INSIDE OUT: A Model for BH Leadership

2016-03-10_22-56-50I am a behavioral health care executive. I know because of my socks.

Many years ago I was sitting in an Atlanta office interviewing with one of the industry’s largest companies for an executive role, and the question on the table was this: how could they be sure this counselor had converted and was now executive-worthy?

Like many of you, I started my career as a clinician. And, when I started, I had everything I needed. On my wall, my LPC and diploma. On my desk, my Zen Garden with its tiny rake. I wore my black dress crew socks every day. And while I didn’t know the meaning of “P&L,” I was very excited about making a difference in mental health.

But years later, here I sat…very nervous. How could I persuade the interviewer I had shed any excessive sentimentality and taken on the full mantle of executive responsibility?

What Does a Mental Health Executive Look Like?

As my interviewer and I talked, I realized that his actual litmus test for whether one was ready for the executive suites was whether or not one’s socks came over the calf (I am not making this up). After I picked my jaw up off the floor, I explained to him that I had obtained my MBA. I pointed to the pinstripe suite and power tie. Nope. These superficial external trappings would be totally betrayed by the presence of crew socks underneath!

I was forced into a corner. I had no choice but to prove my mettle. I lifted my pant leg… and POOF! I was bonafide. My sock went above my calf.

Superficial? Of course. And, a little odd. Some have since joked that he just wanted to see my calves. However, I think the actual question he was trying to get to was crucial.

Many of us among the 25,000+ behavioral health care executives started our careers as counselors, social workers, nurses and psychiatrists. But today, we work in the C-suites of Community Mental Health Centers, lead behavioral health in hospitals and health centers, and administrate in health plans and state authorities.

Our education and professional orientation began with Skinner, Freud, and Rogers. So, interviewers want to know, and we want to know with our own teams, are those the only voices in our head?

INSIDE OUT: What’s Our Model?

Last year, Pixar returned to greatness with a movie about an 11-year-old named Riley whose family was moving to the big city. INSIDE OUT provided us with an up-close and personal look inside the HEAD-quarters of her mind with the personification of five emotions: joy, sadness, anger, disgust, and fear.

We too need a mental model for the voices INSIDE OUT the HEAD-quarters of the BH executive. The old saying is models are a dime a dozen… but you have to have one.

I’m going to propose we need five critical voices. The model I’m sharing is adapted from Reframing Organizations, but it’s fueled and ignited by my own experience with five amazing mentors.

I’ve been really, really fortunate as these five mentors are real champions in the field, and they are my heroes. They have become the voices in my head.

1. FINANCE: “Net”

2016-03-10_23-15-39The first voice is the one that interviewer was trying to locate with his sock test! We’ll call him “Net.” He’s the finance guy.

By the time I met my new boss Richard, I was still wearing the pin stripe and right socks. I knew the difference in a balance sheet and cash flow statement, and I could sniff out BS (baloney and stuff). BUT… my finance voice wasn’t an equal in my command center. Richard was at Magellan Health and leading one of the largest health plan contracts in the country and we were neck deep in the worst economic downturn in our lifetimes.

Richard’s not a CPA, but he had a saying about driving results… “Gentle pressure, relentlessly applied.”

It was late 2009 when I came rushing into the Phoenix conference room for the morning budget meeting. I had been up late and had finally found THE answer. To my team, “Thank goodness everyone, we don’t have to cut Marvin and his program after all (I know it’s not been productive and the outcomes have been poor but Marvin’s really near retirement.) I’ve got an alternative. Instead… if we tweak our travel policy, change our cell phone provider, and save our quarters, we can get the same savings but a different way.”

Richard’s response is the telltale sign that Net’s voice is active and being heard. “These are always difficult decisions, but we’re the stewards of these funds,” Richard replied. “and we need to do ALL these ideas, eliminate Marvin’s program, and get double the savings we were originally seeking! It’s our job.”

It was these actions repeated over and over that dramatically mitigated the actual impact of severe budget reductions upon people receiving vital services. Increasingly, we are in a marketplace. INSIDE OUT the mind of the BH executive: “Net,” the finance voice, must be fully engaged and integrated into all our decisions and actions.

2. FAMILY: “People”

2016-03-10_23-12-16“Net” may on occasion bicker with her, but her name is “People,” and she is constantly thinking about the organization using the mental frame of a family.

I first met Linda in Las Vegas at the MGM Grand at the 2007 National Council for Behaivoral Health conference, and it’s a true success story how she has since grown her national association of community mental health centers and partners into a big tent of inclusion and national influence and accomplishment.

Five years after we met, she and I were participating in a steering committee meeting in a first floor conference room of SAMHSA headquarters in Rockville. She came over and encouraged me to consider pursuing a seat on her board of directors. It was the way she did it that I remember most closely, inspiring me to become part of a group that would put a dent in the universe.

More than ever before, this new generation of workers looks for meaning and purpose in their work. And, the “People” voice is asking some key questions about employees (excerpted from First Break All the Rules):

  1. Do they have a best friend at work?
  2. Do they believe their work matters?
  3. Do they believe a supervisor or someone at work cares about them?
  4. Do they get to do what they do best every day?

“People” suggests that we conduct an annual employee survey to assess their autonomy, engagement, and voice. She asks us to expand the ways in which we invest in our employees with skills and professional development. She is constantly looking to expand the diversity of our workforce.

I recall a corporate executive who chided in an all-employee meeting that the first commitment was to the Company, and he wasn’t interested in those whose identification was first with a professional orientation. “People” reminds us that our staff want to engage in a big dream, in a glorious purpose, and they will commit to a Company that supports them in that endeavor.

3. FACTORY (Clinical/Medical/Recovery): “Soul”

2016-03-10_23-13-13Let’s not run from the third voice. Far from it. Instead, let’s embrace “Soul.”

Underneath the pin stripes and power tie, we clinicians are still clinicians.

“Soul” speaks for what we actually do in our business. In our factory, we deliver services and programs, and the content is clinical, medical, and recovery.

The inspiration is my second mentor named Richard, who leads suicide prevention efforts as SAMHSA Branch Chief and with whom I’ve worked closely since 2005. He’s an architect of policy and national standards, but he always keeps the experience of individuals and the clinical people who serve them front and center, and his work has shifted the tectonic plates in terms of real social change.

There is a sea-change with people with lived experience involved in the leadership and design of programs, and he was leading that charge a decade ago with one of the first national committees for “consumers” and survivors.

However, it was in a cramped meeting room at the Hilton Garden next to BWI airport where I most remember his clinical soul. We were thinking about suicide care in the national community mental health system, and he said the following:

“When I think back over the decades, individual clinicians working under our leadership… they’ve made heroic efforts to save lives, but we administrators, the leaders of systems of care, we’ve done very little.”

This statement was a key driver in launching an international movement to equip clinicians to do what they love better, and to have the confidence to support and engage those at risk so that we together might aspire for something called “Zero Suicide.”

Yes, many of us are clinicians and social workers by background. But it’s not about converting from this disposition. Far from it. Own it. The voice of Clinical Soul must be strong inside all BH executives.

4. INTEGRITY: “Risk”

2016-03-10_23-14-47For us to be successful over time, we need to depend heavily on the voice of “Risk.” And we’re not simply talking about an external analysis, but the core backbone of integrity.

For me, this voice is that of my friend and mentor Sue, who leads a think tank and consulting firm, Crestline Advisors, and has been a corporate executive at the former Value Options and with Tricare.

Over the last several years, I’ve worked closely with Sue and her team on developing a strong compliance program, using the Marguerite Casey Foundation Organizational Assessment Tool for non-profits to establish a baseline, creating an organizational strategy and vision, and creating a road map for a world class program, with Chief Compliance Officer reporting directly to the Board, external and confidential ethics complaint line marketed to employees, stronger compliance education for all board members and staff, etc.

In the short term, it was beyond nerve-wracking. It’s been a couple years ago when Sue and I approached the leadership with the new approach and the investment required, and it seemed quite a contrast from the industry status quo. The memory is extremely vivid as four of us stood around a small round table in my office, perspiring bullets, and waiting for the thumbs up or thumbs down, but Sue emboldened me to take the long term view.

At the end of the day, “Risk” is the voice that presents the core of integrity, of honest and straight dealings, and of acting to protect the organization over the course of time.

5. JUNGLE (Strategic/Symbolic): “Vision”

2016-03-10_23-14-00The last voice is that of the jungle. His name is “Vision.”

One of the highlights of my career is working with Mike. For 30 years he led mental health authorities Connecticut, Ohio and New York, working for multiple governors. And he has been extremely effective in extraordinarily complex environments.

Whenever we talk about a political frame, lots of negatives come to mind. Our jaundiced view only increases if we use the word “power.” But politics is the realistic process of getting things done, of making decisions and allocating resources when interests diverge and resources are scarce.

From Mike, I’ve learned practical insights on how things get done (or not):

  • Research shows that of those in an action group, about 30% are focused on the task at hand (the remainder are focused elsewhere, asking questions like, “what’s my role in this group?” and “is this still a formal group or not?”)
  • And, why do CEOs adopt some new ideas/programs that come across their desk and not others? Research shows there is a bias towards solutions for problems being contemplated at that moment, solutions that fit their preconceptions and ideas that are easy to implement.

These are the dynamics of politics and strategy, of the jungle.

One of my favorite stories is when Mike was chairing the landmark “President’s New Freedom Commission Report on Mental Health.” To my surprise, then President George W. Bush actually spent several hours with the team in a conference room in Albuquerque.

Having never met, the President strided into the room, made his way through a dozen folks and straight up to Mike, taking his hands and shaking them and saying “Michael, thank you for taking this on!” Mike replied, “I hope we’ll do work worthy of your trust Mr. President.” “I have no worries about that.” He then went on to thank the other members of the group by name.

The “Vision” voice knows that we rely too much on reason and too little on relationships. And, there’s simply some horse-trading as part of successful coalition building. Think about all that President #43 communicated that day, both with memorizing the names and faces beforehand and sharing the gift of his time.

Setting the agenda is an important first key strategic step in navigating the maze, but establishing a Big Hairy Audacious Dream is even better.

One more thing. The jungle is not just strategy. There’s an important component that’s part temple/part theater. Call it symbolism.

“Vision” will provide you with metaphors, ceremony, and rituals. Our organizations each have a culture, and these are powerful ways to influence and motivate. Think about the symbolism of the actual title of the President’s New Freedom Commission Report. It was “Achieving the Promise.”

Decisions that get made in the HEAD-quarters of BH Executive minds are tactical, financial, clinical, and strategic… but they are all observed by the employees, partners, funders and customers and they all carry significant symbolic weight.

Reframing Leadership: They Are All Right

You can find a great book on most any of the five frames above in your local Barnes and Noble, and each will explain they have the ONE secret to leadership. My experiences with these five heroes of behavioral health suggests they may all be right. It’s also the message of the book Reframing Leadership.

“Net” “People” “Risk” “Soul” “Vision”
Capacity, Productivity, Value, Cash & Margin Aligning Company & Human Needs Strong Compliance & Risk Mgmt. Foundation Clinical, Medical and Recovery Practices Strategic, Political and Symbolic
Architect Empower Protect Advocate Inspire
Excellence Love Truth Hope Significance

The authors state,

“Explosive technology and social change have produced a world that is far more interconnected, frantic, and complicated.”

In order to succeed, we need a mental model: five voices at the command center in our HEAD-quarters. It’s not about exchanging a clinical soul for finance. It’s about ensuring an equal say by all five voices. We cannot afford to keep even one in a closet, not for a moment. And, we don’t have the luxury to focus on one at a time. This isn’t juggling.

The lesson of the kids’ movie INSIDE OUT. Perky Joy is determined to find the happiness in every moment and keep sadness and other emotions at bay. In the end, she learns that all the voices play a critical role.

We’re all really good at one of these voices, and are all probably lacking in at least one, giving us an Achilles Heel. We need to develop competence incorporating all five. This doesn’t mean we won’t still make mistakes, but it’s essential to our success. Integrating all five is our task and what we must do to succeed.

Like 11 year-old Riley, we’re not in small-town Minnesota any longer, and the world… well, it just keeps a’ changing. But as BH executives, we’re up to it.

I should know. I’ve got the socks.


Note: The YouTube link to the 2016 National Council TED-style Talk on this topic will be posted soon! If you are interested in improving your competency in any of the frames above, check out a few of my favorite references:

  • OVERALL – Reframing Organizations: Artistry, Choice & Leadership by Bolman (1991)
  • FINANCE – Good to Great by Collins (2001)
  • FAMILY – First, Break All the Rules by Coffman (1999)
  • CLINICAL – The Skilled Helper by Egan (1974), and Why People Die by Suicide by Joiner (2005)
  • INTEGRITY – How to Deliver Accountable Care by Lloyd (2002)
  • STRATEGY/SYMBOLISM – What Got You Here Won’t Get You There by Goldsmith (2007)

Also, I would like to credit my friend Dr. John Santopietro from Carolinas Healthcare who used the phrase “clinical soul” when I was visiting Charlotte programs in 2015.

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