A New Frame of Mind

Executive Summary

This guide profiles seven philanthropic foundations that are solving problems in mental health and substance abuse today. For each foundation, there is a description of its approach, some of its most influential initiatives, and how its efforts fit into the broader mental-health landscape. Most of these subjects have a local focus, and a long view on bringing improvements to their communities. One—the Well Being Trust—was created in 2016 to promote mental health across the nation.

The field of mental health has long struggled with definitional issues, and our understanding of the complex ways that brain, environment, and experience interact to create a psychiatric status is rapidly changing. Some analysts focus on hard molecular, genetic, and neurocircuit markers of illness. Broader approaches include factor like life- purpose and meaning. The philanthropists profiled use a range of definitions and demonstrate that it is possible to help people even when experts don’t fully understand the nature of brain health and disease.

Many observers question whether mental illness and substance abuse are different or interconnected conditions. Because they share many symptoms and effects, and because many useful solutions address both problems, both are included in this paper.

The Philanthropy Roundtable’s review of this field was undertaken in response to concern among philanthropists. America is in the midst of a serious crisis in mental health, as seen in statistics on substance abuse, suicide, medication of young people, and other topics. Our members are receiving proposals from every sphere of society asking for assistance. Funding is requested for counselors in schools, screening in workplaces, and new approaches in family services. Nonprofits tackling unemployment, homelessness, crime, family decline, and other issues are seeking help with mental-health aspects of their work.

Many donors want to avoid being reactive and piecemeal in their giving and need ideas, examples, and history to make them more informed grantmakers. This guide summarizes some of the key ideas, important statistics, and notable actors animating contemporary mental-health philanthropy. This guide is illustrative, and should not be read as a definitive survey, or as an endorsement of any single strategy.

Diseases and Deaths of Despair

America is experiencing an epidemic of “diseases of despair,” a term coined by economists Anne Case and Angus Deaton in 2015 to include drug disorders, alcohol-related diseases, and suicide. In a widely read paper, Case and Deaton showed that “deaths of despair” were responsible for an unprecedented drop in life expectancy in America.¹ This drop has now continued for three straight years, comprising the longest sustained decline in life expectancy in a century.

Deaths of despair doubled over the past 15 years, and if left unchecked are predicted to double again in the next decade. Every year 127,500 Americans die from drug- or alcohol-induced causes or suicide. That means 350 people lost every day, 14 per hour, one person every four minutes. By comparison the annual death toll from the HIV/AIDS epidemic in its very worst year was 50,877. The number of Americans killed in all driving accidents every 12 months is 37,000.²

U.S. suicide rates are up among all groups but have risen sharply among certain groups like rural populations, poor whites in middle age, and young teen girls. Deaths of despair appear dependent on place, suggesting a possible linkage between these deaths and the breakdown of social capital in some communities. The epidemic is worsened by a fragmented and broken mental- health delivery system unequal to meeting the demands of those suffering.

Mental illness now causes more disability in America than heart disease, cancer, or stroke. Mental–and substance–abuse disorders constitute the leading cause of years lived with disability.³ People with psychiatric disabilities constitute the largest and most quickly expanding subgroup of beneficiaries receiving Supplemental Security Income payments.⁴

Almost one in five Americans currently has a mental- health diagnosis. This includes mild to moderate cases of anxiety, depression, or substance use. One out of 20 people has a condition that significantly impairs daily functioning.⁵ An estimated one out of 12 Americans uses drugs or alcohol in ways they want to stop.

Mental illness is a chronic disease. It generally starts in young people and persists throughout life, absent effective treatment.⁶ Seventy-five percent of mental afflictions show up before the age of 24.

Looming behind these statistics is a great deal of human suffering. And many other social problems that philanthropists are trying to solve in their communities are aggravated by mental illness.Things like economic failure, family violence, homelessness, and imprisonment are markedly higher among Americans with psychiatric afflictions.

In the pages that follow you will encounter some thoughtful approaches to addressing this serious and growing problem.

Profiles: Leading Funders

Innovations in Care

The Meadows Foundation

At the end of a quiet Dallas street lined with nineteenth-century homes sporting turrets and grand porches sits the stately Victorian headquarters of the Meadows Foundation. Since its creation in 1948 by oil tycoon Algur Meadows and his wife Virginia, the Meadows Foundation has distributed more than $1.2 billion to 3,500 Texas institutions. All of the homes lining this quiet street are owned by the foundation and used to provide free office space to 39 local charities, freeing the nonprofits to spend their resources on programs rather than rent. The Meadows Conference Center also offers meeting and collaboration space free of charge.

After conferring with experts and practitioners, the foundation made mental health one of its areas of focus and approved their first mental-health strategy in 2001. Over the next 10 years, Meadows wrote many checks to support nonprofits working on the subject. But hard data and results were few and far between.

In 2011, when the foundation developed its second ten-year plan, it engaged psychologist Andy Keller to find ways of defining success. He brought in data from around the country, and leaders from across the state to make sense of it. The analysis showed that their region faced serious mental-health problems, and that Meadows was not having the impact envisioned. The foundation realized it needed to change its playbook.

It was at this same time that more than two dozen children and staff were killed at Sandy Hook Elementary by a mentally ill individual. The Texas Legislature went looking for opportunities to improve identification and treatment of disturbed persons. The Meadows planning team realized that better data could help state decisionmakers be more successful.

An institute is born

After consulting across the state, the foundation created an independent, philanthropically-driven institute for improving mental-health policy in Texas. Other funders in the state, including Lyda Hill, the Houston Endowment, and the Hackett family signed on as supporters. The Meadows Mental Health Policy Institute (MMHPI) was formally announced in April 2014 as a multisite, statewide organization with analysts and projects in Austin, Dallas-Fort Worth, San Antonio, Houston, Amarillo, the Rio Grande Valley, and other locales.

To lead the initiative, Meadows Foundation president Linda Perryman Evans brought in people skilled at connecting ideas and policymakers and building coalitions. Tom Luce was a well-known education reformer and political networker. Phil Ritter had relationships throughout Texas in the business, government, and philanthropic communities. Keller worked side-by-side with them for two years and became CEO of the institute in 2015. MMHPI quickly became a valuable resource for legislators, judges, and other state officials.

Keller believes that care for mental health can be improved if it is treated more like other diseases. For instance, clinicians now regularly screen for diabetes in medical settings, and insurers have recognized that diabetes management provides a strong return on investment. Expert medical panels have advised that screening for depression can likewise have a “moderate to substantial net benefit.” Yet many physicians don’t raise depression as a patient health issue without prompting. Thus, one of MMHPI’s early initiatives is promoting universal screening for depression across Texas.

Luce became involved in a plan to consolidate five state health- and human-service agencies into one. He helped fold into this effort more attention to behavioral health. With MMHPI’s counsel, various pots of mental-health and substance-abuse funding, totaling $7 billion, were aligned with a new strategic plan that integrated enhanced tracking and accountability. Included in that sum was more than $3 billion in federal Medicaid dollars.

One result was improvement of intensive, community- based care. MMHPI is now working with the state legislature and regulators to expand intensive, community-based service capacity, particularly for children in the foster-care and juvenile-justice systems, and to better leverage existing Medicaid authorities to promote evidence-based care.

Another result of the new emphasis on behavioral health is a $15.5 million redesign of the Austin State Hospital. The state and UT-Austin Dell Medical School aim to transform this deteriorating mental- health center into a leader in brain health and community-based care. MMHPI is contributing to the project and plans to share its improvements with other inpatient facilities across the state.

Treating Mental Wellness as Part of Everyday Health

MMHPI sees better integration of mental-health care into the wider medical system as a cornerstone of improvement. It supports an approach called integrated (mental and physical) health, which makes the primary-care doctor the “quarterback” who calls on counselors and psychiatrists as needed. The counselor ideally sees the patient the same day that a mental-health problem is detected, via a “warm handoff” from the primary-care doctor. MMHPI is urging medical schools to train students in this method.

One of the institute’s goals is 100 percent detection, treatment, and remission of depression. They estimate that 85 percent to 90 percent of depression can be addressed at the primary-care level, while only 10 to 15 percent will require specialty care. And unlike care in rehab centers, a great deal of depression treatment at the primary-care level is paid for by employers.

MMHPI is building on several decades of work by other philanthropists. Led by the John A. Hartford Foundation, donors supported one of the largest ever randomized clinical trials for depression back in the late 1990s. The philanthropy-supported Project IMPACT demonstrated the effectiveness and cost efficiency of the type of care sketched above. Foundations like Hartford, Robert Wood Johnson, California Health Care, Hogg, and others convened experts to spell out the clinical details of this approach.The National Council for Behavioral Health then advocated for a reimbursement code from the Center for Medicare and Medicaid Services (CMS), giving clinicians a means of billing for their time. When CMS approves a reimbursement code, commercial insurers are also more likely to adopt it.

Relatively few private insurers reimburse for behavioral-health treatment.The insurance industry largely carves out behavioral health into special Employee Assistance Programs. Compared to the broader medical industry, mental health tends to have a separate insurance system, and many cash- only providers. So MMHPI is showing employers how much productivity is lost to untreated mental conditions and urging them to fold mental-health treatment into their wider medical services. The Texas Business Group on Health, a purchasing coalition of human-resource executives at large companies, is an ally in this.

The institute is betting that when employers start demanding mental-health care, insurers will expand reimbursements for integrated care. More family doctors will then open their practices to counselors. And patients will experience the trickle-down effect in easier access to help.

“We have to treat mental illness the same way we have approached other physical illnesses,” urges Dr. David Lakey, former commissioner of the Texas public-health system and MMHPI’s partner in developing a coalition of department of psychiatry heads across all the medical schools in Texas. “This is just another physical illness.”

One barrier, Lakey and MMHPI agree, is limited interest among primary-care doctors in adding more mental-health treatment. Their solution is to train more family physicians and convince them to add drug and psychological counselors into their practices.

Fixing small blockages and inefficiencies in the system is often more effective than pursuing grand-scale policy efforts, according to Luce. The Meadows vision is to keep chipping away at these small obstacles until there are none left.

One Mind

One Mind has been a philanthropic leader in funding brain research and reframing serious mental illness as a brain disease. A public charity that has raised $380 million over the past two decades, the organization is a leading funder of basic and applied science on mental illnesses like schizophrenia and bipolar disorder.

The organization’s Rising Star award program, launched in 2005, distributes $250,000 grants to promising brain-science researchers. Several Rising Star winners have gone on to make significant contributions to the field. Joshua Gordon, a 2010 awardee, is currently the director of the National Institute of Mental Health.

Traditionally, mental illnesses have been grouped by symptoms, by thoughts and behaviors. One Mind takes a different approach. The organization identifies the basic biological mechanisms at work in conditions like schizophrenia and traumatic brain injury.

This approach recognizes that while the behavior of a person with bipolar disorder may at times be similar to someone with depression, the origin of the first disease has more in common with autism or dementia. The foundation’s bet is that illuminating the physiological processes of brain diseases will help researchers develop cures. Insights developed at the molecular, neurocircuit, or biological level for one brain disease may be translatable to others.

One Mind also recognizes that life events and other environmental stressors can have physiological effects on the brain. The group recently launched an initiative to identify biomarkers in the brain that are associated with trauma or serious stress. If those are found, linkages between experiences and brain changes could be traced out and acted upon.

While the foundation’s focus has been science and research, it also participates in public advocacy. It is funding a PBS series by Ken Burns to raise awareness about brain disease. It campaigns for “open science,” the widespread sharing of findings in basic research to accelerate new treatments and techniques. It created a group, the Kennedy Forum, that brings together leading experts on mental illness, substance abuse, and intellectual disabilities for discussions about brain health. The forum has since spun off as a separate nonprofit.

Venture Philanthropy

One Mind sees itself as a “venture philanthropist.” Much of this derives from the entrepreneurial background of its early backers. As a young man, president Brandon Staglin landed in a hospital with a diagnosis of schizophrenia. He and his parents eventually tracked down a skilled psychiatrist. Through trial and error they found a helpful medication. Computer-based cognitive exercises that were precursors to current apps like Brain HQ and Lumosity were therapeutic. Social engagement, including ongoing support from his family, auditing classes at UC Berkeley, and volunteering at a marine mammal center was also foundational to his recovery. These experiences cemented for Brandon and his family the importance of early intervention, active experimentation, and a holistic approach to beat mental illness.

Brandon’s father Garen Staglin built and sold Safelite AutoGlass, then took another company public a decade later. Using his business skills, he started raising funds for One Mind in 1995. He pushed the foundation to pursue research funding for experimental concepts.

One Mind’s current bet is on aggressive early intervention immediately after a young person experiences a first psychotic break. Its leaders believe the disease course, and life course, can be altered by a form of team care called Coordinated Specialty Care, which combines medication, psychotherapy, family-based therapy, and supported education and employment. This approach was tested in the multisite clinical RAISE trialfunded by the National Institute of Mental Health. Individuals who get this treatment within 18 months of showing symptoms improve one and a half times faster than persons getting standard care for schizophrenia. Individuals who access this type of care are more likely to stay on their parent’s employment-sponsored plans and find work of their own, reversing what is often instead a downward spiral to disability.

Fixing small blockages and inefficiencies in the system is often more effective than pursuing grand-scale policy efforts.

The Substance Abuse and Mental Health Services Administration currently earmarks $50 million for this kind of care, which along with state and local funds plus Medicaid payments enables treatment of almost 8,000 people. One Mind estimates that another $1 billion would be needed to treat the 75,000 patients who could benefit from this approach. Staglin believes this could save the U.S. much larger sums in the long run, by reducing later costs for emergency-room treatment, hospitalization, or accommodation in lockups and homeless shelters. One Mind has convinced California legislators to expand funding for this approach and hopes to spread the effort nationally.

Cohen Veterans Network

With a $275 million gift in 2015, Connecticut financier Steven Cohen launched the Cohen Veterans Network with a philanthropic charge to improve mental-health outcomes for post-9/11 veterans and military families. The organization has a particular emphasis on post-traumatic stress, depression, and pressures experienced in transition from active duty to civilian life. The group has established clinics in 11 cities, with 25 planned by 2020, treating thousands of individuals. These clinics provide high-quality, low- or no-cost mental-health care in community settings that are convenient for vets and active military, with innovative approaches and privacy protections unavailable to persons who use V.A. or Defense medical facilities.

Cohen clinics feel like friendly mom-and-pop establishments…but on the back end they are as sophisticated as any elite medical institution

To run his new creation, Cohen recruited Anthony Hassan. Starting as a radio operator with field artillery soldiers, Hassan had a 25-year Army and then Air Force career. He deployed to Iraq in 2004 as a military social worker on the first-ever Air Force team created to prevent and control combat stress. He also ran the largest military substance-abuse and family-advocacy programs in the Pacific, and earned his doctorate in social work while an officer in the Air Force.

Hassan counts his overseas military time among his most rewarding work. “People in deployed locations are more willing to ask for help, so helping people there is very gratifying,” he says. After leaving the service he became a director of social work at the University of Southern California.

Culturally Competent, Family Friendly

At one of the clinics Hassan established for Cohen, in Silver Spring, Maryland, a visitor is met by a smiling receptionist and children playing in the waiting room. Clinic director Tracy Neal-Walden wore the Air Force uniform and earned a doctorate in clinical psychology. When asked if veterans’ families exhibit more signs of trauma, she registers veiled surprise at the question. “Veterans and their families, if anything, show more resilience,” she says, “They are trained to make sacrifices.”

Employees of the Cohen clinics are culturally competent and evince pride in military culture. Across the network, nearly 50 percent of all workers are either veterans, military family members, or former DoD or V.A. employees.

The treatment rooms of the clinic are painted in calm blues and filled with green plants and natural light. The soothing atmosphere matches the clinic’s philosophy. CVN coaches its clients in healthy thinking, coping strategies, and various behavioral therapies. Between 20 and 30 percent of clients have a diagnosis of post-traumatic stress disorder—which Hassan notes is highly treatable. The clinics also treat depression, anxiety, and substance abuse.

The system Hassan has put in place starts with the idea that individuals cannot be understood in isolation and are best treated as part of their family unit. CVN has found that military veterans often come for help at the urging of a spouse or other loved one. Clinics often encourage whole households to be seen together.

The clinics are designed to remove barriers to treatment and care. They open after typical business hours. They are free or low cost. They provide child care. Staff can order clients an Uber if they do not have access to transportation. If they prefer, patients can be treated from home via video conferencing.

CVN clinics build important partnerships with long-standing community nonprofits that offer parallel services. For instance, the Silver Spring clinic enjoys a warm relationship with the regional Easter Seals chapter, which provides employment, respite, and child-development services. Recognizing that there are many physical, social, and economic factors that go into health, the Cohen network works with universities, community-health organizations, and veterans’ centers. Hassan is currently talking with doctors and clinics about the possibility of more closely folding behavioral-health interventions into primary health care.

On the front end, the Cohen clinics feel like friendly mom-and-pop establishments. They intentionally share office space with local community nonprofits in many cases. But on the back end they are as sophisticated as any elite medical institution, with electronic health records, and dashboards tracking utilization, outreach, and appointments. Such tools allow the clinic directors to meet goals like screening clients the same day they call and seeing them within seven days. CVN allocates substantial funding to financial modeling, utilization review, and follow-up outreach. The clinic directors and CVN leadership confer regularly. All the clinics adhere to a guidebook that spells out daily practices in detail.

Research and Data

The CVN clinics have also developed a research and training pipeline that attracts interns from schools of social work like the University of Pennsylvania, Columbia University, and the University of Southern California. Three of the CVN clinics are co-housed at universities, allowing a close relationship with academic researchers and access to the Institutional Review Boards that must approve any medical research today. (Difficulty navigating IRB bureaucracies is often a significant obstacle to independent science investigators.)

All of this is important because Cohen has plans to use high-quality research to advance the entire field of military mental health. Hassan recently hired Rajeev Ramchand, a research expert on military families with experience at RAND and Johns Hopkins, to make intensive use of CVN’s voluminous clinic data to predict high-risk patients, make the system smarter over time at diagnosis and treatment, and develop better leadership.

CVN is considering expanding its reach through some form of virtual community designed for veterans and military family members. It is also expanding its telehealth capacities to care for clients in their homes. This will allow CVN to reach more veterans in rural or remote areas, cities without clinics, and neighborhoods where traffic is an obstacle to clinic visits.

The charity has a sister organization known as Cohen Veterans Bioscience. Led by physician- scientist Magali Haas, CVB is a research arm incubating diagnostics and treatments for brain injury and traumatic stress. It is hoped that the close relationship between the two organizations will reduce time lags between discovery and changed practice, an issue across much of medicine. The effort is still in its early stages—finding researchers, sharing data, and seeking better biomarkers of mental illness. One early product will be a packet of data indicators that can be used to identify and manage high-risk clients.

Launching and operating a Cohen clinic is a complex effort. To get the most bang from Cohen’s gift, there are efforts to find partners for each new clinic who can contribute or help raise 50 percent of the operating costs by year six.

Because of its emphasis on quality and personalism, low patient costs, open access, and high-quality research, the clinics are not cheap. The clinics accept TRICARE insurance for military families, and Humana and HealthNet private insurance. The network also participates in the V.A. Choice program.

These insurance reimbursements, though, cover just a third of the cost of care. Reimbursement rates are simply too low. “We argue that mental-health reimbursement should cover the true cost and value of care, not some antiquated fee-for-service reimbursement rate,” states Hassan. But until that changes, national and local philanthropy are central to sustaining these clinics.

Hassan is unapologetic about CVN’s costs. “Providing accessible quality care is expensive,” he says. But “to cut corners on mental health care is disastrous. It is a small price to pay to prevent a suicide or to heal a family.”

Mental Health in the Community

Well Being Trust

Well Being Trust is a nonprofit established in 2016 to advance mental, social, and spiritual health in California and across the country. One year after its creation the Trust released a seminal report called Pain in the Nation. It launched a social-media campaign focused on teens and tweens. It has developed partnerships with nine health systems that are administering care for high-cost and high-needs patients.

The story starts with the Sisters of Providence and the Sisters of St. Joseph. Nuns from these two orders came to America more than 160 years ago with a few hundred dollars in their pockets to do the healing work of Jesus for the poor and vulnerable. Over many generations, their ministry grew into today’s Providence St. Joseph Health—a Catholic network of hospitals and clinics operating in seven states stretching from Alaska to Southern California to Lubbock, Texas.

With the merger of Providence and St. Joseph in 2016, Well Being Trust was established as an independent public charity with an initial seed endowment of $100 million. The Trust’s charge is to focus on the many elements outside of the traditional medical-care system that influence whether people will flourish.

Trust CEO Tyler Norris co-founded a sobriety and employment organization for the homeless when he was in his early 20s. Thirty-plus years later, the organization is still thriving. Norris subsequently founded more than a dozen social- entrepreneurial efforts that touched more than 500 communities. Now his mission is turning the tide on diseases and deaths of despair and improving psychological well-being.

The Trust’s Pain in the Nation report, which garnered substantial attention, pointed out that more than 1 million Americans have died unnecessarily in the past decade from drug overdoses, alcohol misuse, and suicide. It called for a national strategy to help Americans facing “pain, despair, disconnection, and lack of opportunity.” Sixty promising programs offering prevention, early intervention, and effective treatment were reviewed in the report.

Redefining Well-Being

The Trust defines mental health broadly. Its community transformation strategy emphasizes affordable housing, improved schools and lifelong learning, jobs, neighborhood improvement, and other factors that extend far beyond individual treatment, or even health as traditionally defined. It encourages teaching the young life skills, thinking patterns, and emotional regulation that it says can head off problems and build resilience. It hopes to help people coping with early trauma and stress bounce back from adverse events and use their lived experience as a fount for leadership.

Even within the health-care industry, Well Being Trust promotes a broad approach. It wants to fold integrated (mental and physical) health prevention and early-intervention efforts into traditional primary-care clinics and other community and clinical settings, and experiment with a vast range of recovery tactics.

One of the first projects backed by the Trust is the Whole Person Care initiative in Napa County, California. This pilot program, funded within California’s Medicaid system using a national waiver, serves high-cost, high-needs patients with a mix of physical health care, behavioral health care, housing support, food supplementation, and other supports. The pilot targets homeless or near- homeless individuals, including heavy users of emergency rooms. Many of these individuals have disabilities, serious mental illnesses, or substance-use disorders. This sprawling program requires the involvement of nine agencies, including the county health department, the housing authority, the police, and more.

The philosophy underlying this approach is that identifying high-cost and high-needs patients, intervening earlier, and investing in social supports cuts the total health spend. Public-assistance programs can be restructured to spend more on lower-cost elements like nutrition, housing, and behavioral health and to save money through the resulting decrease in emergency-room visits typical of high-needs patients. The Trust partners in this work with the Institute for Healthcare improvement, a 25-year-old national think tank, which provides analysis of health-quality initiatives.

WBT is pressing for policy reforms that would require insurers, employers, government, medical providers, and other entities to assure mental-health and substance-abuse care is in “parity” with care and coverage for other physical conditions. Working with iHeart Media, which owns 800 radio stations around the country, the Trust is training DJs to talk about mental health, suicide, and substance misuse on their programs.

Well Being Trust is one of a small number of funders seeking to reframe our understanding of mental health at a fundamental level. Its leaders wish to change the nation’s definition of mental health to one that embraces social, emotional, physical, and mental states. If voids in today’s culture are not filled with social connection, economic opportunity, family repair, and hope, this nonprofit argues, more violence, anger, substance misuse, and self-destruction will result.

Jolene McCaw Family Foundation

Jolene McCaw Family Foundation (JMFF) is a relative newcomer to mental health, having entered the field in 2015. In just half a decade, though, the foundation has built a strong partnership with a national organization specializing in youth mental health, nurtured a promising local nonprofit, and launched programs at 26 high schools and 13 colleges in the foundation’s home state of Washington to reduce psychological distress. Preventing suicide among the young by influencing school culture is now a major emphasis of this funder.

As her own children grew up,Jolene McCaw observed that today’s teenagers seem to be experiencing heightened levels of anxiety and depression. National statistics confirm her observation. Suicide recently passed homicide as the second leading cause of death for Americans age 15 to 24. Over two decades, the suicide rate among young teen girls (age 10 to 14) has tripled. In 2017, 17 percent of all high-school students said they had contemplated suicide.

People with psychosis sometimes attempt suicide as a result of their mental illness. However, otherwise healthy young people who are experiencing acute emotional distress can also be prone to what is sometimes called “impulsive suicide.” These suicides are not exclusively the product of long-held mental illness, but rather acute pain exacerbated by impulsive behavior. The risk of this type of suicide is greater in young people whose brains haven’t fully developed their impulse controls.

In 2013, McCaw and her foundation were introduced to two organizations—one national and one local—that share the same crucial insight: suicide is highly preventable among most young people. Simply putting time and distance between an adolescent in crisis and a means of ending her life is often enough to prevent a tragedy.

Two Fertile Partnerships

In a chance encounter on an airplane, Jolene McCaw sat next to Larry Lieberman, a board member at the JED Foundation. JED had been founded to create a national blueprint for suicide prevention on college campuses. Lieberman got involved after seeing evidence of increasing childhood distress. He had a connection to MTV, the music-television network that has surveyed young people extensively since the early 1980s. Lieberman noticed in these surveys that the percentage of young people answering “yes” to the simple question “Are you happy?” had hovered around 80-90 percent for years, until the early 1990s. Then something changed, and the rate dropped to 60 percent.

Suicide recently passed homicide as the second leading cause of death for Americans age 15 to 24.

After their airborne conversation, McCaw investigated the JED Foundation. She started funding the group in 2014, then joined its board in 2015.

JED’s work on any college campus spans a four- year cycle of assessment, planning, implementation, and improvement. It all begins with a 130-question inventory of readiness, to establish whether the school has a plan in place for a suicide crisis, how well the school’s health clinic is equipped to handle mental-health problems, and so forth. A dedicated adviser provides technical assistance and connects campus leaders to experts. As schools make progress, they turn their attention to transforming the broader campus culture in healthy ways.

More than 170 schools, enrolling nearly 2 million college students, have now obtained the “JED Campus” seal of approval. JMFF made a large grant to JED to bring its program to 13 colleges in Washington. This was the largest single expansion of JED’s portfolio.

McCaw also catalyzed another expansion at JED. At the very first meeting between the organizations, McCaw asked, “Why aren’t we starting this process younger, when students are still at home with their parents?” This led to a new program. With McCaw funding, JED developed Set to Go, an online resource to prepare students emotionally and socially for the transition from high school to college and adulthood. The program launched in 2018 and is now distributed to high-school students, parents, and schools.

The foundation’s interest in helping at the high- school level connected it to a group called Forefront Suicide Prevention, housed at the University of Washington School of Social Work. Forefront has become a McCaw grantee and partner in reaching adolescents across their state.

JMFF funded the development of a comprehensive suicide prevention and emotional well-being program that Forefront uses to train parents, teachers, and school counselors, who are then taught to train other peers. This builds up a broad expertise in suicide prevention throughout each participating institution, and spreads lessons widely to many relevant parties. The effort continues for three years.

The foundation fully funded the training in a first group of 13 schools starting in 2015. Two years later it provided substantial funding for a second cohort of schools. The donors are tracking results carefully. The goal is to create expertise among administrators, students, and families that will endure long after the end of Forefront’s monthly coaching sessions.

With these two close partnerships, the Jolene McCaw Family Foundation is simultaneously pursuing national and local strategies. The two relationships reinforce each other. Discoveries, test results, and new findings made at one level allow the foundation to improve and more tightly focus its work at the other level. This has allowed a relative newcomer to mental-health funding to emerge as a leader in suicide prevention.

Safety Nets

Hogg Foundation

Any compendium of mental-health funders would be incomplete without a profile of the Hogg Foundation, established in 1940 as the first philanthropy in the nation devoted solely to mental health. Throughout the 1950s and 1960s, this foundation was the most influential donor in the field. It helped fuel the movement for deinstitutionalization that led to the closing of many state-operated psychiatric hospitals, and today Hogg remains an influential voice in mental-health philanthropy.

The Hogg Foundation’s founder “Miss Ima” Hogg grew up in the center of Texas political life. Her father served as the state’s attorney general, leader of the Texas Democratic Party, and governor from 1891 to 1895. He was a social reformer, and the Hogg children were taught to “nurture the communities that nurtured them.” With her father, Hogg sometimes visited state hospitals for adults and children with mental illness, and this had an effect on her.

By the time Hogg was 23 years old, she had lost both her father and her mother, after nursing them through debilitating illnesses. She fell into a five-year depression marked by severe insomnia. In search of a cure, she relocated to the Berkshire mountains of Massachusetts, where she met a psychiatrist who helped her recover.

Shutting Down Psychiatric Institutions

Hogg’s psychiatrist connected her to the fast- growing mental hygiene movement. Its messengers argued that asylums imprison people and fail to mend conditions that are often eminently curable.

The organizer of the movement, the National Committee for Mental Hygiene, was founded in 1909 by Clifford Beers, a Wall Street financier who had been hospitalized after an episode of bipolar disorder and a subsequent suicide attempt. He spent three years in private and state mental institutions. His autobiography A Mind That Found Itself gave disturbing accounts of how mentally ill people fare in asylums. The National Committee was ultimately renamed Mental Health America, which is still today a leading mental-health advocacy organization. It focuses on promoting mental health as a critical part of community wellness.

While an estimated 18 percent of the population copes with some form of mental-health condition, only three to four percent-roughly 10 million Americans-have a serious mental illness.

NCMH insisted that mental illness stems from adverse psychological experiences, which can be prevented by creating positive social environments. It sped the creation of a hundred child-guidance clinics in the U.S. to offer prevention and early intervention with children at risk. The group conducted surveys of mental hospitals and agitated for uniform standards of treatment at psychiatric institutions. And it pushed for laws making it harder to commit someone to an asylum. The NCMH had a chapter in every state by 1920.

At around this time, the prospecting company built up by Hogg’s father, later known as Texaco, struck oil, and she became wealthy. With this infusion of funds, she launched the crusade for “positive mental health” that her foundation waged for decades, right up to the current day.

Through the Rockefeller Foundation’s Commonwealth Fund, which was opening child- guidance clinics across America, Hogg opened a clinic for children in Houston. She joined with Rockefeller and other philanthropists in efforts to “influence social policy and government spending by identifying a need, financing and organizing pilot programs, garnering public enthusiasm, and then turning to government agencies for funding and maintenance,” as historian Kate Kirkland has summarized.

The mental-hygiene movement sparked many battles. Whether insanity was curable. Whether it was even a brain disease at all. How best to protect the lives and civil rights of the seriously mentally ill. Differing philosophies on fundamental questions like these still divide mental-health advocates today.

The Hogg Foundation, however, unambiguously won its argument in favor of shutting down state-operated psychiatric hospitals. It was the most influential philanthropic force behind this cause, and due in no small part to its efforts, the number of beds in psychiatric hospitals fell from 340 per 100,000 Americans in 1955 to just 12 per 100,000 today.

Congress fueled the effort to move psychiatric patients out into everyday life by passing the Community Mental Health Act of 1963. The advent of the Medicaid program in 1965 and discoveries of the first antipsychotic compounds further sped the transfer of mentally ill individuals into neighborhoods. Hogg Foundation advocacy thus helped drive seismic changes in the structure of our society and the operation of our public safety net, setting the stage for many of the challenges we grapple with today.

To help communities cope with new problems, the Hogg Foundation funded what it called “circuit riders for mental health,” modeled after eighteenth- and nineteenth-century preachers on horseback, to lecture and distribute pamphlets promoting “positive mental health” in towns across Texas. These advocates addressed 2,000 audiences in 152 communities, reaching roughly 400,000 people at colleges, schools, churches, and Rotary Clubs. The aim was to bring hope to communities who were struggling with interrelated social issues still very familiar to us today.

Today, the Hogg Foundation grants about $9 million per year. Promoting the integration of primary health care with behavioral treatments by counselors is a primary interest. One signature project is the Hogg Policy Fellows program, which trains individuals to lead and influence mental- health policy. Another is trying to build up the mental-health workforce by training more than 500 peer counselors with lived experience in mental-health problems. This is now run by a separate 501c3 organization spun out from the foundation called Via Hope.

Other efforts to build mental-health capacity in communities are in the works. Rural areas are a special focus. One $400,000 grant aims to design rural wellness plans that help localities map their mental-health assets and then plan new initiatives. These will be implemented across Texas over the next decade.

The Achelis & Bodman Foundation

For several years, The Achelis & Bodman Foundation has supported groups that serve people with mental illness, and projects that address the confluence of untreated mental disorders, substance abuse, and violence. The foundation draws important distinctions between serious mental illness and commoner mental-health conditions. A serious mental illness is defined as a behavioral, emotional, or psychiatric disorder that substantially interferes with major life activities. While an estimated 18 percent of the population copes with some form of mental-health condition, only three to four percent—roughly 10 million Americans—have a serious mental illness.⁷

Achelis & Bodman focuses on these people coping with problems like schizophrenia, major depression, or bipolar disorder. Antipsychotic medicines, antidepressants, and lithium for bipolar disorder are currently able to reduce symptoms in about two thirds of such patients (or even more if treatment begins early). These medications are not cures, but they allow many mentally afflicted individuals to live comparatively normal lives, and their efficacy rates compare well with many other branches of medicine.⁸

However: several million individuals with schizophrenia, bipolar disorder, or dangerous depression are untreated today. In many cases this is simply because patients refuse to take their medications. Sometimes resistance is sparked by fear of side effects like weight gain, loss of libido, or mental flatness. Other severely mentally ill individuals don’t even know they have a problem—something specialists call anosognosia, meaning lack of insight. Just as an Alzheimer’s patient may not be aware of his deficits, perhaps 40 percent of people with schizophrenia are anosognosic.

Off their medications, or never treated, mentally ill patients can pose a danger to themselves or others. This reality has led to sharp disagreements about whether the mentally ill patient or a family member has better insight into the right course of treatment. For instance, headquarters staff of the National Alliance on Mental Illness, one of the nation’s leading mental-health advocacy organizations, generally hold that the civil rights of patients forbid letting anyone else make decisions about their treatment. Most local chapters of the same organization, however, support efforts to make it easier for family members to initiate treatment of disturbed individuals. The Achelis & Bodman Foundation exclusively supports groups that champion this family point of view.

One of its grantees is the Mental Illness Policy Organization, founded in 2011 by advocate D. J. Jaffe. Jaffe’s 2018 book, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill argues that the U.S. spends too much on psychological issues but not enough on the seriously ill. His organization and others supported by Achelis & Bodman promote a loosening of civil commitment laws so families can commence treatment for the 40 percent of seriously mentally ill persons who are so sick—often in the throes of psychosis—they don’t realize they need help.

Jaffe also blames perverse reimbursement incentives in the federal Medicaid program for some of the problems in getting treatment for people with serious mental illness. Before Medicaid started paying most health costs for the indigent, state and county governments covered mental treatments. But once Medicaid started to gush states began discharging patients from state hospitals before they were well, trying to shift costs onto the federal program.

That is because the federal government instituted an “IMD exclusion” in the original Medicaid legislation in 1965, banning care for mental health or substance abuse in institutions with more than 16 beds. In late 2018, the Department of Health and Human Services announced states can seek waivers from the exclusion. This marked an advocacy win for Achelis & Bodman’s grantees.

Nearly every mental-health advocate believes that the optimal solution for most mental patients is local community treatment. Jaffe celebrates the “clubhouse” model used by New York City’s renowned Fountain House as one of the best approaches. This combines supported employment or other work with strong communal peer support, close management of care, and housing when needed. The Fountain House model has been replicated in 300 locations and now serves 100,000 people with mental illness.

Unfortunately, “not in my backyard” pressures make it hard in many cities to create as many group “clubhouses” as are needed. Plus, Medicaid has not historically covered the social supports that keep seriously mentally ill people complying with treatment. More flexibility may be possible with waivers and other regulations that allow some flexibility with the Medicaid program. Government incentives are hurting in other ways as well. Payer cost-shifting because of Medicaid caps often forces patients to move from psychiatric units to ill- equipped general hospitals and nursing homes. Or seriously mentally ill patients are just released and end up at homeless shelters or jails.

Something called “assisted outpatient treatment” is favored by many Achelis & Bodman grantees. AOT is mandatory court-supervised treatment within the community, with local mental-health systems playing important roles in helping participants adhere to their medical plans. If someone has a history of arrest, incarceration, homelessness, or needless hospitalization because of noncompliance with treatment, AOT provides a way to take them to court, under due process, and gain supervised community-based care. Assisted outpatient treatment has been endorsed by prominent mental-health advocacy groups, and by the International Association of Chiefs of Police, the National Sheriff’s Association, and the U.S. Department of Justice.

Because a court is ordering the intervention, there is a case manager responsible for monitoring the person and keeping him or her in treatment. This has reduced homelessness, arrest, and incarceration by 70 percent in places where it is put into place—cities, rural areas, Southern regions, Northern regions. Although nearly all states now have AOT laws, these programs aren’t enforced or funded consistently, even though AOT is less expensive and less restrictive than alternatives like in-patient hospitalization or involuntary commitment.

One Achelis & Bodman grantee pressing government officials for fuller implementation of assisted outpatient treatment is the Treatment Advocacy Center. TAC develops briefs, research, and policy advice to assist states in changing their civil-commitment laws. It provides technical assistance and resources that help counties, cities, and courts put their AOT programs into effect.

Another element of education and advocacy supported by the Achelis & Bodman Foundation is its funding for a documentary film detailing the work of Judge Steve Leifman in Miami-Dade County. In 2000, Judge Leifman created a Mental Health Project in his Eleventh Judicial Circuit. This diverts from incarceration into community-based care people with mental illnesses who have committed low-level offenses. Individuals accepted into the diversion program receive case management, housing, and other services. Judge Leifman’s program has been particularly successful in scooping up “super-utilizers” who consume large public resources as they bounce from emergency room to emergency room, from homeless shelter to jail.

Some individuals have such severe mental illness they are unable to live in the community. For these individuals, Jaffe argues, a psychiatric hospital is the most humane option. But with the closure of most such hospitals over the last generation, it is tremendously difficult for any but the criminally mentally ill (who occupy nearly half of the remaining beds) to find a spot. That’s why advocates supported by Achelis & Bodman—like the Mental Illness Policy Organization and the Treatment Advocacy Center—believe that the number of psychiatric hospital beds needs to be increased from the current level of 12 per 100,000 population to more like 40- 50 beds per 100,000. At a minimum, Jaffe argues, mental-health advocates should oppose further closures of state-run psychiatric centers. ⁹

By carefully zeroing in on a small number of grantees who are tightly focused on securing treatment for persons with serious mental illnesses, Achelis & Bodman executive director John Krieger and his trustees are having effects on a field where many funders get lost in tangles of complexity and fuzzy targeting.

This is bringing crisp life improvements to individual patients. And, more broadly, the foundation aims to alter perspectives among mental-health advocates. What is most lacking today when it comes to solving serious mental illness, Achelis & Bodman believes, is not good intentions or even richer resources, but more realistic understanding of the roots of today’s problems, followed by pragmatic responses.

Additional Funders

Along with philanthropists who are funding research, creating clinics, promoting strategies for helping the mentally ill cope in residential neighborhoods, or pressing governments for different policies, there are donors who are devising alternative forms of care. These include new treatments, new technologies for diagnosis, and care in non-traditional settings like homes, jobsites, and schools.

The Lynde and Harry Bradley Foundation supports clinics and day treatment directly inside inner-city schools primarily private religious schools participating in the state-funded parental-choice program. The counselors who staff the clinics provide direct services and also train teachers in how to address children with behavioral issues. Schools need only make minor physical accommodations to meet the requirements for licensed mental-health professionals to see students on a consistent basis. The foundation has connected the program’s leaders to legal and policy experts who can help navigate the complex world of insurance and Medicaid regulations to ensure financial solvency and a high standard of care.

Bob Anthony runs a nonprofit called Adolescent Wellness that develops curricula to help young people cope with anxiety and depression. His resource Breaking Free from Depression is an online program that teaches teachers and parents how to recognize and respond to problems in children. He is now funding a referral program that allows school counselors and nurses across the state of Massachusetts to get professional recommendations from a psychiatrist within 20 minutes when a child is in crisis. It is called the Massachusetts Child Psychiatry Access Program.

The Anschutz Foundation gave a $10 million gift in 2016 to launch the National Mental Health Innovation Center at the University of Colorado Anschutz Medical Campus. One project of the center supports new technologies that might be helpful in fighting mental illness. Some people believe, for instance, that virtual-reality devices could be effective in forming empathy where it is lacking. Entrepreneurs like Tom Insel are developing apps for smartphones, now in clinical trials, which may diagnose mental illness more accurately than current survey methods.

The foundation also supports entrepreneurs who have invented a novel technology but need assistance in getting it into health centers. It offers clinical validation, beta assessment, and help with FDA studies. The hope is that new diagnostic devices, wearables, and uses of artificial intelligence might not only improve the effectiveness of psychological care but also reduce its cost.

Telehealth─networks which allow patients to consult with physicians and other experts from a distance—can also be used to improve diagnosis and care. The Robert Wood Johnson Foundation and other grantmakers have funded Project ECHO to link primary-care doctors in rural areas to academic medical centers where they can get advice on mental and behavioral issues.

Social-support services are another area where philanthropy is funding improved attention to patient needs. The nonprofit website 7 Cups organizes hundreds of thousands of volunteers to provide free emotional support via online chat rooms. The chat rooms also offer referrals to low-cost online therapy. The system’s anonymity allows people to engage without stigma, and use of the site has been growing by 12 percent a month, to a current level of two million monthly clients.

A somewhat similar effort has been organized by the Crisis Text Line, a New York-based nonprofit. Its hotline receives about two million messages per month. It is staffed by 6,000 volunteers around the country who are able to respond to an emergency within 30 seconds. This is an alternative to crisis phone lines, which have grown much less popular, particularly among the young.

Not only are philanthropists supporting non- traditional alternatives to care, they are broadening our definition of mental health to include related social and cultural influences. With funding from the John Templeton Foundation, Harvard School of Public Health epidemiologist and biostatistician Tyler VanderWeele is conducting research on the influence of religious attendance and prayer on physical and mental health. He has created new measures of human well-being that are broader than simple behavioral, mental, or emotional indicators. Close social relationships, personal character and virtue, financial and material stability, personal meaning and purpose, and indicators of daily satisfaction and happiness are interlaced in his framework. He is studying the well-being of individuals in businesses, universities, and health systems using his cross-linked measurements.

Many philanthropists are emphasizing the personal skills and habits that lead to mental flourishing, and the cultural practices and institutions that nurture these habits. Rather than funding mental-health clinics in schools (which it found often closed after its grants expired) the Richard M. Fairbanks Foundation decided to invest in classroom programs that teach children how to cope with adversity and build healthy habits and practices that will fend it off. In 2018, Fairbanks distributed $12 million to 24 organizations operating in 151 schools in the Indianapolis area.

Elizabeth Fowler of the Triad Foundation in Ithaca, New York, is a founding board member of Frameworks of Tampa Bay, a nonprofit organization that supports educators in implementing research- based social and emotional learning (SEL) programs. In the 2017–2018 school year, Frameworks impacted more than 41,000 students. Central to Frameworks’ programming is Community Building Sessions, an original SEL program that builds positive culture and climate in classrooms and schools. Through practices that include mindfulness, breathing, compliment giving, greetings, focused activities, and more, students build deeper relationships with each other and with their teachers.

The Anne and Henry Zarrow Foundation of Tulsa, Oklahoma, also funds interventions that boost social connections. It supports activities that get children participating in school nutrition programs—like free daily breakfasts—to engage with each other in healthy ways while eating.

Philanthropists are willing to try novel approaches. They are intervening earlier. They are building approaches that involve new actors within a community. They are moving beyond crisis centers and hospitals and jails and into the preventive-health system. They are seeking alternatives to prevailing mental-health financing. They are interested in new delivery systems. They are experimenting with technology, and with alternative care provided in settings like schools and homes. Some are seeking tighter definitions of mental illness based on molecular, neurocircuit, and genetic biomarkers. Others are broadening definitions to include social, spiritual, and economic factors that correlate with mental health.

One thing all of these philanthropists have in common: They channel empathy for fellow human beings into improved health, stability, and happiness for all.

Acknowledgments

This white paper was a collaborative project. We are grateful for the input of a working group on mental-health philanthropy that included: John Krieger of The Achelis & Bodman Foundation, Bob Anthony of Adolescent Wellness, Ted Harms of The Anschutz Foundation, Aurelie McKinstry of the Jolene McCaw Family Foundation, Anthony Hassan of Cohen Veterans Network, Stacy Warren of The Duke Endowment, Claire Fiddian-Green of the Richard M. Fairbanks Foundation, and Cindy Patrick of the Meadows Foundation. We appreciate all who shared their strategies and introduced us to their grantees.

We also thank all the experts who gave of their time to discuss and frame issues: Octavio Martinez of Hogg Foundation, Brandon Staglin of One Mind, Tyler Norris of Well Being Trust, Matt Vogl of National Mental Health Innovation Center, Andy Keller and Phil Ritter of Meadows Mental Health Policy Institute, John MacPhee and Larry Lieberman of JED Foundation, Jennifer Stuber of Forefront, Katherine Switz of The Stability Network, Linda Rosenberg of National Behavioral Health Council, D. J. Jaffe of Mental Illness Policy Organization, Stuart Butler of the Brookings Institution, Laudy Aron of Urban Institute, John Snook of Treatment Advocacy Center, and Tom Insel of Mindstrong.

Special gratitude to The Anschutz Foundation and The Achelis & Bodman Foundation—whose generous gifts made research and publication of this work possible.