Mental Health Field Ushers in New Generation of Leaders

Mental Health Field Ushers in New Generation of Leaders

Role of Chief Executive Has Changed Over the Years

Mental Health Weekly August 2, 2004

In the leadership arena, the U.S. presidential race may be claiming the spotlight, but for those in the mental health field, there are a few other top positions worth focusing on as well.

At least three of the field's most visible policy or advocacy organizations have been without permanent leaders for several months - the National Council for Community Behavioral Healthcare (NCCBH); the National Alliance for the Mentally Ill (NAMI); and the United States Psychiatric Rehabilitation Association (USPRA), formerly known as IAPSRS.

For two of those organizations, NCCBH and NAMI, the search for a leader has come to an end. This week, Linda M. Rosenberg steps into the chief executive role at NCCBH, arriving from the New York State Office of Mental Health. She succeeds Charles G. Ray, who retired last year due to health reasons (see MHW, June 21, 2004 and Nov. 24, 2003).

NAMI last week awarded its executive directorship to acting director and policy guru Michael J. Fitzpatrick (see story on page 6). He replaced Richard C. Birkel, Ph.D., on a temporary basis in January after the board declined to renew Birkel's contract (see MHW, Feb. 9).

At USPRA, meanwhile, efforts to replace Ruth A. Hughes, Ph.D., who stepped down in January to pursue other challenges, are expected to continue for several more months (see MHW, June 28 and Feb. 9).

When installed, the trio effectively will amount to a new generation of leaders in the field. Ray, Hughes and Birkel's predecessor at NAMI, Laurie Flynn, each had served at their respective helms for at least 15 years.

To be sure, a sense of opportunity beckoned during those years - with expected health care reform, for example.

But Ray's, Flynn's and Hughes's terms, which came during and after the Reagan-era retrenchment, also saw their share of headaches. The times were marked by a de-emphasized federal role in policy-making and funding; a shift to managed care; increasing pressure on money and other resources; health-related business mergers, acquisitions and failures; and continued fierce stigma against people with mental disorders.

"Amazingly, they made it to quit and didn't die of a heart attack," observes Paul J. Seifert, USPRA's director of government affairs. They served during a time that was very different from the 1960s when an evolution of the new age of mental health was underway, (ushering in) community-based services. By the 1990s, it was clear that the challenges were quite different. We have pedaled awfully hard. It's taken 40 miles of effort to get two miles down the road. I can't imagine what it's like to be a CEO and have to do that for dozens of years."

Ray, whose special challenges also included managing a membership that was shifting from providers to funding authorities, adds, "It really was an impossible mission&.The big policy decisions at the state level didn't seem to have a defined role at the national level."

In many ways, the political, financial, scientific and cultural landscapes surrounding mental health are vastly different now than they were a generation ago. There is greater knowledge and understanding of mental illness, grounded in research. New medications have brought more stability to the lives of many people with mental disorders. The field has a solid and influential grassroots movement, with NAMI arguably at the helm. A more hopeful, recovery-oriented treatment model is taking hold over the traditional maintenance model.

The political culture has made room for discussion, if not passage, of important potential milestones such as parity legislation. A Democratic administration through its surgeon general's report and a Republican administration through its executive branch report underscore the bipartisan recognition that the public mental health system must change.

At the same time, many people with mental illnesses have yet to lead fully productive lives, partly because of inadequate supports such as housing and employment. The numbers of mentally ill people on the streets and in jails have soared. The nation's leaders remain focused on fighting a global war against an elusive, ill-understood enemy called terror.

And money is still a problem. Ray predicts that there will be renewed interest in resource-based care, and rationing of care unless a way is found to align mental health and general health care.

"It's difficult," he tells MHW. "And it's no less oppressive."

How the post-9/11 challenges translate into the skills needed or desired at the CEO level depends in part on the national organization's role. But key among the qualities, according to leaders and experts interviewed by MHW, are the ability and willingness to collaborate, both in terms of setting the mental health agenda within the field, and with the greater health and safety communities.

The reason: "Too many jurisdictions (are) trying to govern too few resources," says Ray, who has formed his own consulting firm, CGR & Associates in Fairfax, Va.

Within the field, says Chris Koyanagi, policy director with the Judge David L. Bazelon Center for Mental Health Law, "Nothing has killed us as much over the last years as the way different groups have fought tooth and nail in different directions. We've stalled a lot of initiatives ourselves by our own fighting."

An "organization's aims are furthered if everybody pulls together," says Koyanagi. Leaders must be open to finding common ground with others in the field, something that requires getting to know the other executive directors and advocacy groups and not getting lost in boards and internal administration. Many (directors) come in with good intentions and then they disappear. It's as if they get swallowed up in keeping their own organizations afloat," Koyanagi tells MHW.

Beyond collaboration, the list of needed attributes is clear - if a lot to be asked of one person. Jeri Davis is president of Jeri Davis International Healthcare Consultants and Recruiters, of Silver Spring, Md., which offers CEO succession planning for both mental health provider groups and national organizations.

A potential mental health leader of the 21st Century, Davis tells MHW, must be a sophisticated manager and a visionary, with experience in creating and integrating programs. He or she must be financially resourceful, politically savvy and committed to developing partnerships.

Why? Because of dramatic changes underway in the ways that public mental health services are structured and funded, Davis says. The structure has changed largely from a single-designated provider to multiple payors from both the public and private sectors, requiring managers to be more externally focused and proactive. Greater opportunities to gain or lose money through cost-shifting requires strong business skills.

As structures and funding streams change, and as resources tighten, short-term planning often is edging out longer range thinking among providers. Meanwhile, leaders must be integrating narrow "silos" of care and creating better models of care based on practices shown by the research to be most effective, while never losing sight of clinical quality, productivity and treatment outcomes.

While anticipating and responding to these pressures facing payors, providers and clinicians, national organizations must be developing new models for membership.

All of which requires a business mind as well as a public mental health mind, Davis says.

Incoming CEOs are "far more savvy about business administration &with boards that are demanding that," USPRA's Seifert tells MHW. "They don't need innovators and they need someone to run programs. While vision is important, administrative capabilities are equally important now. There is the need for people who can pick up and run large, ongoing business concerns."

Such qualities, while necessary, are hardly the stuff of inspiration, some argue. "I personally believe the leader of the organization has to be the person who articulates the issues coherently," and who has an energizing effect, says Flynn, who resigned her NAMI post of 16 years in 2000 after the board issued a no-confidence vote. Certainly, a strong business focus is needed to put systems in place and create infrastructure, but deputies can help there, she tells MHW.

"There are cycles and we all feel like the '90s were exciting and tumultuous. There was great excitement about the possibility of health care reform, a rising tide of expectations. And then we had managed care. I think people in the mental health field were particularly unprepared for managed care. It shocked people, and they watched it eat their lunch," says Flynn, executive director of Columbia University's Carmel Hill Center, whose initiatives include one geared toward preventing suicide among teens.

Flynn concedes that "maybe the energy is there, and I just don't see it." In quieter times, times in which the discussion is dominated by dollars, "organizations tend to keep their heads down. And they lay low and keep the lights going until they can find another sense of energy. My belief is you make your own energy, you pull people into a sense of vision and mission."

"Now perhaps people are ready for some new energy, some ideas, some fresh perspective. What we don't need are calm caretakers or business heads and that's what we've got now," says Flynn.

Koyanagi agrees. "These are very exciting times in many ways. We have lots of information about how to treat and organize services both for people with serious mental illness and those who manage their disorders. In that sense we have a much stronger case to press and we're pressing it in a difficult time."

"There is a need to be visionary but perhaps in a different way," Koyanagi says. "Everyone says, 'We've been getting our money this way. We can't rock the boat.' "Well, maybe we need to rock the boat. Maybe the vision and leadership on the part of the organization is to be able to accept change," said Koyanagi.

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