Insights

During the month of May, HMA is featuring thought leadership and insights around Behavioral Health (BH) and changes within the BH delivery system in the U.S. Along with several presentations happening at NatCon25 in Philadelphia, May 5-7, we want to highlight some of the work done by HMA experts.  Starting us off, Josh Rubin, HMA Vice President, Client Solutions, has spent his career working with BH, intellectual and developmental disabilities, and child welfare service providers. In this post, he discusses the changing BH delivery system, and the issues surrounding the treatment of co-occurring mental health conditions.     

Ever since the 19^th century when Dorothea Dix crusaded up and down the east coast encouraging state legislatures to fund state psychiatric hospitals, we have had separate systems for medical and mental health care. I mean Ms. Dix no disrespect, far from it; before her work we simply had no system of care for people with mental illnesses. Her contribution was immeasurable. But in 1963 when President Kennedy signed the Community Mental Health Act, it was an acknowledgement that the “out of sight, out of mind” warehousing of people with mental illnesses in large state psychiatric hospitals was inappropriate and had to end.

Those of us who remember the heady days of the 1960s rightly celebrate the advance this represented in acknowledging the rights of people with mental illness to live in the community, and the opportunity it created for people with behavioral health conditions to build lives of dignity, productivity, and inclusion. And while we ought to celebrate that important advancement, we must nonetheless acknowledge that it maintained a separation between the underfunded mental health system, and a significantly better funded medical system. And thus, the community mental health system in America was built. It was designed to provide mental health care to the roughly 5% of the population that has a serious mental illness (SMI). In the nearly 60 years since, much has been done of which community mental health providers should be proud. We have transformed countless millions of people’s lives (and those of their families), built new program models, identified and implemented new practices, and built a service delivery system that offers a comprehensive continuum of care for people with SMI.

Unfortunately, that system was not built to address the needs of people with co-occurring mental health and substance use disorders (SUD), which is problematic because nearly half of people with a substance use disorder have a mental illness and nearly half of people with a serious mental illness have a substance use disorder. This is no surprise; the conditions are related. Some people with mental illnesses use drugs to manage their symptoms. Sometimes drug use can cause or exacerbate mental illnesses. In most cases, it is impossible to figure out where a mental illness ends, and a substance use disorder begins, or vice versa.

Yet in the U.S. we have always had separate service systems for these two conditions. Our systems grew up this way because although the stigma of mental illness is bad, the stigma of substance use is worse. While we have frequently been willing to address mental illnesses as health problems, we have long treated substance use disorders as criminal justice problems. We created community mental health centers. We launched a war on drugs.

The federal government provides two separate funding streams for states, one for mental health, the other for substance use disorder services. In many states there are separate agencies overseeing the two conditions, separate funding streams, and separate regulatory structures. Many providers respond to the funding and offer separate programs for one condition or the other.

This systemic failure leads every day to the death of Americans who have co-occurring mental health and substance use disorders but cannot access treatment for the two conditions together. Treatment works, and recovery is possible, but treatment works best when you are able to get treatment for your entire problem.

And just as the mental health and SUD systems were separated, they were both also segregated from the general healthcare delivery system. The stigma of our clients’ illnesses attached to us and our service system, so we were largely ignored by the healthcare delivery system and the people who funded and oversaw it.

While we have, as I said, much to be proud of, we cannot ignore the impact of our segregation. Our clients continue to die much younger than their peers. BH-related hospitalizations continue to increase. Overdose deaths and completed suicides, the worst possible outcomes, keep climbing, leaving incalculable suffering in their wake. And the financial costs of BH conditions continue to escalate, falling hardest on the historically underserved and marginalized communities that can least afford them. When America establishes a separate system, it isn’t equal; being ignored has consequences.

The good news? BH is not being ignored any longer. The bad news? BH is not being ignored any longer.

Healthcare policymakers have finally awakened to the reality that they will not be able to achieve their goals of better outcomes, lower costs, and improved customer service unless they address the BH needs of their populations. They are figuring out that everyone needs behavioral healthcare, and that a dichotomy that focuses BH care only on those with the most significant BH issues is ill serving. They are coming to understand that the skills, capabilities, and expertise of community BH providers have extraordinary value. It’s nice to be acknowledged and invited to help.

But it’s not all good news, because while being ignored left us underfunded and disrespected, it also protected us. Now that hospitals (which have been buying up outpatient practices at a remarkable pace) have started opening up BH services, we must compete with their deep pockets. And private equity (with even deeper pockets) has increased the pace at which they are acquiring BH providers, forcing additional competition on us. We are not even safe from our own phones. 10,000 mental health apps in the app store offer our clients a totally different paradigm for care, much of it lacking any evidence-based foundation. This makes it more dangerous for our clients, not less competitive for BH providers.

This environment requires fundamental changes in the way BH providers operate. We need new models of care that better meet the needs of the people we serve. Certified Community Behavioral Health Clinics (CCBHCs) are a step in the right direction, but they’re not a significant change in the service delivery model. If you look at the history of the BH system in America, from Dorothea Dix through today, you will see that the movement has been consistently in the same direction – inward. We have moved out of the hospitals in the countryside into clinics in the neighborhood. We have slowly chiseled away at the barriers dividing mental health from substance use disorder services. We have patiently worked to integrate with our health care colleagues. Now things are accelerating, and the pace of change is scary, but we should embrace the opportunity. We have a once in a lifetime chance to build something new, better, more effective.

HMA consultants are participating on four panel sessions at NatCon25 in Philadelphia, May 5-7. In this blog, HMA Principal Suzanne Daub offers a peek at her session topic and explains how improvisation is being used in behavioral health.

In the fast-paced, high-stakes world of behavioral health, case and care managers are often the steady bridge between crisis and stability, support and recovery. Yet the complexity of their roles—navigating systems, engaging clients with diverse needs, adapting to change in real-time—requires more than clinical knowledge. It calls for presence, empathy, adaptability, and clear communication. These are exactly the skills honed through applied improvisation.

Several years ago, I attended a national healthcare conference and found myself in a session on applied improvisation for medical professionals. I expected a few communication tips. What I experienced instead was a transformative, embodied approach to learning that blended empathy, collaboration, and spontaneity in a way that felt deeply relevant to behavioral health. I knew immediately: this belongs in our field.

That session sparked my own journey. I began formal improv training, developed a personal improv practice that I’ve now sustained for over five years, and eventually became a certified trainer in applied improvisation for healthcare professionals. Since then, I’ve been focused on bridging this work into behavioral health—especially to support case and care managers, who often work at the emotional and logistical front lines of client care.

What Is applied improv? Applied improvisation takes the tools and principles of theatrical improv—like active listening, collaboration, spontaneity, and “yes, and” thinking—and uses them in professional, non-performance contexts to strengthen human interaction. It’s grounded in neuroscience, play theory, and experiential learning.

In medical training, applied improv is used to support communication, teamwork, leadership, and emotional resilience. It helps providers stay grounded in the face of uncertainty, build trust with patients and teams, and respond rather than react. Academic medical centers, residency programs, and interprofessional training teams are increasingly turning to improv to improve quality of care and reduce burnout.

Applied improv is still emerging in behavioral health, but momentum is growing. Innovative programs are using improv to support:

• Engagement in developmental disability services where play-based, nonverbal, and responsive communication is vital.
• Reducing isolation among older adults and dementia caregivers through shared storytelling, and connection-building.
• Substance use disorder recovery by helping individuals rediscover joy, flexibility, and authentic connection in group work.
• Supervision and team development where role-play and real-time scenarios help staff practice challenging conversations and build peer support.

For case and care managers in behavioral health, applied improv can help:

• Enhance engagement, improve presence, listening, and rapport-building with clients across cultures and abilities.
• Build comfort with unpredictability and navigating uncertainty —essential when managing client crises or changing systems.
• Foster collaboration and trust in interdisciplinary teams.
• Bring joy, presence, and creative reset—tools we all need to stay grounded, prevent burnout and foster resilience.

If you’re attending NatCon25, I invite you to join our interactive workshop: “Improv in Behavioral Health: Strengthening Empathy, Collaboration and Adaptability,” where you’ll gain hands-on tools, and leave with a new lens on what it means to connect.  There are two sessions available, Monday, May 5, 4:30 PM – 5:30 PM ET or Tuesday, May 6, 11:15 AM – 12:15 PM ET, both located in room 204C.

Don’t miss these other HMA presentations at NatCon25:

Monday, May 5, 10:15 AM – 11:15 AM ET session A3 in room 103B
Harnessing Your Superpowers in Times of Disaster
Breakout Presenter: Monica Johnson, MA, LPC – Health Management Associates

Monday, May 5 10:15 AM – 11:15 AM ET session A13 in room 115BC
Building Sustainable Pathways for Behavioral Health Careers
Breakout Presenter: Allie Franklin, MSSW, LICSW – Health Management Associates