In this interview, Rebecca Boss expands on her journey to her new (or not so new) position, and shares her vision for leading a state agency, with an eye on prevention.
You have worked at BHDDH for years. How is your role as Director different from your previous roles?
This November will be my 13th anniversary with BHDDH. I came in as the administrator for the substance use treatment unit. As Director, the role has changed significantly in that I have oversight of areas that beyond behavioral healthcare and greater responsibilities for Department management including roles related to legal and legislative affairs; communication; budget; and licensing. The role of Director includes oversight of the Division of Developmental Disabilities and the Eleanor Slater hospital. These are all huge operations with different populations and sometimes different priorities. As a person previously focused on program operations, the area that challenges me most is oversight of the budget, though I am fortunate to be surrounded by exceptionally capable staff with whom I work very closely.
My understanding of this role is that I cannot know everything, and I need to have strong people around me supporting the work so that I can rely on their expertise.
What are the key priorities for BHDDH under your direction? How does prevention fit into
My motto is “We’re going to do good things.” I think it is time for us to get back to the basics of what the department is charged to do. We have accomplished much in each of the divisions through targeted initiatives, but it is sometimes easy to lose sight of the broader mission when you are focused on specific programs.
We have a mission and a vision, but we need to have a common focus. I have areas of focus that are going to be guiding us in the next several years: access to care, person-centered care, community integration, evidence-based practices, and special populations.
I am a firm believer that prevention should be an integral part of public health, because the more we do in terms of wellness, mental health promotion, and preventing the onset of substance use disorders and other behavioral healthcare conditions, the less we have to do on the other end of the continuum. Universal screening and early identification is key. We know we are more successful with individuals who have an intervention early on as opposed to suffering the consequences of behavioral healthcare conditions that are undiagnosed, and under-treated or not treated at all. Prevention and early intervention is critical to the success of this department.
You can stand on river’s edge and pull people out of the water as they drown and call that success, but if you want true success you have to go up the river, find where people are falling in and fix it before it happens. To have a greater impact in the long run, we have to focus on prevention.
Why did you decide to accept your position as Director of BHDDH?
I have been with BHDDH for almost 13 years, and I have seen many directors. Each one has brought something different to the department, but there has been more transition than stability.
I accepted this position because I believe it was the right thing to do for the department in bringing stability, and it is much like the reason I accepted the job with the state in the first place. When I worked in direct care I had the benefit of working with people one-on-one and seeing and sharing in their successes. I came to the state with the expectation that I would have a broader impact on a greater number of people. By working with the state, developing good treatment systems, developing policies that improve our system, and being able to expand our healthcare – at that time focusing on substance use disorders – I knew I could impact the quality of services in Rhode Island. That is why I came to the state and why I took the role as Director.
In each phase of my career at BHDDH, I have widened the scope of my impact on a greater number of people. As Director, I get the opportunity to impact lives by creating better systems and better standards of care. I will lead the department in doing this by targeting the areas of focus and maintaining and fostering a deep understanding of our mission and responsibility to meet the needs of the individuals we serve.
What prompted you to move from substance use to behavioral healthcare?
Behavioral healthcare incorporates mental illness and substance use disorders. This department was well on its way to making sure we were merging behavioral health and substance use when I came to the department in 2004. Co-occurring disorders are so relevant. When you are thinking about a system of care for individuals, silo-ing mental health and substance use disorders is a mistake. They should be thought about collectively, because it is the system of care that you are really promoting.
When I first got here there was the behavioral healthcare division and it had a substance use unit, mental health unit, and a prevention unit. Recently, I reorganized so that there are not really separate units, but common functions. There is policy and planning, contracting that oversees contracts with providers, and community engagement. Instead of looking at the pieces that make up behavioral healthcare, we are looking at the functions that span across all pieces. That work started well before I got here. We are finalizing how that plays out, but there has not been a mental health unit and a substance use unit for a long time.
What are the major behavioral health challenges in Rhode Island?
Rhode Island has had an opioid issue for a long time. Heroin has been a drug of choice. The experience that the rest of the nation had in terms of the increased prescribing of opioids and then resulting deaths from prescription opioids only exacerbated the problems that were already happening here.
In some ways, the opioid crisis has drawn attention to the issues that we have been trying to deal with for a very long time, and that have continued to be some of the biggest challenges.
We have also had dwindling resources. There has not been as much investment in our mental health system – not just in Rhode Island, but across the nation. When we deinstitutionalized and moved people out of the Institute of Mental Health many years ago, there was a lot of money put in the community to make sure that individuals who had serious mental illness were cared for into the community. Over time, those resources have shrunk and that support from the community has diminished.
Another challenge is specialized populations. Youth are changing. We do not message to them well. Our system has not kept up with engaging and informing youth. We need to work more closely with some of our sister agencies in terms of planning for transition from Department of Children, Youth, and Families to our services. We need to ensure that we have the right kinds of systems and services in place to meet needs. Individuals with intellectual and developmental disabilities and co-occurring behavioral healthcare diagnoses are challenging in the system that we have now. We need to work closely with the provider communities to ensure that our system is keeping up with the needs. Historically, we have had a certain standard of care that we have tried to apply to everyone across the population. We recognize the need to change that approach.
Stigma is also a major challenge. There is stigma around behavioral health conditions and some of treatments for them . Particularly in the treatment of substance use disorders with medication assisted treatment. This is an evidence-based intervention, but some people are experiencing barriers to access because personal beliefs are thrown into the mix. This means they are not suffering from a stigmatized disease, but they are stigmatized if they get the treatment they need.
How can prevention community providers help you better address these challenges?
Addressing stigma has to happen on a community level as well as on a government level. We can talk to leaders in the community, legislators, and folks at the federal level, but if it is not happening in the community, then it will not have the kind of impact that we need.
Prevention and early intervention is key to us making progress. Prevention needs to broaden. It is mostly addressed in the school and it needs to expand beyond that. Prevention providers can help by thinking more broadly about their scope and their impact. Schools are important, but we need to reach people who have dropped out, are truant, work instead of go to school. What about elders who struggle with these issues? Prevention should happen throughout the lifespan.
Are there specific BHDDH resources or initiatives you would like to promote to prevention
The prevention community needs to be aware of Healthy Transitions, which is part of the Now is the Time grant and is implementing a first episode intervention with at-risk youth or others in communities. We have also been working on the state youth treatment intervention grant in collaboration with the Parent Support Network to build and strengthen a peer and family based group to inform treatment.
Those are all areas I think the prevention community needs to be well aware of. I would add that we have been trying to work collaboratively with DOH because they are operating the Healthy Equity Zones and they are spearheading suicide prevention work. We as a department need to think about who our partners and stakeholders are; Prevention providers need to do the same thing.
Prevention communities should be working with the police and fire departments. They should be collaborating with the Health Equity Zones, the schools, and with providers in the community, because prevention incorporates treatment as part of the continuum.
Collaboration is important, because if we stay silo-ed, we are never going to accomplish the kinds of goals that I would like to see for this department and for our work in behavioral healthcare.