While deputy health commissioner for New York City from 2014-2019, I developed what became ThriveNYC – an ambitious set of initiatives with the potential to bring the city’s role in mental health closer to other robust, science-based, public health practices.
But that potential lost its footing. Criticism that ThriveNYC did not prioritize the needs of the “seriously mentally ill” – used by critics mostly to denote those who are homeless, perhaps violent, and have psychosis – caught fire. Clarity as to its purpose got muddied in the public eye. ThriveNYC was quickly becoming a casualty of an old habit that has derailed serious systemic change for too long: setting up a false zero-sum game between serious mental illness, and everything else.
This week, the city released a progress report on ThriveNYC performance. Skeptics of ThriveNYC, such as the Daily News editorial page, saw in the report the trimming back of programs and some other data as potentially positive signs of a shift in focus towards serious mental illness, but also concluded it remains to be seen if still-promised overall outcomes are forthcoming. I share that latter concern, but for opposite reasons.
While underscoring some real progress in advancing prevention and more paths to access treatment in New York City, much about the purpose and what remains of ThriveNYC were left uncertain in the report. It is necessary now to double-down, not back-down, in the face of mental illness-first criticism, on what is needed and ThriveNYC set in motion, to bring mental health up to par with other public health efforts.
For one thing, ThriveNYC actually injected an array of dramatic, overdue investments in reaching precisely those New Yorkers through precisely the kinds of solutions the most vocal critics of ThriveNYC called for. There is no question our society has failed those with serious mental illness. Indignation on that score is legitimate. No one should be homeless, or in jail, because of untreated or undertreated illness. It is obscene that people with mental illness die a decade younger than the general population. Our system is underfunded and understaffed to reach them and meet their needs.
But changing those realities has to look beyond a handful of specific programs, or calls for hiring more clinicians without also innovating what they can do and the larger system they work within. Those critical of ThriveNYC for not doing enough for serious mental illness actually demand too little, and aim way too low. Narrowing, rather than finally broadening, the scope of what the mental health system is tasked and resourced to do, heads in the wrong direction.
That full scope includes the range of far more common, pressing, unmet mental health needs. Those needs are not competing distractions of “the worried well,” as critics liked to portray them. Indignation should equally apply to the fact that a majority of pregnant or postpartum women with depression aren’t identified or treated for it, more so among women of color, worsening the life and health outcomes of their children; that so-called common mental illness (depression, anxiety, substance use) is actually the leading contributor to disability in the world, and has outsized impact in making all social and health outcomes – including risk of premature death – worse. Yet odds are the vast majority of people in the United States with such common, and debilitating, conditions, do not get appropriate care for them.
These common things are quite “serious,” and also affect the lives and outcomes of those with serious mental illness. As are efforts to promote mental health – also opportunistically mischaracterized and ridiculed – including promoting resilience for children facing adversity and addressing the paralyzing toll emotional trauma has on lifelong health. Just as promoting overall health is not peripheral to reducing premature mortality from heart disease, promoting mental health figures in some of our most pressing social and health challenges.
In fact, mental health, captured in measures of things such as subjective wellbeing and resilience, increasingly appears to be central and predictive of the quality of societies' overall health, safety, justice, and economic participation. It is integral to the collective ability of neighborhoods to lead and navigate through all sorts of challenges such as economic and environmental threats, public safety and epidemics.
Reaching more deeply into neighborhoods is also important to start to contend with how racism and economic inequality aggravate risk and consequences of illness and impaired mental health. This reality falls hard on SMI as well: Those with court-ordered outpatient treatment in New York City are mostly black men.
But while referencing some of these broader goals, the report says less about the means to get there. Missing are three features for ThriveNYC to advance this broader scope:
First: it was necessary to focus beyond conventional mental health clinics and hospitals, the mainstays of mental health policy for a century. Specialized and office visit-based access is often a cumbersome way to get care and these institutions can’t carry the full range of treatment, prevention and promotion work.
But many other people and settings can fill in. Evidence increasingly tells us that many tasks of that work can be adopted by all sorts of people. A range of counseling, screening and self-care (such as anxiety reduction) methods can be put in the hands of clergy, community health workers, teachers and parents. That approach, widely endorsed globally, is often described as “task-sharing,” and research shows that spreading ownership of steps in treatment and prevention this way makes them far more widely accessible, and tailored to the cultures, contexts and other related issues facing communities.
For example, mobile counseling teams of peers living with mental illness are more effective than emergency rooms and clinics at getting homeless people who won’t engage in care to stay in housing and to reduce hospitalizations. Parents can coach other parents in their community in proven practices to boost early emotional attachment or bonding. Screening for depression or traumatic distress by familiar and trusted staff at neighborhood job training programs or day care reach high-risk people sooner and with high rates of formal care follow-up when needed. Giving neighborhood organizations tools to map gaps and lead in designing solutions to close them, puts existing resources to more effective use.
ThriveNYC did all these and more. It showed it was feasible to extend the real estate of mental health work beyond (but partnered with) the conventional system to include primary care doctor’s offices, police cruisers, street corners, NYCHA community rooms, parks and public-school classrooms – all places where need and opportunity are often more readily found and acted on. It showed how clinics and providers could coach and support these approaches, expanding the impact of their expertise and points of contact to access them. The report conveys some of these ideas, but more as (fewer) stand-alone programs or added subsidies to the status quo, than as a coherent and intentional strategy and basis for this way of doing things to be the new normal.
Second: ThriveNYC initiatives were also intended to progressively iterate and innovate treatment and prevention along such a strategy. Each initiative was grouped within one of six key directions or principles for change that were developed by input from over 200 organizations across the city and a Scientific Advisory Group, and peer-reviewed. The initiatives were therefore largely designed to start as a focused program (with specific outcomes), but then grow into a platform for spurring more of the direction of change its parent principle staked out.
A few examples: A number of initiatives under the key principle of “Close treatment gaps” took on different aspects of reinventing access. The 24/7 call center NYCWell was expected not to just help people get referrals to care, but to evolve to be home to an array of digital open-access treatment, and to monitor gaps in access in actually reaching care. The Mental Health Services Corps wasn't expected to just integrate mental health care in hundreds of underserved primary care settings – which it did – but to then evolve, as it started doing, to help those same neighborhoods task-share in response to locally defined priorities and gaps. The Maternal Depression Learning Collaborative was expected to not only get New York City hospitals to identify and connect to care all new mothers with depression, but to see how the Collaborative approach of rapidly testing and sharing learning around different tactics to achieve shared aims, could spread other ways to improve access.
Third, these initiatives were openings for structural change. Increased capacity and payment for the conventional system is more under the regulatory and spending authority of the state, rather than the city, and thus less of a focus of ThriveNYC directly. But many initiatives were also chosen to provoke such change, such as showing where and how the state should bring more funds to core hospital and specialized mental health outpatient-based care.
For example, many initiatives had the potential to generate data to justify changes in Medicaid to pay for more capacity and flexibility for outpatient care, and provide proofs of concept for system improvement. Among those, the New York state 1,000 Days on Medicaid Initiative whittled down hundreds of potential ideas of how Medicaid could improve early-life outcomes to ten recommendations by having invited experts statewide rank the most worthwhile ideas. A ThriveNYC effort to pay clinicians to flexibly work in and coach early care and school settings got top ranking.
And structural change also includes government. ThriveNYC initiatives were purposefully distributed across multiple city Departments such as Education, NYPD, Child Services, Social Services, as well as Health, to start getting more of government to incorporate this work, including addressing social and structural determinants, and impacts, of mental illness.
These ambitions of broadened scope, coordinated growth of place-based and task-shared work, expanded and resourced roles for conventional providers and community partners, should not get lost. That needs ongoing engagement with elected officials, community groups, users of care and their families, and their doctors and therapists, to stick with and join that vision. It needs investing in methods of complex evaluation, implementation, and management to pull this all off in ways that build the confidence, and the data, that it's the right path.
Instead, the toll of old habits seems to have the upper hand. Cuts and re-allocations starting in the fiscal year 2020 budget and since, have eaten away at that potential and capacity. Those included loss of the Maternal Collaborative, Mental Health Services Corps, and of a team recruited to provide expert mental health services implementation and data evaluation – delaying the essential work of overhauling antiquated approaches measuring outcomes for population mental health.
And while some dollars were re-allocated in ways that extend ThriveNYC principles – like spreading socioemotional learning through expanded home-visiting nurses and teachers – those efforts could have been more aligned and integrated under a shared strategy, but instead risk falling back into their silos. Retrenchment rather than reassertion of ThriveNYC’s goals, especially in response to a simply wrong, but too familiar, habit of aiming low, isn’t good news for anyone (especially those with serious mental illness).
New York City has long been a leader in public health. Its current response to the daunting challenge of coronavirus spread is a reminder of what we need from such leadership: that it be science-based, with equipped management, clear strategy, all-of-government hands on deck, marshal a credible range of care and preventive capabilities, and rest on social trust, knowledge, and engagement. These are the building blocks for everything else.
ThriveNYC was built to address mental health in this way, as the broad and critical public health issue that it is, and show a different path, away from old habits of fragmented responses. All who care about these issues should energize, not evade, its promise. In the long saga of trying to get the mental health care system we deserve, old habits die hard.
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