Jennifer Colamonico
Welcome to Vital Viewpoints on Healthcare, where we explore the biggest challenges and innovations shaping the future of health and human services. Our guest today is a true leader in behavioral health. Monica Johnson. With over 25 years of experience at the state and federal levels. Monica has been at the forefront of policy and system transformation. She was the first director of the 908 and Behavioral Health Crisis Coordinating Office at SAMHSa.
The substance Abuse and Mental Health Services Administration, leading the national rollout of the 908 system and expanding crisis response services. Monica previously held key leadership roles in Georgia's behavioral health system, overseeing a $600 million budget and driving statewide initiatives for mental health and substance use care. With a new administration underway. Behavioral health policy is at a pivotal moment, so I'm really thrilled to have Monica here today to talk about these issues.
Thank you so much for joining us.
Monica Johnson
Thank you. Thank you for having me.
Jennifer Colamonico
So first, I wanted to just talk a little bit about your journey and how you've kind of landed in this leadership role. You started out working in local clinical care with children and families. So what was the moment at which you decided to effectively get into policy, leadership at that state level?
Monica Johnson
So I think I'm going to go a little bit south before that because it's, I think, pivotal and put me on the pathway that got me here, which was not intended to be a pathway about policy. It was a pathway related to wanting to help, youth and so I was still working on my psychology degree, and I took the job.
It was a part time job at a children's psychiatric residential treatment facility, and no clue what I was stepping into. Probably at the time was only, maybe 3 or 4 years older than some of the adolescent girls that I had an opportunity to work with. And, and going in there very naive, not knowing again what to expect.
There was an incident that took place on my first day of work. On that first day, two girls got into an altercation, mostly verbal, and one of the girls threw a chair. I remember what the argument was about. I remember all those things. And after the event, there was, you know, we had to process what happened.
And again, remember, this is my first day. And one of the girls said to me, go ahead and tell us, like, tell you what? It was like, this is your last day. And I was like, it's my first day. How could it be my last day? And she said, because nobody ever stays. And at that time I was contemplating either, you know, moving forward in psychology, thinking I'd be a clinician, a therapist of some type or going to law school.
That was the moment that I knew I was to go into law school. I knew that whatever it was going to look like, I wanted to help people and I did not leave. That was not my last day. I stayed working there for about three years, and that was really what got me here. And I think that's important because I started out as a tech, what would be, you know, considered a technician at that time, probably $9 a dollar an hour job and doing something that was life changing for me.
And I've never looked back. So subsequently obviously moved into other roles. But that moment felt like what put me on the trajectory to getting to this point.
Jennifer Colamonico
Wow. And doesn't that just crystallize what public service really means? Right? Doing trying to help the most people at the highest vantage point and certainly not doing it for money. Right. Right. So how did, how did you come into state policy, leadership talk maybe about your your role in Georgia?
Monica Johnson
Yeah. So I had an opportunity from there to, you know, do a variety of things. Working with a bunch of different populations, children and adolescents was kind of my jam in the beginning, but I ended up working with adults that had chronic schizophrenia. I did geriatric, psychiatric, care day treatment, partial stuff, and a lot of opportunity to see the system from a different vantage point.
I've been the therapist. I've been the, clinical supervisor, operated, outpatient clinic setting. And I used to be the provider in the community that would go to state meetings and say, oh, my God, they have no idea what this policy is going to do. They just roll it out and announce this policy. Who did they ask? I will never work in government because this is not how you do policy.
And then I started working in government. So seriously, an old mentor of mine, saw that the state was advertising for this was the state of Georgia was advertised for child and adolescent mental health director, and that mentor was my boss at the time and said, your job was just posted it. And I'm like, am I fired? That's what it sounded like.
When your boss is, your job is being is posted. But he was talking about the job at the state and I was like, yeah, so not on my bingo card. I don't want to work in state government. I like the contact with people. I like the direct care, whatever role it looked like. And I just had never had any aspiration of going into state government, but he convinced me to give it a shot.
I did the interview and, obviously ended up in the role, and I realized immediately that this was probably what I was meant to do, and that it made me drawn a different set of skills using the experience that I had had in the community. And one thing that I had promised I would always do, and I've never not did it.
At state or federal levels of government work, I will never forget what it felt like to be on the provider side. On the community side, and feeling like there was a disconnect between policy. So it's important to me to always remember where policy and practice meet. And so once I had the opportune pretty to be in a position where I could make a difference on a different scale, impact maybe more people through policy making, program development, etc. that I would not squander that opportunity.
And I always went back. I always stay connected to people in the community and always keeping the end user kind of in mind. What is this feel like for people that will be impacted by anything? We write with a pen who.
Jennifer Colamonico
That's so powerful. How so? I want to understand. Kind of, you know, you were pivotal in setting up this crisis system. So I want to sort of get to that point, but like, building off of what you just said, how did you do it differently? So what what did you see inside? And, you know, you can speak to either the state or the federal or both.
That, you know, that clinical experience that holding the the people at the center, you know, people always give that lip service, but like, to really do that. What does it really look like to change policy making where you're keeping people at the center of your focus?
Monica Johnson
So, I'll speak because they, they carry in both spaces. Right. So I'll just say from a government perspective, for me, it is not just going out beyond the walls to go into communities. That's very important. But it's also making sure that you are intentional about having the right people at the table that are part of decision making.
And so if you believe in the voice of lived experience, where is that represented at the policy table? That is not the same as going out is not the same as going out into the community the way I described earlier. You also need people that are part that have a pin and are part of that decision maker.
You cannot be uncomfortable with being challenged. You you need to purposely seek out opinions that may not be your perspective. Everybody brings something different to the table. And if you do not have, a very clear sense of intentionality around seeking out those that may come from different backgrounds, have different experiences, what? And fill that in, whatever it may be, then you're going to be in this siloed kind of way of thinking and policy making.
So you got to make sure you have people at the table. If you're talking about developing programs for youth. And we did this, so this is not lip service. Now, we did this, then we hired youth, not just say we're going to put a committee together and we're going to, which is nothing against putting committees together and having different, you know, ways to get voices represented, but push a little bit more, push more.
And I think sometimes when you work in government, people think that you're you're you're kind of unable to do certain things. And, I've gotten through and I have figured out that you can x, y. Don't we do it this way? Why can't we talk to such and such? Why can't we include x, y, z, x, y? Be curious and not just accept?
Well, this is just the way it is. We don't do that in government. You know how many times I heard that, I can only.
Jennifer Colamonico
Imagine.
Monica Johnson
I can't tell you how many times. Because that's been the story of my government career. Just combining the state and federal is. I don't think we can do that. And then you dig deeper and it's like, well, maybe we can't. Has anybody adds. That's what makes a difference. I think pushing beyond the normal approaches and being bold, even in environments that don't necessarily invite that, if you don't act or insist for it.
Jennifer Colamonico
Yeah, yeah. So now you, you know, you've been involved in creating, the 908 system, which is interesting, creating and leading. I should say. But it's interesting to think about, you know, crisis. We think about emergency room. Right? You so you think about people in crisis. People call for help. They. It's either a police or emergency room.
And that's where people in mental health crisis show up. And neither of those are good environments, right, to really treat their needs. And so what you just said about, you know, maybe we could do this differently. How did that happen? How did this sort of idea, take root and, and, you know, how did we go from a system that, you know, wasn't really serving these folks to at least a promise of a system that could better serve people in mental health crisis?
Monica Johnson
Yeah. So, Nancy de it was built on the decades worth of work that existed before the three digit number. Which will be three years old in July. So it's still in its infancy. But 988 was built off of the former ten digit suicide, crisis hotline. And, there are so many pioneers and so many people that led in this space prior to the launch of 988, dedicated advocates and people across this country that were already, answering the call.
I would like to say so, but, I became involved in this work in this formal way. And as the former 988 director, what was different for me and why it still feels and I will never change my mind. And it was one of it remains to be one of the most transformational things that's happened, or the field of behavioral health and, it's many reasons for that.
But going to your point about people showing up in emergency rooms, people typically show up in an emergency room and I'll speak just in a space of talking about behavioral health crises because they don't know where else to go. They don't know what to do. They don't know who to call this system, is not necessarily easy to know those answers when you are having your best day.
So when you are not having a great day and you are having it, whatever the behavioral health crisis may be, and then you're expected to know how to navigate a system, let alone remember a ten digit number. So the ability to transform the way people can initially reach out when they are experiencing a crisis versus showing up in emergency room or versus.
Dowling now on one for, mental health crisis, then, I mean, that alone is why I'm standing down with my comment with is the most transformational day. And so the thing that no matter where you are, you can remember a three digit number, which a diverse, unnecessary maybe police response that may not be needed, should not be needed.
We have such a history of criminalizing mental health, and I won't even go on that soapbox. But, but then also, maybe there's resources that can divert you from this situation becoming more of a crisis. So I think it's endless the possibilities and what can still be done to continue those efforts to transform the way we respond to people that are having a crisis.
And when I say people, I want to be clear that people includes us. It can be me. They could be you. It could be anybody listening. And that's been a big part of this dynamic, too, is changing the conversation and helping to reduce stigma related to what it means to be having what it means to have a mental health illness, period.
But what it means to also be experiencing any form of a crisis related to behavioral health.
Jennifer Colamonico
So that sort of takes me to think about, I guess there's two questions I want to ask about that. One is, you know, you mentioned that the work preceded the three digits. And I know that's really important. And as we're at this sort of a bit of inflection point, which gets me to maybe my second question is sort of the role of the federal government in supporting and nurturing and strengthening these programs.
They started at the local level. It rose to the level of the federal government. I think as of right now, that's still that's still there, right. That hasn't been displaced. So there's some, I'll say, bipartisan, some kind of universal, which I think is what you're getting to. Right. There's sort of a universal agreement that there's something we need to do here.
I guess my question is, what is the what is the distinct role of the federal government in, in sustaining these programs? And if that for some reason went away with these programs still exist?
Monica Johnson
I think that the role of the federal government is to continue to support the this work, not as they had described earlier, is like in its infancy. And there's so much more that needs to happen to really bake this fully in the cake, I feel is baked into the fabric of the country. But there's so much more that needs to happen around education and awareness states and territories and tribal nations still need support in building out their systems because we we talked about on IT aid in the sense of contact, but it's also that the other parts of it the right response.
So rather than mobile crisis, the right place to go, whatever that may look like for, for help if that's what's needed. And so because it's in that infancy, what the, the original vision was, was that there would be this collaboration that was this federal and state territory, you know, tribal nation collaboration. Because you need both you need the, the federal to take lead because of its infancy.
Does it always look like that? Probably not. But for now, it is that you still need that for the cohesiveness to really understand impact, to understand national impact, right. You'll have local data, local differences. But to really understand what was the true impact of this work for this federal program that is the federal law. And so I think that the intent was always to have this strong partnership.
States and, local communities have stepped up in so many ways that, that, that have been so important because at the end of the day, all of this goes back to local community connections. We want people to be connected to their communities for all the reasons that should make sense. Natural supports, natural resources. There's a whole bunch of things that you know are different from one community to the other.
So my hope is that that partnership will continue so that it can get more mature before it starts to look different. And I'll say this before I pivot away from it. The golden nugget about 988 was that thinking about the call? Was that like now one one if you are, I'm in Georgia, but if I came to new Jersey that if I was in new Jersey, unfamiliar with the health system there in new Jersey, because I'm not familiar, but I had what felt like a mental health crisis for me.
If it was a physical emergency, like a heart attack, if I was having some sort of a stroke, I would know what to do. I would down 911 and I would have some construct of what to expect. After that, an ambulance might come. I would have a construct for mental health crises if, in new Jersey and I need a support for mental health, I wouldn't have that construct before 988.
So I would know I can call 988. I also know if I popped up in Arizona and I had another crisis and it was related to behavioral health, I could call 988. So that's the the the point of it is that knowing what to do, no matter where you are and being able to get the support that you may need, that is pivotal.
And I don't want that to get lost. So that education, the awareness that takes place on a national level is important so that people understand that nugget, which is so important,
Jennifer Colamonico
So much to take from that. There's one thing to have consumers empowered to make choices, and there's another thing to expect people to really understand how to navigate a complex system in a moment of crisis. And, you know, that can also even be true in physical crisis. We see that all the time. But that, you know, that construct of just I'm going to call and I know that somebody is going to help me.
That's a very simple and powerful idea. Talk about your experience at SAMHSa over the those three years. You know, how, what really stands out to you, about the work that you all did to, you know, nurture this program? As you said, it's still in its infancy, but, you know, arguably making some really significant progress.
What are the moments that stand out for you over those years?
Monica Johnson
Like I said, one of the most transformational things in that role, I came to SAMHSa to further implement 988. I got there when, 90 day was six months old is I'm counting this like it's a baby, right?
Jennifer Colamonico
That's right. I it feels like it's our baby here. That's right.
Monica Johnson
Next month all. And again I got to work with some incredible people. We built a team really fast. So we were. The plane obviously was already flying. Has circled the globe a couple of times, and we had to build an office and and do all the things, make sure that, we were working with stakeholders, that we were listening, that we were because we were moving fast, implementing policy, getting this out there, public awareness, communications, marketing was was huge.
And so I said when I came in the door that we were going to go fast, as my son say to me, we were going to go hard in the paint and we were going to be as assertive as possible. We understood that, you know, government is cyclical. I understood that I already spent 12 years in state government.
You know, up to that time in county level, I understood the how government works. And so you have a limited period of time. And so let's do everything that we can. And, I mean, I could not have asked for more. I think we did every single thing that we set out to do in the time that we had.
And, and people are still there, you know, doing this work and pushing and, and, and continuing on the, the work. And just like people are across the country in states, in places that you wouldn't even by some of the most remote, some of some frontier areas of this country, people are still, pushing forward. I want to say this too, because in that time.
So from the time 19 eight went live to now, 50% of the states have done some type of appropriation, some type of legislative act to further cements nanny state locally. Some states have done trust funds, other states have done study committees. Some states have done appropriations for some part of the crisis. Continue. I raised that because it's hard to find and behavioral health history where something so quickly, so quickly is almost three years old, so quickly has garnered that type of response locally, where states are investing in that way.
So I think that's so important to underscore, and hopefully that work continues.
Jennifer Colamonico
I think it's testament to the universality of the challenge. As you said, given what folks are trying to do, you know, what IT funding, I'm sure is there. But sort of funding and policy structure, like what would best support doing the work at the local level, which as you make the point is where the, the solutions are, you know, what, what have you learned or what would you advise based on having gone through all of the parts of the circle that that serve the system?
Monica Johnson
I think a few things here. I want to say something before before I do that too, because one of the things that I think is important is that when you start trying to build out in design a crisis system, in your communities, it is a really hard task to do that without thinking about prevention and without thinking about what happens when the crisis is over.
I feel like a broken record. I say that anytime I get a chance. So I had to get it in there because it's so important. If you build a system only for crisis on a poor behavioral health general foundation, then you are setting up a system for failure. So that's important to remember. The entire continuum, was needed to continue the work forward is leadership that is invested in the mission.
One of the things that I learned how to do over time in government is to figure out ways to make sure that the things that you use this term, already baked in the cake, can outlast you, because you should expect that you won't be there to maybe see certain things through. So how do you find the ways to make sure that the work and the momentum can go on without you finding the ways to tie the work into the fabric so that it doesn't matter the whole.
As long as people buy into the what, the who should and matter. And so people sometimes make it about themselves. And it's like my legacy, my things, my whatever. Well, when you do that, the minute you're gone, all that work is gone. And so I think that to me is what I mean when I say leadership. The second thing I would say here is being able from the start, to understand what data is needed to be able to tell the impact story that is required to continue to convince, persuade others who will show up again.
And government is a game of musical chairs. So when the chairs change, you have to be ready. Not scrambling, not now. Trying to think about, well, what was the impact. We now we save lives. But how many what was the percentage? Did we reduce homelessness by accident because we were doing this work we're notorious for and behavioral health.
We are people who want to help. We want to help others. We think about just how do we help? How do we just make a difference? You can do that at the same time that you are strategically thinking about what is the data point that I need to collect? Because I'm going to have to be able to tell this story, and that story has to have something beyond anecdote.
Anecdotes are nice, but it cannot be the way you tell a impactful story, especially when you need ongoing funding support. You need ongoing, you know, whatever support that may be. So those are the things that I think are probably the most critical.
Jennifer Colamonico
If you had a magic wand and you could wield it, in any way to improve the chances of this system kind of enduring, how would you wield that magic wand?
Monica Johnson
I think that what 988 did was start to change the conversation around stigma. If I had a magic wand, though, I would say we need to do something more bolder to attack the stigma. And my magic wand would do something bold. But at the same time may seem obvious and it goes to prevention. Every year I get a reminder to do a mammogram.
I go do it every year, and I don't have not. I don't have breast cancer. I don't have, a no mother grandmother, but I go do it. Every year. I get a reminder to go do my physical. I go do it every year. I go get my teeth clean. These are all preventive things that we go do.
And when you're doing those things, you. But you begin to have a construct of what? Why? I go get a physical. Why go get the mammogram. Well, I go do these things. Why don't we have a annual mental health checkup? Why is that not a thing? And I don't mean questions that are added to my physical that say, have you been feeling sad lately?
No. Most people don't have a construct of what it's like to see a psychiatrist, a psychologist, or any clinician because you only wait to see them until you're probably in a crisis of your own, so you don't have the construct. Why don't we make that be an annual requirement like we do you, I'm a therapist. I can tell you, if I had to show up every year.
Up. I'm a fill up. That whole 45 minute, 50 minute slot that they give me for my annual check in for my mental health. Wellness. I imagine most people will fill that spot up. Then you get to see what it's like to interact with professionals in this field, that when you're not having a crisis, why don't we do that?
Even if you have a warranty that we recently had to replace our air conditioning whole unit, I got a warranty that I have to pay for, but I got a warranty, and in order for them to keep my warranty viable, they have to come out twice a year to check my system. They do that because they rather spend the time trying to prevent before the whole system goes kaput.
I cannot understand why for all the other parts that I name, and I just gave some examples. I at my age now we're into colonoscopies right? There won't be the now to go do because we're trying to prevent. Why don't we invest in something I don't know, as bold as an annual mental health wellness check up and not adding some questions to my physical health questionnaire.
So that's what I would do if I had a magic wand. That is what I would do. That would change stigma. That would reduce stigma. That was less than confusion about what do I do when I'm having a mental health crisis? People think when I say crisis, it has to be something, you know, like the most horrible thing you can think about.
It could be I'm experiencing anxiety right now. That's different because, I'm unsure about my employment. It could be that I am experiencing loss because I'm an empty nester now. It could be so many things, right? But we don't invest in an annual mental health checkup. And that's what I would do with Monica's magic wand. If I get one thing to do.
Jennifer Colamonico
I want Monica's magic wand to exist. That, Wow, that's so powerfully said. It's. There's no good answer to why we don't do that, right? I mean, there's a lot of answers, but there's no good answer.
Goodness gracious. I want to maybe, end with kind of where you started thinking about that girl that through the chair. What would you what would you want her to know about? Kind of how she's inspired you in the work that you've done since.
Monica Johnson
Oh, then you gave me goosebumps. You are not about to make me cry as positive.
Jennifer Colamonico
You're about to make me cry on the podcast. So there we go.
Monica Johnson
You know, I think life is, is a collection of, moments and decisions and, the fact that I can see her face and I can, and the fact that I remember her name, I remember where she was from. I remember why she was there. And, the fact that that is the moment that put me on this trajectory, because it is I would not be here if not for that day.
And that individual that said that I wasn't coming back, I think that for me, I would tell her, thank you. And even though at some point I didn't, you know, I left three years later that she somebody who was built broken for her words, not mine. Somebody that felt forgotten, that felt unwanted, that was that experience.
More trauma than I have in my 52 years of life compared to her 16 at that time. Thank you. And it is because of people like her that when I am frustrated, when I am frustrated with the system that I am trying to remember, what what what who it is, I do think about how I started. And this isn't the stuff you get taught in school.
You don't get taught this stuff in graduate school. You don't, and you don't know how to prepare for those moments. But she was my first moment. And I would just say thank you. And I hope that Miss Monica, as she would call me, would make her proud. Because that's been the center of I hold on to my wife because I remember her faith, but I remember other faces along the way, and I hold on to those memories because you need them.
This is not always easy. And so you need them. You need to be grounded in your why. And that's a part of mine.
Jennifer Colamonico
Monica. Thank you. Where have I feel like I should say, on behalf of this country. Thank you. On behalf of all of us. But thank you for making time to talk to us. This is. We could talk for hours, but this has been great. I appreciate you.
Monica Johnson
Thank you, I appreciate you. Thank you so much for this, for lifting this up and giving voice to this. Thank you.
Jennifer Colamonico
For this episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMAIS has all the information you'll need to power your initiatives to success.
This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
