer Staff. People, Inc.’s Living Room, peer staffing and retreat provide safety, relief and recovery in environment more like the home than the institution.
  • Power of Going to the Person. Colorado Access’ mobile crisis teams don’t wait for law enforcement to transport a person in need to the hospital. They go to the person. Colorado is the first state to prove this can be done in urban, rural… and yes, even frontier areas.

Now is the time for a new approach.

crisis services graph

California, Colorado, Georgia and Washington State were driven to new approaches because of vastly different primary drivers, but five key elements stood out.

  1. The Expansion of Community Based Mobile Crisis Services to a 24/7 outreach and support with a contractually required response time (Colorado and Georgia)
  2. The introduction of Crisis Stabilization Programs that offered 23 hour observation and sub-acute short-term stays, at lower costs and without the overhead of hospital-based acute care
  3. Crisis triage call centers with strong use of technology and information across a system of care, leveraging big data for performance improvement and systems accountability while providing high touch support informed by suicide prevention best practices
  4. The engagement of peer staff, trauma informed care principles and recovery cultures to improve the experience and outcomes
  5. The involvement of government leaders, with activating legislation in California and Colorado, key engagement of the governor in Colorado and Georgia, and the judicial branch (DOJ, Supreme Court) in Georgia and Washington State2016-01-19_14-45-49

Now is the time for crisis, and we can do far better.

Our society takes for granted a national emergency medical response system. 911 centers with high technology to assure individuals with other medical problems do not fall through the cracks. These have transformed stroke and heart attack care. Ambulance services go to the person directly to assure immediate life-saving care, with  emergency medical services in every area of the country, urban, rural and frontier. We can do the same for other brain health crises. We must.

Defend the Alamo.


Note: In 2015, the National Action Alliance for Suicide Prevention launched a consensus expert task force on crisis that I have co-led with Dr. Mike Hogan. He and I co-authored the majority of the blog above and this content will appear in the foreword to the upcoming white paper, “Crisis Happens Now: Transforming Services is Within Our Reach.” 

Also, the #NatCon16 conference in Las Vegas March 7 – 9 will host its 3rd annual crisis track, featuring a stellar line-up including Carolina Healthcare’s Dr. John Santopietro, Beacon Health Options’ Dr. Chris Carson, ConnectionsAZ’s Dr. Margie Balfour and Community Health Network’s Dr. Marlon Rollins and Suzanne Clifford and others. Click here for more info.

Finally, I would like to credit the leader of RI Crisis Leon Boyko, who developed the “Defending the Alamo” metaphor. Since beginning with RI International in 2014, he has partnered with health leaders in Arizona, California, Delaware, North Carolina and Washington State to launch half a dozen new recovery-based crisis stabilization and crisis respite programs. 


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The Bugs and the Bees: Mental Health Really Matters for All of Us

beesAs we kick off 2016, it’s time to sit down and have that awkward “bugs and bees” talk. We cannot put it off any longer. It’s time to explain why mental health really matters for all of us.

Business leaders are not unacquainted with the negative impact of mental health. In any given week, nearly half a million Canadians are unable to work due to mental health problems. One in three disability claims are related to mental health, and the cost of claims and lack of productivity is exorbitant (70% of disability costs are attributed to mental illness). Despite this, many of us view mental health as something that pertains to other people.

Perhaps a story from nature will help us understand why mental health matters, and help us better connect with how life works. Believe it or not, we humans have a lot in common with ants and bees, as well as other eusocial species like mole rats. These groups all share intergenerational and cooperative care of their young, and division of labor is critical to their survival. Just like humans.

Dr. Thomas Joiner’s team at Florida State University has been studying the “bugs and the bees” to look for parallels with the Interpersonal Model of Suicide. This breakthrough concept, introduced just over a decade ago, suggests that people end their life by suicide because of two dominant intrapsychic pains:

  • They believe they are a burden to others
  • They have a sense of thwarted belongingness

When this happens to a bee or ant (because of injury or disease, for example), three things occur. First, it becomes very agitated. Next, it separates itself from the group. Lastly, it dies. Joiner’s team suggests that suicide among humans is a derangement of this self-sacrificial process observed among other eusocial species.

Feeling alone. Feeling that others would be better off without them. On the continuum of mental illness, this represents the darkest side and generates tremendous emotional pain and thoughts of death.

But consider the flip side of these two coins: contribution and connection. Two words. What do these words tell us about mental health? That instead of feeling like a burden to others, one perceives they are making a difference for their family, friends, and/or community. And this belief is inextricably tied to an engagement to others in the “colony.”

It’s early in 2016, which means that about a third of us are still thinking about our New Year’s resolutions. Perhaps you want to improve your health. You’ve committed to losing weight. Exercising more. Quitting smoking.

If you’re a smoker, giving up cigarettes is only the second most powerful thing you can do to improve your health. You’ll never guess what the best thing is.

Strengthening social supports.

In 2010, Julianne Holt-Lunstad performed a meta-analysis of nearly 150 scientific studies on morbidity and mortality. She concluded that the most powerful predictor was strengthening social supports. Being alone and feeling lonely increased the likelihood of death by 30%. By contrast, having friends and strong social connections will help you live longer and live better.

This isn’t a feel-good theory. It’s science. We thrive in work and life when we feel connected and are making a contribution. We despair when we feel alone and feel others would be better off without us. There is a long continuum in between the two.

The Mental Health Commission of Canada has created a simple continuum model to help explain how this works. There are four categories, ranging from healthy to ill, and the model describes the symptoms and states for each, as well as important actions to take at each phase. We are all on this line, moving back and forth along it throughout our lives.

mental health continuum modelSurprisingly, this continuum can be a hard concept for those individuals who have spent most of their days in the green, feeling like they are on top of the world. What they don’t realize is that they feel that way largely because of their social support network and the influence and impact they perceive they are making.

But we are all part of the colony. Life happens. The marine who has no memory of a time that wasn’t green gets injured, is discharged, and finds himself in the red very quickly. Same for the senior executive who for years has had thousands depending on her and when she retires, she suddenly perceives her life more of a burden than a benefit.

Now imagine how a serious mental illness such as schizophrenia, bi-polar disorder, major depression, or an addiction might skew a person’s view of their role in the colony. We tend to view suicide risk as a symptom of the mental illness, but the real threats are lack of contribution and connection.

The Harvard Business Review agrees. The recent article “Proof That Positive Work Cultures Are More Productive” by Seppälä and Cameron describe the negative outcomes of high-pressure companies. Healthcare costs are doubled and productivity is siphoned away. There is a 50% increase in voluntary turnover in these environments and errors and defects are 60% more likely.

Their answer for managers is simple. Go out of your way to help. Show empathy. Encourage people to talk to you. And most importantly, foster social connections.

In “First, Break All the Rules: What the World’s Greatest Manager’s Do Differently,” authors Marcus Buckingham and Curt Coffman show us that the best managers have staff who can answer yes to all the following key questions:

  • Do I have a best friend at work?
  • Does my work matter?
  • Does my supervisor or someone at work care about me?
  • Do I get to do what I do best every day?

I’m not naïve. The challenges of work can be intense, but they’re much more manageable when the work is shared and the worker is valued. It’s a little like charging into my first mud runner event a few years ago. Seemed like a great idea as I was sprinting along at front of the pack, and at the very first obstacle, our group came to a sloshing stop in muddy water. The person immediately to my right stumbled full up to their neck.

None of us could find a way to scale the muddy hill in front of us. We slipped and slid with others piling into the muddy pool, pressing us from behind. The guy next to me found a small stick and tried to claw his way out, but he failed. I grabbed the stick from him and forced it into the dirt so that he could plant his foot and lunge to the top.

My fellow ant looked back ever so briefly to express his thanks, and I yelled for him to reach down and help pull me up, too. He hesitated for an instant, and then leaned over, extending his hand and working to pull me up the mudslide, but our grip failed.

I urged him to give it one more try. He did and a moment later, I was up and over the top and the two of us were on to the next obstacle.

No, I didn’t win a Nobel prize and he didn’t cure cancer. But those brief moments demonstrate the essence of how life works, and why mental health matters for everyone. We’re part of a community. We work together to care for each other across generations. We divide labor to survive. We thrive when we are connected, and when we realize what we do helps others.

Ants do it. Bees do it. Humans do it, too.

Let’s stop putting it off. It’s time to talk about the bugs and the bees.


Note: I’m posting this blog from Washington DC participating in tomorrow’s The White House Dialogue on Men’s Health, an unprecedented event featuring the U.S. Surgeon General and Cabinet Secretary Broderick Johnson. Speakers include international leaders like Dr. Sally Spencer-Thomas and Kevin Hines.

Coming Out Day! Courtyard Exhibit in Phoenix

2015-12-15_8-59-31Dese’Rae Stage describes Live Through This as a collection of portraits and stories of suicide attempt survivors, as told by those survivors.

“The history of the movement shows the true power our stories have to change hearts and minds. Coming out to family, friends and coworkers has caused the opposition to equality to fall away. As more and more people continue to speak their truth, we’re inching closer to a day where no person ever feels compelled to hide who they are out of fear.”

Actually, this 2015 quote from the Human Rights Campaign referred to National Coming Out Day and the LGBT civil rights movement. But, it could have just as easily been applied to the pioneering efforts of Dese’Rae Stage, Cara Anna, Heidi Bryan and the many others, who like Harvey Milk, have spoken out and encouraged others to do the same.

2015-12-15_9-02-55On Thursday night, December 10, RI International hosted a different kind of Coming Out Day with a twilight courtyard exhibit featuring Dese’Rae’s award-winning collection of portraits. In addition, the event featured Philadelphia’s Behavioral Health Commissioner Dr. Arthur C. Evans, whose recovery oriented approach is transforming the City’s service system.

Dr. Evans began with a brief YouTube video on the City of Philadelphia Porch Light Mural Arts Program, and asked, “what does healing look like?” The answer. A space and place to share… that is created together, as a community.

The Philly experiment is big and bold. The Virtual Tour website showcases 20 murals that have been created around the city in partnership with behavioral health clinics and people receiving services. In just one of those examples, over 1,000 community members put paint to the wall with the three story, 100+ foot long “Finding the Light Within” mural at 120 South 30th Street.

2015-12-15_9-04-26Working closely with the American Foundation for Suicide Prevention, the Crisis Response Team of Philadelphia and many other local advocacy groups, muralist James Burns set out to shed light on suicide by providing an opportunity for relationship building among those bereaved by suicide, those with a history of attempts and their families and friends. The result is visually stunning and filled with rich and amazing detail.

Dr. Evans’ presentation inspired us that art can light the way to hope, resilience and a connection to each other.

Next, Dese’Rae shared her own painful story of depression, loss and suicidal thoughts. “But, I’m not a special little snowflake,” she followed, and pointed us to the amazing collection of photographs that encircled us. These included friends and leaders like Leah Harris and Dr. Bart Andrews, the latter of which came out of the closet about suicide just last year.

2015-12-15_9-07-58We’re afraid of death. We’re afraid of suicide. We’re afraid of those people. But, Dese’Rae reminds us that individuals who have survived suicide attempts look just like us. “These feelings could affect your mom, your partner, or your brother, and the fear of talking about it can be a killer.”

“Historically, people have spoken about their experience only under condition of anonymity in order to save them from being discriminated against. The silence and shame this creates are dangerous, and individuals are encouraged to own their experiences publicly, using their full name and likeness, and stripping the issue of anonymity and raising awareness by talking about it. It’s been a taboo too long.”

This quote in fact came from Dese’Rae’s Live Through This website. But, it could have just as easily been used on National Coming Out Day. It’s time to tackle the last stigma.

Notes: More on RI’s special guests Dese’Rae Stage and Dr. Arthur Evans, both of whom reside in Philadelphia

The Live Through This project has been covered by the New York TimesAssociated PressUpworthyNPR, the Glenn Beck Program as well several other radio and TV programs.  In 2015, Dese’Rae won the inaugural Paul G. Quinnett Lived Experience Writing Contest and was named New Yorker of the Week by NY1 News.

In 2015, Dr. Arthur C. Evans was recognized by the White House as an “Advocate for Action” by the Office of National Drug Control Policy. In 2013, he received the American Medical Association’s top government service award in health care, the Dr. Nathan Davis Award for Outstanding Government Service. Dr. Evans is also regarded as a strong advocate for people experiencing behavioral health conditions and was recognized by Faces and Voices of Recovery with the Lisa Mojer-Torres Award.

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