Jay Chaudhary is a Senior Fellow for Mental Health and Community Wellness at the Sagamore Institute. Previously, Jay served as the director for the Division of Mental Health and Addiction with the Indiana Family and Social Services Administration. Jay is also an Aspen Institute Ascend Fellow and writes the newsletter Favorable Thriving Conditions. Below, he shares leadership lessons learned from implementing changes in the behavioral health system in Indiana.

Over the last several years, I was lucky enough to be at the center of some remarkable behavioral health system policy and program improvement in Indiana. While the job was far from done when I left the state in October, the last three years saw:

• A new infusion of $50M annually in state funds towards a new behavioral health infrastructure with two core components: (1) a comprehensive 3-part crisis response system and (2) transition to a better model of care delivery called Certified Community Behavioral Health Clinics (CCBHC)
  
• Significant progress towards building that system in a short period of time, including selection into the federal CCBHC demonstration program to accelerate the transition 
• A top 5 answer rate for the 988 Crisis Hotline and an 80% reduction in time to treatment for justice-involved individuals with severe mental illness 
• After years of consistently ranking in the 40s in Mental Health America’s “State of Mental Health” rankings, Indiana is now 24th overall and 18th for access to care

This change was driven by radical collaboration and sustained commitment from a broad group of advocates and stakeholders. Here are four lessons learned from the Indiana story.

Lesson 1: Avoid the fundamental attribution error—work at the system level.

In social psychology, the “fundamental attribution error” is a cognitive bias that causes people to attribute behaviors to innate personality traits, rather than situational factors. For example, if a new co-worker shows up late to work the first few days, we think it is because they are a chronically late person, rather than considering that the new job might have disrupted childcare arrangements or commute patterns.

We do the same thing when confronted with a broken system: blame the individual actor, rather than the system.

Each Indiana county has a designated community mental health center. I met with county leaders from two different counties in the same general region of Indiana, and both were unhappy with their own center, citing long wait times and lack of operational flexibility—evergreen problems caused by structural issues. They each requested a switch to the other county’s designated center, the same one that their counterpart was equally unhappy with!

The first step to systems change is avoiding the fundamental attribution error. In a flawed system, it is a mistake to focus on the individual actors. The problem must be fixed at a system level. 

Lesson 2: Make your messaging mechanically resonant.

When crafting a state budget, lawmakers are constantly bombarded with competing demands. Schools, roads, law enforcement, and child welfare budgets all need bolstering, and all have strong and compelling cases for more funding.

To break through the noise, effective advocates emphasize messaging that is both emotionally and intellectually resonant.

What the Indiana story reinforced is a hidden dimension of messaging that is just as important: mechanical resonance. The more that decision-makers and the public understand how something will improve the problem, the more likely they are to support those changes.

The behavioral health field loves its buzzwords. The current vision promotes an integrated, evidence-based, trauma-informed, recovery-oriented, whole-person continuum of care. A laudable goal—but largely undecipherable to people who are not already experts.

The three-part tagline for Indiana’s behavioral health system change was “someone to call, someone to respond, and somewhere to go.” It was a sticky phrase, because the mechanics of change are intuitively clear. Lawmakers may not have understood all the details of each crisis response component, but they basically understood how it would work, and that made it much easier for them to support.  

Lesson 3: Compromise is key.

There is a constant battle raging within the behavioral health world between a wide diversity of actors with disparately aligned interests and incentives. Each type of provider business (community mental health, health systems, independent practitioners) and provider type (psychiatrists, psychologists, clinicians, front-line workers) are simultaneously trying to protect their quasi-monopolistic niches, while also trying to expand their footprints and influence. 

What we were able to do in Indiana, albeit uncomfortably and temporarily, is intentionally and collaboratively agree on a truce. All the systems and different provider groups rallied around the same vision for system change, and this unified front made a huge difference. 

Lesson 4: Answer “bids.”

Famous relationship experts Drs. John and Julie Gottman center their philosophy on what they call “bids.” These are often subtle, frequently clumsy, and occasionally hostile attempts by one person to open or stoke a connection with the other through words, gestures, or actions. The key to relationship health, according to the Gottmans, is for most bids to be answered by the other person. 

Collaboration works the same way–bids must be understood and answered. Sometimes they are subtle–a request for a coffee or Zoom meeting to share stories and ideas. Sometimes they present as openly antagonistic–such as a complaint about a policy, or questioning decisions or strategic directions. We tried, when we could, to answer these bids, and that was really the key to building the trusted relationships necessary for collaborative systems changes.