Behavioral Health Care: How Far We’ve Come in 15 Years

Fifteen years goes by in the blink of an eye. This summer I’m stepping down after 15 years as president and CEO of the National Council for Behavioral Health, which is celebrating it’s 50th anniversary. This is a good time to take stock of where we have been as a field and where we are going.

When I joined the National Council in 2004, some in the behavioral health community spoke of a system in shambles and unfairly pointed fingers at others. But my perspective was from the ground up and I saw a different reality. When I testified before the Institute of Medicine, I described our members as essential community providers, chronically underfunded, struggling to transform lives.

I told them how our members were reimbursed at rates far lower than others that share the safety-net – hospitals, health centers, the Department of Veterans Affairs – creating a workforce crisis and compromising quality. Then, together, we went to work.

We moved health care integration from concept to reality. Today, integrated physical and behavioral health care isn’t the flavor of the month – we know it’s the best way to meet the complex needs of individuals with chronic, co-occurring conditions.

We embraced the science and practice of recovery and of trauma-informed care. Recovery is now the expectation, not the exception, in mental health and substance use treatment. We recognize and are increasingly prepared to respond to the trauma the majority of our patients’ experience. We have stopped asking, “What’s wrong with you?” and started asking, “What happened to you?”

We successfully advocated for parity, for full inclusion of mental illnesses and addictions in the Affordable Care Act, and for creation of Certified Community Behavioral Health Clinics (CCHBCs). CCBHCs are remaking specialty behavioral health care in this country by providing crisis services; integrating physical and behavioral health; delivering medication-assisted therapies; implementing evidence-based practices; partnering with peers; and collaborating with law enforcement, schools, and hospitals. They are working with groups that have special needs, such as veterans, who may not otherwise receive evidence-based services. CCBHCs are hiring new staff, easing the critical shortage of psychiatrists, especially in rural areas.

We don’t pay for cancer treatment with demonstration grants, and we shouldn’t do so for mental illnesses and addictions. Today, lack of access to care has replaced stigma as the leading barrier to a healthier America. We need sustained funding that supports a comprehensive continuum of services, and the Excellence in Mental Health and Addiction Treatment Expansion Act is a good start. The Act extends the CCBHC program, meeting the growing demand for more mental health and addiction treatment capacity and giving more people the opportunity to recover.

The National Council brought Mental Health First Aid to the United States and we have trained 1.7 million people. This means 1.7 million people from all walks of life are now able to initiate a conversation with someone experiencing a mental health or substance use crisis and refer them to community resources and professional help, if needed. We are well on our way to making Mental Health First Aid as common as CPR.

We continue to promote the adoption of technologies that have revolutionized other industries and are now being applied to health care – technologies that support and educate staff, increase treatment capacity and measure outcomes, put patients in charge of their own health, support the office operations vital to effective care, and deliver psychiatric services into our clinics and homes from across the country. We can be both high-tech and high-touch.

Working together, the National Council and its members have done this challenging and rewarding work. But we have much left to do.

Startling figures show that average life expectancy in the United States dropped for the third straight year, driven by increases in overdose deaths and suicides. You are now more likely to die in this country from an opioid overdose than a car accident. Partisan divide over the Affordable Care Act persists and Medicaid is still under assault.

Where do we go from here? To begin with, we need leaders who have a bias toward action, who are fearless but not reckless.

Behavioral health executives need to make decisions and respond quickly to changing markets. They need digital dexterity, using data for strategy and change and using technology to reengineer processes and relationships with staff and patients. This requires leaders schooled in business, not just social work or psychiatry.

We wanted to decrease stigma and we have. Now, the demand for mental health and addiction services far exceeds supply, and we need leaders who can participate in solving the treatment gap.

We need leaders who can operate in a transactional economy, creating networks across communities and even states; forming independent practice associations (IPAs); and negotiating for capitations, case rates, and bundled payments.

We need leaders that embrace local, state, and federal advocacy as fundamental to their jobs. Leaders ready to advocate for the most viable way to ensure the availability of effective community behavioral health care – CCBHCs. With unemployment at a 49-year low, we need rates that cover competitive salaries, and prospective payment is how federally qualified health centers have closed the primary care treatment gap. It’s time for parity in the safety net.

We need leaders who understand that our patients live in a world of responsiveness and convenience. They can watch a movie, call for a ride, or order groceries at the touch of a button. Agencies that are mired in “they way we’ve always done things” will falter. Challenge time-based assumptions. Eliminate patient waiting, friction, and cumbersome forms and procedures. The National Council has been preaching same-day access for more than a decade because it works!

Finally, we need leaders who question beliefs even when doing so makes some people uncomfortable. Can harm reduction in the form of supervised injection sites co-exist with abstinence-based addiction treatment?

What does it really mean when we talk about the social determinants of health? When people who are poor in this country die 13 years earlier than people who are not, doesn’t that mean that poverty is bad for your health? We need government policies that pave a pathway out of poverty.

What about the terms, “trauma competent,” “culturally competent,” and “military competent?” All are important, but we need care that is clinically competent. If we want better outcomes, we need to be teaching the basic skills of making connections, establishing relationships, and delivering effective treatments. Never forget that we got into this business to help people.

Fifteen years goes by in the blink of an eye. The National Council has grown from a $2 million organization with a staff of 12 to a $54 million organization with a staff of 140. Along the way, we’ve become a force to be reckoned with. We’ve passed legislation. We’ve changed practice. We’ve saved lives. Our good work continues under the capable leadership of our new president and CEO, Chuck Ingoglia.

As I step down from the National Council, I’m not setting down my mantle. This work is too important to me, to the people we serve, and to the nation. I’ll be continuing my board and advisory work with government, philanthropic, and business sectors, and I’m especially honored to be joining the Columbia University Department of Psychiatry as Professor of Mental Health Policy and Director of External Relationships. I look forward to fighting alongside you for effective, respectful care for all people with mental illnesses and addictions.

Please visit the National Council at or contact me at

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