10 Problems and 10 solutions for Behavioral health funders.

Do you want to be a good funder in the Behavioral health industry? It’s time to step up your game. There is a lot of money in healthcare grants and research. But very little of it is going to where it  needs to go.  In grant-making, many health organizations don’t bother to include patient advocates in their RFP writing process, in their grant review board, or on the scoring panel for deciding grants. “Nothing about us without us.”  Yet the behavioral health care funding world is still almost completely excluding the communities they purport to serve. Even the term “behavioral health,” is offensive to many advocates – it’s not our behavior that caused these issues – it’s a social thing.

Why is including mental health advocates important? Because people who recovered know how to recover, because advocates are more up to date on the science than professionals, because advocates are in touch with more innovative approaches, and because advocates are actually addressing root causes.

1. Philosophical issues: In mental health, there has been constant debate between people who support a bio-psycho-social-spiritual approach and between those people who just think bio-bio-bio. On the federal level, the first group formed SAMHSA (The Substance Abuse and Mental Health Services Administration). They do “services” which actually help people. While NIMH just beats this “bio bio bio” bandwagon even though the disease model has been pretty much disproven by now. The billions spent by NIMNH through the years have gotten us nowhwere – there no “genetic cause.”   Mental health issues ARE about life situations, nothing happens “out of the blue.”  And if it does, it’s probably a mis-diagnosed physycial illness. So if you are still promoting brain disease, genetics, illnesses, and disorders, you are promoting disproven dogma. However, most funders have no idea how dogmatic their RFP’s really are.

2. Federal blockades: SAMHSA does the best of all federal agencies about supporting inclusion of advocates or people with lived experience of recovery. However, as much as SAMHSA tries, they are still blocking progress in many ways. There are regularly large federal RFP’s where SAMHSA designates a required lead applicant that knows nothing about recovery. It’s darn near impossible for peer organizations to find the grant writer for those RFP’s in time, then explain the benefits of actual inclusion, then negotiate a role for inclusion, then correct false assumptions in the rest of the grant that are harmful, then actually create a useful project. Believe me, we’ve tried.

3. “Systems of care” without inclusion: The Systems of Care grants could have included peer organizations to share trauma informed care, resilience information, outreach work, young adult support, community wrap around services, and other work that peers excel at, but instead SAMHSA is just giving most of that money to mental health centers.

4. Focusing on “treatment” vs. prevention and community:  The state targeted opoid response grants are bringing $2 to $35 million to the 42 states who applied for them. But very few states actually included peer interventions. In Missouri the only peer intervention included was recovery community centers. This was only 1 of 10 possible interventions in a Recovery Oriented system of care. SAMHSA could have funded collegiate recovery centers, peer recovery coaching, peer led prevention activities, alternative high schools, peer led housing, and other recovery approaches but they didn’t. They are giving most of the money to treatment providers, which means inpatient units. OK, great, we got a person de-toxed, but if you dump that back into their previous environment with no support, what do you think will happen next? If the treatment providers knew how to solve the problem, why is the problem so bad? We should be trying something new.

5. Innovative approaches that neglect peer organizations: The federally qualified community behavioral health center (CCBHC) grants just gave 76 behavioral health clinics in the country a wishlist of everything they would want to fund for the next 2 years. These grants could have included different models of peer support but In Missouri and New Jersey they ONLY looked at certified peer specialists embedded in mental health centers. NYAPRS and MHASP, the two biggest freestanding peer support programs, each employ 250 peers. The whole state of Missouri doesn’t even employ 250 peer specialists. By fixating on embedding peers into mental health centers, where they are exposed to all kind of exploitation, role conflicts and HIPAA violations, we are ignoring the full impact peers could have. In other states like Oregon the mental health centers on these grants on the CCBHC grants are funding warmlines, peer housing, peer outreach, peer coaching, health homes, and peer care integration models. All of these are independently functioning peer models, where peers are much more likely to experience job satisfaction and to able to actually help people.

6. RFP’s that are fixated on non-scalable models:  Both KS and MO are only planning to include drop in centers and warmlines in their next two peer services RFP’s. The recovery community centers and the drop in center grants require a brick and mortar structure even though there are tons of other (and sometimes more cost effective) ways to deliver peer support. Why are so many funders fixated on models that have proven not to be scalable? We’ve been harping these models in the US for 30 years now, if they were scalable they would have scaled up by now. But “drop -in centers” are not a business system, they are instead independently operating units that require a person who has a lot of charisma and nonprofit management skills to work significantly below market wages. Just in case you hadn’t noticed, there’e not a huge labor pool of people out there who  “have a lot of charisma and nonprofit management skills and are willing to work significantly below market wages.” That’s why these models aren’t scaling up. A proper business system requires acceptance and not defiance of market forces.

7. Community approaches that are all talk and no action. Ten cities just got a million dollars with the ReCAST grants to promote resilience and address trauma and police shootings. Peer Run Organizations could have helped with CIT trainings, social justice issues, health disparity issues, or promoting resilience. Instead, most of this money is probably going to “sit around and talk” type of groups. This grant had forced coalitions. This is just like the Creating Community Solutions national mental health dialogue project, which was huge fail for many reasons. 

8. Mandatory coalition participation. There are many reasons why coalitions damage advocates. Most of this comes down to coalition leaders keeping all the money and expecting all the coalition action to be done by volunteers. Also, coalitions repeatedly try to do things that coalitions do poorly, instead of focusing on things coalitions do well. If you’re a behavioral health funder, rethink using the coaliton approach. It’s mostly going to support the status quo and exclude novel and innovative and unheard voices.

How to fix this? 10 solutions for behavioral health funders:

1. Share letters of intent. Ask for a letter of intent. When peer organizations ask, “Who is applying in my region for this grant?” At least give us the names of the people who sent in the letter of intents so we aren’t hunting people down like a needle in a haystack.

2. Have small grants for all the big grants you put out. For every million dollar grant, have a $40,000 grant available, too. Say that the smaller grant can be for a peer organization to find the lead entity and build relationships. SAMHSA told me that aren’t currently doing this because, “a minimum amount for inclusion is often becomes a ceiling, or a maximum amount.” Ie, the grant that might have spent $100,000 on peers might only spend that $40,000 now. But right now we aren’t getting included at all. It takes time to build relationships and right now all the “relationship building,” is unpaid work and gambling that may or may not even pay off. Usually it doesn’t pay, really, as very few of these lead applicants understand peer inclusion principles.

3. Score the lead entity a LOT more on peer input. (like 20% of the grant score) for how well they include peer and recovery organizations. This could include scoring for budgeting the peer organizations in, so it would raise the ceiling quite a bit.

4. Require that the lead entity budgets in a “placeholder” for peer activities. Just in case they can find the peers later, once they are awarded the grant. Or that the lead entity puts out a RFP specifically to find and fund peers later.

5. Put a cap on the % of money that can go to service providers or academic groups. The rest needs to go to community organizations. If you think recovery is in the community, start funding community.

6. Include us in the review panel. If you are funding behavioral health, make sure your funding review committee inlcudes people from mental health organizations. Check the links page at the National Empowerment Center for a whole list of good organizations. If you have never heard of any of these organizations and you are funding mental health, it’s time to get a clue!

7. Use less reliance on evidence based practices. Since many EVP are based on concepts that actually harm people.

8. Outreach. Have you done some marketing of the RFP to get more diverse grants in? A lot of “community mental health” grants just end up being “psychologists in social service agencies.” This is a low value intervention, as relationships do 85% of the benefit of therapy and relationships can be built with significantly lower cost and lower stigma.

9. Give Advocates visibility. Do you have advocates speaking at the pre-proposal conference? That’s a good way to indicate the value of peer and stakeholder engagement.

10. Most important – emphasize prevention and community resilience (80% of health care outcomes) vs. treatment (20% of health care outcomes). If you you are working on a culture of health or social determinants of health, it’s time to include the peer organizations who have asked for this stuff for 30 years. We’re the ones who can actually solve the issue.