Zero Suicide: The Dogged Pursuit of Happiness

The special report in the January 2019 issue of the Psychiatric Times addresses the Zero Suicide Movement including the rational behind its importance, the efforts made to reach this pivotal landmark, approaches to use to reaching Zero Suicide, and the next steps to follow on the way forward.

Read the full report here

A Huge Step Forward


 inaugural meeting of the federal Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC)

Yesterday was the inaugural meeting of the federal Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). While the acronym is a mouthful, the meeting is an important step to better health and quality of life to members of our community with the most significant needs; individuals with schizophrenia, bipolar disorder and major depressive disorder. Health and Human Services (HHS) has prioritized mental health alongside two other top priorities: opioid abuse and childhood obesity.I’ve attended many government meetings on mental health and suicide prevention in Washington DC over the past decade but this represents my first mental health meeting next to the Capital at the HHS offices Hubert Humphrey Building. It’s a clear signal that mental health is a priority to the US government and our healthcare system.

HHS Secretary Dr. Tom Price began with the challenges for the 10 million people with serious mental illness; including lifespan, homelessness and incarceration disparities. “Recovery is the expectation” with employment and social connectedness being mentioned during the discussion. According to Price, prejudice and apathy have weakened the way we address these issues but they require the same expertise and commitment as cancer or heart disease treatment. Secretary Price also called out the importance of family support and inclusion in the collaborative process to evolve our health care system.

There were prior mental health initiatives under Presidents Jimmy Carter and George W. Bush, but Secretary Price explained that the ISMICC is the first to report to Congress and he expressed strong confidence in the newly appointed Assistant Secretary for Mental Health Dr. Elinore McCance-Katz. This new role reports directly to the Secretary of HHS and Dr. McCance-Katz is the first psychiatrist to lead SAMHSA.

The charge of the ISMICC is three-fold:

  1. Report on advances in treatment, recovery and prevention;
  2. Provide rigorous assessment that is candid and sober; and
  3. Make specific recommendations on policy reform.

“I firmly believe mental health care does not receive the emphasis or resources it needs,” Secretary Price stated, adding “We need a true continuum of care from outpatient to inpatient.” Lisa Dixon from Columbia University shared her feelings on the inspirational opening: “My heart is in my hands with the promise for what this group might achieve.”

All branches of government were represented. Department of Housing and Urban Development Secretary Dr. Ben Carson spoke next sharing his lifelong interest in psychology. He explained that his mother struggled with major depression when he was growing up and was hospitalized.

One of the highlights for me personally was the active participation of the Center for Medicare and Medicaid Services. Kimberly Brandt described the largest health insurer in the world with 130 million covered lives and $1 trillion in spending. She identified several key CMS initiatives; including states reporting on outpatient follow-up to psychiatric inpatient services, the prevalence of smoking for individuals with serious mental illness, and expanded telehealth opportunities for delivering crisis psychiatry services. She also pointed to an upcoming CMS meeting on September 8 which will lay the groundwork for innovations in behavioral healthcare payment models.

Dr. McCance-Katz shared with the ISMICC ten key areas that she hopes to hear addressed in the dialogue:

  1. How do we move treatment back to community supports and services for those in jail or prison?
  2. How do we improve therapeutic relationships and what role might advanced directives play?
  3. How do we increase evidence-based practices like Assertive Community Treatment, Assisted Outpatient Treatment, and linkages to peers?
  4. How do we improve civil commitment laws?
  5. How do we improve access to care, especially given that 35% of people with serious mental illness receive no treatment at all?
  6. How do we address the long waits frequently experienced in hospital emergency departments, ensuring adequate acute care, crisis intervention and additional levels of care?
  7. How do we improve recovery supports and ensure better evidence for these approaches?
  8. How do we protect privacy rights?
  9. How do we address workforce deficits, including the numbers and geographic distribution?
  10. How do we incorporate co-occurring substance use services?

Next, four panelists presented on federal advances to address challenges in SMI and SED.

Dr. Joshua Gordon from the National Institute of Mental Health offered a strategic framework for SMI and SED research that would deliver personalized interventions. He presented RAISE as an example of success using this approach (RAISE stands for Recovery After an Initial Schizophrenia Episode).

Gordon also prioritized suicide prevention and described the NIMH RFA on applied research to evaluate the effectiveness of the Zero Suicide in Healthcare systems model.

SAMHSA’s Paolo del Vecchio leads the Center for Mental Health Services and started with the stark disparity between people with SMI/SED related to receipt of evidence-based practices. For example, unemployment rates for individuals with serious mental illness are extraordinarily high. 70% of individuals express a desire to work but only 2% receive evidence-based supported employment services.

Del Vecchio surveyed the principles of coordinated care: medications, therapy and recovery supports while highlighting approaches that integrate all three components. Great emphasis on the need for a coordinated continuum of crisis care and the Zero Suicide in healthcare. “We prepare people for a life of recovery, not a life of disability.”

Dr. John McCarthy with the Department of Veterans Affairs, Office of Mental Health Operations, described the advances in treatment and access. While the overall number of veterans in the US has declined since 2005, the penetration for those receiving treatment with the VA has increased 24%. The growth in outpatient mental healthcare is up 85% over the same time period.

McCarthy reported on the substantially increased hazard ratio of suicide for individuals with serious mental illness and the July 2017 findings from Dr. Mark Olfson related to the very significant suicide risks for individuals in the immediate aftermath of a psychiatric hospitalization. He described several VA initiatives to address these risks; including the Veterans Crisis Line, 400 suicide prevention coordinator staff nationwide and the REACH vet program, which uses predictive analytics to determine those at highest risk.

Finally, the Bureau of Justice Assistance’s Ruby Qazilbash shined a light on the prevalence of people with SMI in the criminal justice system. She cited data that approximately 4% of the general population has a serious mental illness, but 17% of the 11 million annually incarcerated in the jail population has a serious mental illness. She also described the frustrations of local law enforcement, whose experience can find one in ten calls involve mental health, contacts which require twice as long to resolve as other police activities.

After the lunch break, a second panel presented non-federal advances.

Lynda Gargan with the National Federation of Families for Children’s Mental Health shared her own powerful personal journey of challenges and successes regarding her son.

Columbia University Medical Center’s Dr. Lisa Dixon reviewed the evidence for Coordinated Specialty Care for individuals experiencing a first psychosis, which demonstrates dramatic reductions in inpatient hospitalization and strong improvements in school and/or work progress. She asserted that “being productive equals a basic human need.” People want to work. It’s an essential part of recovery. And… Individual Placement and Support (IPS) is very effective, creating employment rates as high as 78%.

Dixon also reviewed the impacts of peer supports strategies; concluding that they reduce the use of acute services, result in decreased depression and substance use and increase engagement and hopefulness (Bellamy et al, 2017, “An update on the growing evidence base for peer support,” Mental Health and Social Inclusion).

Dr. Sergio Aguilar-Gaxiola from the University of California encouraged a focus on a comprehensive view of the non-medical determinants of health, including co-morbid medical diseases, smoking, obesity, physical inactivity, poverty, trauma, poor social connectedness and homelessness.

Formerly medical director for the state of Missouri, Dr. Joseph Parks is the lead psychiatrist at the National Council for Behavioral Health. Parks discussed the challenges of access to care; including a psychiatry workforce shortage, psychiatric boarding with people waiting in hospital emergency departments for mental health services and insurance gaps. He also encouraged the enforcement of parity requirements to appropriately resource services.

Using a data driven approach, Parks recommended a framework for strengthening community treatments and crisis services. He stated that standard definitions of levels of care (using placement criteria like the LOCUS and CALOCUS) will ensure better matching to needed supports and ultimately decrease the shortage of psychiatric inpatient beds.

Committee member Elyn Saks summarized the four presentations stating the most important element is access to care. She also encouraged a thoughtful analysis of the use of coercion and force in behavioral healthcare treatment, and suggested we create more engaging treatment.

There was generous and passionate input from everyone in the room. One of the most memorable threads related to the word “Interdepartmental.” Dr. Ken Minkoff with ZiaPartners, Dr. Clayton Chau of the Institute for Mental Health and Wellness St. Joseph Hoag Health System and author Pete Earley, among others, encouraged the ISMICC to action around the central importance of integrated solutions across federal departments. Minkoff shared his involvement in both the prior Presidential mental health initiatives and stated this is the first-time integrated solutions have been the goal.

What an amazing day… an amazing opportunity… an amazing mission… and an amazing group of people. I am truly honored!

Key Timeline

  • December 13, 2017 – First report to Congress with a summary of advances in SMI and SED, evaluation of the effect of federal programs and impact on public health and specific recommendations for actions that the departments can take to better coordinate.
  • October 15, 2017 – First draft of the report with a seven-day turn around for feedback from the ISMICC.
  • November 15, 2017 – Second draft modified with comments with another seven-day turn around for further feedback.
  • ISMICC Non-federal committee members are serving a three-year term.
  • A second report to Congress is required by the 21st Century Cures Act in 2022.

Returning to the Why in Behavioral Healthcare

whyThe most important question is always why. So, why do we do what we do in behavioral healthcare? Put simply, we seek to equip individuals with serious mental illness to live happy, healthy, productive, and connected lives.

On Thursday, August 31, 2017, the 21st Century Cures Act takes a very important step forward with the inaugural meeting of the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). The ISMICC is composed of senior leaders from 10 federal agencies; including HHS, the Departments of Justice, Labor, Veterans Affairs, Defense, Housing and Urban Development, Education, and the Social Security Administration along with 14 non-federal public members. I am exceptionally appreciative of the opportunity to be a part of this amazing team.

HHS Secretary Tom Price will introduce the proceedings and review the charge to the committee and recently confirmed Assistant Secretary for Mental Health and Substance Use, Dr. Elinore McCance-Katz, will kick off a discussion of federal advances, challenges, and recommendations. The focus will be on outcomes; including rates of suicide, employment and education as well as other measures that might be used to evaluate the efficacy of efforts to address the needs of individuals who experience serious mental illness (SMI).

I’m very optimistic. The ISMICC charter and first meeting’s agenda point to a central focus on why. “WHY are we doing this work?” (HINT – It’s about real-life outcomes). It’s the best and right place to start, and should serve as a call to action to open our collective minds to a multitude of options of WHAT we might do and HOW we might do it to realize better outcomes.

In recent months, we in the field wrung our hands during the congressional debates over healthcare. Our talking points referenced WHAT we do: educational programs like Mental Health First Aid and services like case management and peer and recovery supports. We talked about HOW we deliver care and we contrasted our engagement now with the institutions of the 1950s. We looked at ways to do the things we have been doing better. These are worthwhile discussions. It’s so very easy to get caught up in the how and the what but it looks like we will now be challenged to dig deeper and focus on why we do what we do. This is not a completely foreign notion to many of us who have seen significant efforts in our Medicare and Medicaid programs to engage in value based contracting arrangements.

Several years ago, I was working as a counselor with a young man who was hard-charging through an advanced degree; seemingly destined for great success in life. He initially came to me because of grief around a broken relationship. Over the course of a six-month period, our team concluded that he was experiencing his first onset of serious mental illness.

Today, he would be in his 40s. As a person with a serious mental illness, there is only a one in five chance he will be employed. He would be twice as likely to be employed if he had instead been in a tragic accident that resulted in a visual, hearing or mobility disability. If unemployed, he would likely be missing the sense of contribution to community and the connection to others that many of us feel as a result of our work.

Additionally, he would be two to three times more likely to have developed diabetes, heart disease, or obesity than the general population. The average American has a life expectancy of 79 years. In 2006, the National Association of State Mental Health Program Directors (NASMHPD) found that a person with serious mental illness in the US dies on average 25 years younger than the general population (that’s 54 years). In comparison, the average life span in war-torn Afghanistan is 61 or seven years longer than someone with a serious mental illness in the United States.

Valuing Recovery - SMI Outcomes

These outcomes are relatively well-known but in recent years more attention has been paid to the impact of non-medical determinants of health that warrant consideration. Holt-Lunstadt and colleagues conducted a meta-analysis of health outcomes that revealed friends and social supports are the single most powerful indicator of health life and longevity. Simply put, loneliness increases the likelihood of early death by 30%. For context, increasing one’s community connections correlates more closely to longevity than quitting smoking according to the study.

When Americans are asked if they have “someone to rely on in times of trouble,” 90% answer yes. In Iceland, the answer is nearly 100%. Not a lot of research has been done in this area for people with serious mental illness. However, Magellan Health contracted providers surveyed over 20,000 people with a serious mental illness in Arizona between 2010 and 2013 with similar questions about whether the person has “someone to talk to about problems” and “someone who invites me out occasionally for dinner/activity.” The findings would suggest that only 55-65% of respondents with serious mental illness  have “someone to rely on in times of trouble;” which is again on par with Afghanistan where 57% answer in the affirmative.

Lastly, the young man I saw all those years ago was accustomed to making decisions about his life. Tragically, many individuals with serious mental illness realize less autonomy and self-direction, and may even be incarcerated. Elyn Saks is a non-federal member of the ISMICC, an expert in mental health law, and a person who lives with schizophrenia. Her recent article in Politico, The Consent Dilemma, thoughtfully examines the negative impact of increasing coercion and force in behavioral healthcare treatment.

These real outcomes can be measured and tracked for improvements. I’ve summarized them in the balanced scorecard graphic (above), Valuing Recovery: Real Outcomes for People with Serious Mental Illness.

WHY do we do what we do in behavioral healthcare? We seek to equip individuals with serious mental illness to live happy, healthy, productive, and connected lives. It’s not only their illnesses that conspire with barriers to achieving these objectives, but our society also limits their potential success through low expectations and discrimination. We can and must move beyond a focus on symptom reduction and stabilization to support people beyond their behavioral health needs to succeed in the community where they live, work, and play.

Thomas Joiner’s groundbreaking 2005 work “Why People Die by Suicide” suggested that the two most painful experiences in life are loneliness and feeling like a burden to others. By contrast, he suggested that people who are connected and perceive they are making a contribution to others are protected. We tend to think of suicide as simply a symptom of serious mental illness, but the outcomes generally experienced by SMI individuals (lonely, unemployed, etc.) would suggest tremendous risk for any population. In fact, the hazard ratio for suicide for people with SMI dramatically exceeds other “at-risk” groups like LGBT, older white males, active duty military and veterans, and Native Americans/Alaskan Natives.

SAMHSA reported national expenditures for mental health treatment of over $200 billion in 2014. Despite this investment in services and programs, the typical outcomes experienced by the nearly 10 million people with serious mental illness in the United States look more like those from impoverished and war-ravaged Afghanistan.

The young man I worked with had a past, one in which accomplishing his goals in life seemed straightforward. He had a future in his mind’s eye, a roadmap for meaning and purpose. But if he experienced the outcomes most typical for people with serious mental illness, our view of him in the present would miss so much of that potential. This can change!

We can imagine that what he wants today may very likely be what all of us want in life. We want to make a difference in the lives of those around us. We want to work. We want friends and family that love us and that we love back. We want to live a healthy life. And we want to be the ones responsible for our decisions. These are the things that make humans happy, and their absence makes any one of us grieve.

Today, the national expansion of First Episode Psychosis programs led by SAMHSA based on the National Institute of Health’s Recovery After an Initial Schizophrenia Episode (RAISE) study is transforming care for young people just like the man described above. RAISE began with two studies of Coordinated Specialty Care (CSC) and a clear focus on the why, but the approach is too rare an example of starting our program development with the end in mind.

We in behavioral health have lost sleep this past year over the how and the what. But we started the Community Mental Health movement over 50 years ago with a strong why — introducing services and programs that would empower individuals with SMI to live in local neighborhoods, not institutions.

On first take, the ISMICC seems focused on the heart of the matter; on the outcomes experienced by those with schizophrenia, bipolar disorder, major depression, and other serious mental illnesses. It’s time again for us to ask and answer the question why and begin taking strong actions to achieve measured success.

I’m inspired that the ISMICC is returning our focus to the purpose of our work and I’m confident this approach will engender actions that over time dramatically improve the lives of those with serious mental illness.

Note: The SAMHSA website includes information to join the August 31 ISMICC Advisory Committee meeting by teleconference as well as additional resources like the ISMICC charter.

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

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 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.


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 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
  • 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:

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


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!


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