Reimagining Behavioral Health A New Vision for Whole-Family, Whole-Community Behavioral Health KALI GRANT, SOPHIE KHAN, INDIVAR DUTTA-GUPTA, NATHANIEL COUNTS, MADELINE REINERT, & THERESA NGUYEN SUMMER 2019 Georgetown Center on Poverty and Inequality The Georgetown Center on Poverty and Inequality (GCPI) works with policymakers, researchers, practitioners, advocates, and people with lived experience to develop effective policies and practices that alleviate poverty and inequality in the United States. GCPI conducts research and analysis, develops policy and programmatic solutions, hosts convenings and events, and produces reports, briefs, and policy proposals. We develop and advance promising ideas and identify risks and harms of ineffective policies and practices, with a cross-cutting focus on racial and gender equity. The work of GCPI is conducted by two teams: the Initiative on Gender Justice and Opportunity and the Economic Security and Opportunity Initiative. Economic Security and Opportunity Initiative at GCPI The mission of the Georgetown Center on Poverty and Inequality’s (GCPI) Economic Security and Opportunity Initiative (ESOI) is to expand economic inclusion in the United States through rigorous research, analysis, and ambitious ideas to improve programs and policies. Further information about GCPI’s ESOI is available at www.georgetownpoverty.org. Mental Health America Mental Health America (MHA)—founded in 1909—is the nation’s leading community-based nonprofit dedicated to addressing the needs of people living with mental illness and to promoting the overall mental health of all Americans. Our work is driven by our commitment to promote mental health as a critical part of overall wellness, including prevention services for all, early identification and intervention for people at risk, integrated care, services, and supports for people who need it, with recovery as the goal. Much of our current work is guided by the Before Stage 4 (B4Stage4) philosophy—that mental health conditions should be treated long before they reach the most critical points in the disease process. Learn more about MHA, go to: www.mentalhealthamerica.net. Creative Commons (cc) 2019 by Kali Grant, Sophie Khan, Indivar Dutta-Gupta, Nathaniel Counts, Madeline Reinert, & Theresa Nguyen Notice of rights: This report has been published under a Creative Commons license. This work may be copied, redistributed, or displayed by anyone, provided that proper attribution is given and that the adaptation also carries a Creative Commons license. Commercial use of this work is disallowed. Reimagining Behavioral Health A New Vision for Whole-Family, Whole-Community Behavioral Health BY KALI GRANT, SOPHIE KHAN, INDIVAR DUTTA-GUPTA, NATHANIEL COUNTS, MADELINE REINERT, & THERESA NGUYEN SUMMER 2019 Reimagining Behavioral Health Acknowledgements & Disclosures We appreciate the generous assistance provided by the following individuals, who shared their insights and advice early on in the drafting process or reviewed a draft of the report: Jessica Kennedy, Isha Weerasinghe, Erik Stegman, Mary Ann McCabe, Caitlin Schnur, Quintin Williams, Kathryn Kaplan, Nila Rosen, Anne De Biaisi, Peggy Bailey, Chelsea Prax, Conni Wells, Josh Leonard, Nazghol Ghandnoosh, Alex Briscoe, Kimá Taylor, and Julie Kerksick. We also thank everyone who attended one (or more) of our four invitation-only, expert convenings and also thank the many people who gave feedback over the course of the project, including on background material, for their insights and expertise. We thank Isabella Camacho-Craft for providing substantial writing, editing, and design support. We are grateful to Funke Aderonmu, Huixian (Anita) Li, and Madeline Halpern for significant research and writing assistance; Kaustubh Chahande for significant research and data visualization assistance; and Aileen Carr for editing assistance. We are also grateful to Christopher Brown for data visualization and editing assistance, and for providing logistical support for the convenings. We thank Monique Manansala for providing logistical planning support for the convenings. We thank Tony Hernandez for research, writing, and editing assistance. Thank you also to Jay Christian Design for the report’s design and layout. Any errors of fact or interpretation remain the authors’. Further information about GCPI’s ESOI is available at www.georgetownpoverty.org. Further information about MHA is available at www.mentalhealthamerica.net. We are grateful to Kaiser Permanente for their support of this report. The views expressed are those of the GCPI ESOI and MHA authors and should not be attributed to our advisors or funders. Funders do not affect research findings or the insights and recommendations of GCPI’s ESOI and MHA. A New Vision for Whole-Family, Whole-Community Behavioral Health Contents Abbreviations, Acronyms, & Initializations 1 Methodology 4 Message from the Authors 5 Executive Summary 6 We Need Systems Change 7 The Whole-Family, Whole-Community Approach 8 Report Structure 8 Summary of Recommendations 9 Introduction 11 We Need Systems Change 12 The Whole-Family, Whole-Community Approach 13 Report Structure 13 I. A Whole-Family, Whole-Community Behavioral Health Approach 14 Supporting Behavioral Health Requires a Holistic Approach 17 Everyone Has a Role in Promoting Whole-Family, Whole-Community Behavioral Health 19 II. Background: Common Behavioral Health Conditions & Compounding Factors 22 Behavioral Health Conditions 23 Mental Health 23 Substance Use 26 Co-Occurring Conditions 28 Social Determinants of Health & Compounding Factors 29 Social Determinants of Health (SDOHs) & Health Determinants of Social Outcomes 30 Adverse Experiences 33 Bidirectional Relationship Between Economic Insecurity & Behavioral Health 35 Identities, Experiences, & Other Non-Health Factors Can Also Impact Behavioral Health 37 III. An Agenda for Whole-Family, Whole-Community Behavioral Health 45 1. Health Sector & Systems Should Account for & Respond to Realities of Behavioral Health & Compounding Factors 47 1.1 Ensure Access to Needed Health Services & Supports 47 1.2 Leverage Opportunities to Improve Holistic Health Services Delivery 55 1.3 Establish Shared Goals & Hold Health Stakeholders Accountable 57 1.4 Strengthen & Expand the Health Workforce 60 1.5 Re-Orient Systems to Prioritize Agency of Individuals & Families in Health Sector 64 Reimagining Reimagining Behavioral Behavioral Health Health 2. Health-Adjacent Sectors & Systems Should Support & Improve Behavioral Health 66 2.1 Strengthen & Establish Foundational Economic Security & Opportunity Supports 66 2.2 Nurture the Relationship Between Employment & Behavioral Health 71 2.3 Help Families Meet Their Intertwined Caregiving & Behavioral Health Needs 75 2.4 Re-Orient Health-Adjacent Sectors & Systems to be Responsive to Behavioral Health 76 3. Health & Health-Adjacent Sectors Should Close Gaps & Smooth Transitions Between Them 78 3.1 Create Seamless User Experiences Across Sectors 79 3.2 Promote Effective & Efficient Cross-Sector Collaboration 81 3.3 Ensure Accountability for Effective Service Delivery & Handoffs 84 4. Communities Should Support Behavioral Health & Well-Being at All Times for Everyone 86 4.1 Leverage Community Assets for Holistic Service Delivery 86 4.2 Build Safe, Inclusive, & Supportive Environments 92 4.3 Universalize Access to Behavioral Health Information & Supports 95 IV. OPPORTUNITY AREA: Maternal Behavioral Health 99 At-Risk Populations & Factors 100 Motherhood, Economic Disadvantage, & Behavioral Health are Interwined 101 Reproductive Health & Behavioral Health are Interconnected 102 Young Mothers Experience Unique Behavioral Health Challenges 102 Mothers of Color Face Large Barriers to Meeting Behavioral Health Needs 103 LGBTQ Parents Face Unique Obstacles to Care 104 Urbanization Influences Maternal Behavioral Health Incidence & Access to Care 104 DV/IPV & Sexual Violence Can Lead to Worse Health Outcomes for Both Mother & Child 105 Behavioral Health Conditions & Challenges 106 Mental Health 106 Substance Use 107 Recommendations 108 V. OPPORTUNITY AREA: Behavioral Health & Child Welfare 112 Overview of the Child Welfare System & How It Intersects With Other Systems 113 Systemic Racism Has Affected The Child Welfare System Since Its Creation 114 The Intersection of the CJ/JJ Systems & Child Welfare System 115 At-Risk Populations & Factors 116 Factors that Increase Risk of Involvement with Child Welfare System 117 Child Welfare System-Related Factors that Contribute to Harmful Health & Other Outcomes 120 Behavioral Health Conditions & Challenges 123 Toxic Stress & Trauma 123 Mental Health 124 Substance Use 126 Recommendations 127 VI. OPPORTUNITY AREA: Behavioral Health & Criminal Justice/Juvenile Justice 130 Overview of Criminal Justice & Juvenile Justice Systems 131 Trend Overview 132 A New Vision for Whole-Family, Whole-Community Behavioral Health At-Risk Populations & Factors 133 Factors that Increase Risk of Involvement with CJ/JJ Systems 133 CJ/JJ System-Related Factors that Contribute to Harmful Health & Other Outcomes 136 Behavioral Health Conditions & Challenges 145 Overview 145 Mental Health 146 SUD 148 Recommendations 149 Conclusion 154 Appendices 156 Appendix I. Summary of Report Recommendations 156 Appendix II. Medicaid & CHIP 157 Appendix III. Emphasizing Similarities in Behavioral Health-Related Concepts Across Sectors 159 Appendix IV. Economic Security & Opportunity Programs & Behavioral Health 159 Appendix V. Funding Sources 160 Major Child Welfare Funding