National Collaboration to Transform Behavioral Health System

April 20, 2021

The following article was written by Fred Karnas, Senior Fellow, Richmond Memorial Health Foundation (RMHF) and co-director for the national Mental Health Strategic Impact Initiative (S2i).

In the year since the first COVID-19 case in the U.S., it has become increasingly clear that the impact of the pandemic far exceeds even the tragedy of the hundreds of thousands of lives lost across the nation.  Grief, loss of income, long-term illness and isolation have driven an unprecedented increase in mental health challenges, and exposed the lack of supports needed to address those challenges.

The reality is that this nation’s mental health system was broken long before the pandemic.  The failures of our mental health system disrupt education and employment, test family relationships, result in over-incarceration and, too often, further traumatize those who need support the most. These failures cost businesses in the form of increased turnover and reduced productivity, adding to the billions of dollars spent on mental health treatment. Far too often, the system failures cost people their lives. For Black or Brown people, the disparities in treatment access and quality are unacceptable, and compound the failures of other systems.

Even before the pandemic, RMHF recognized the importance of investing in behavioral health and made grants to key organizations in the region. And, over the past year, RMHF has provided in-kind support, to help create the Mental Health Strategic Impact Initiative (S2i), a national effort, housed at the Jed Foundation. S2i is focused on:


  • Embedding of racial equity principles in mental health policy and practice in an effort to eliminate racial disparities in access to mental health supports.
  • Engagement of persons with lived experience in the design of mental health policy and practice, advocacy, and leadership.
  • Increased funding for NGO and other organizations promoting reform in mental health and related systems.
  • More effective and efficient use of system dollars.
  • Alignment among key players to advance deeper and more coordinated efforts.
  • Building consensus on gaps across mental health policy and practice.
  • Innovative ideas worthy of seeding and development, including use of new technology.


S2i’s creation is rooted in the belief that this moment in time is ushering in increased public and private sector understanding, broadened general awareness, reduced stigma, and, most significantly, potential national demand for change. Given these starting points, the goal of S2i is to collaborate with partners across sectors to translate these seeds of change into long-term efforts that drive transformation.

S2i has spent the early months of its existence learning from experts with lived experience of the challenges of mental illness, long-time advocates, mental health professionals, and individuals across sectors whose work intersects with mental health.  In those discussions it has become clear that, while there are numerous issues that will need to be addressed to improve the nation’s response to mental illness, there are a number of immediate opportunities for change. Among them are:


Crisis Response:   Given the tragic high profile events in Rochester, Richmond, and too many other places, there is a growing recognition of the need for mental health crisis response systems that reduce the role of police, and bring to bear evidence-based tools and a new set of actors. There is also a growing understanding that the redesign of the crisis response system must recognize cultural differences in response to intervention, and that a crisis response system is only as good as the resources in place to provide support after the initial engagement.


Workforce:  There is a growing recognition that the existing mental health workforce is entirely inadequate to meet the level of demand for support, and that the need will not be met by simply training more people to enter the traditional professional mental health workforce. Individuals, across sectors, need to be trained to recognize mental health issues and offer support and guidance. And there is a need to expand the paraprofessional mental health workforce (e.g., peer counselors) who are attuned to cultural differences and can meet individuals where they work, live, play and worship.


Lived experience:  While the mental health field has often led the way by including persons with lived experience in the planning and design of policy, too often those efforts have been perfunctory.  Authentically engaging persons with lived mental health challenges requires mental health professionals to respect lived experience as real experience, and to be willing to listen and learn from that experience.  Furthermore, here is a need for significantly more opportunities for persons with lived experience to hold key frontline and leadership roles in organizations addressing mental health challenges.


Housing:  Almost universally, the experts that S2i talked to identified finding and maintaining stable housing as a significant barrier to addressing the nation’s mental health system challenges. Efforts to create supportive housing and other housing with service wrap-arounds need to be accompanied by policies that protect the tenancy of persons living with mental illness who may be in a state of crisis.


Financing the system:  Though many thought parity, covering mental health conditions at the same level as other health conditions, would address the financing problem faced by persons needing mental health supports, it has not.  The uneven enforcement of parity requirements has resulted in the policy having limited impact.  There is a good deal of thinking among advocates and others about how to reform both the public and private payer systems to provide better access to both traditional mental health care and new models.


Technology:  From telecounseling to artificial intelligence tools for self-care, there are many innovations happening in the technology space that seek to improve mental health. But advocates and mental health professionals confirm that, when new technology is designed without input from the end-user, it often results in unwanted, unusable technologies that cost millions of dollars,


Even as the distribution of Covid-19 vaccines expands, we are far from recovery. This is particularly true for those struggling with mental health challenges in the midst of insufficient systems and supports. It’s time that we acknowledge the gaps that have been exposed, and work to address the inequalities and inadequacies in our current mental health policy, infrastructure, crisis response and delivery. Supporting and continuing this work is the aim of S2i.



Bio for Fred Karnas

Fred Karnas is a Senior Fellow for RMHF and a co-director of S2i. He serves as a resource to the foundation and community, as an expert on the intersection of health and housing. Fred has devoted his career to addressing health, housing and homelessness issues, at both the state and national levels. He holds an undergraduate degree in City Planning from the University of Virginia, a master’s degree in social work and certificate in gerontology from Virginia Commonwealth University, and a PhD in architecture from Virginia Tech.