Departing Q and A With John Snook: Nothing Will Get Better For The Seriously Mentally Ill Without Difficult Conversations

(1-4-21)  John Snook is resigning as executive director at the Treatment Advocacy Center after six years. In this Q. and A. departing interview, he discusses the role of TAC.

Question: Why do we need TAC? What makes TAC unique besides the fact that it doesn’t accept Big Pharma money?

TAC plays a role that no other mental health organization does – it’s the only organization focused exclusively on the care of those with severe mental illness. Those with severe mental illness unfortunately don’t have a lot of champions; it’s TAC’s job to ensure that their needs aren’t ignored by policymakers or the mental health community.

The sad fact is that it’s much easier to make the case for mental health than it is for mental illness reform. People don’t want to be reminded of the homeless woman on the street corner or the psychotic man trapped in solitary confinement. And so we often see the conversation drift to talk about everyone’s mental health and away from tough issues like the role of untreated mental illness in fatal encounters with law enforcement.

TAC is there to remind us that unless we have those difficult conversations, nothing is going to get better and those most in need will continue to be left behind. 

Question: You’ve spent six years running the Treatment Advocacy Center, why are you leaving now?

I am really proud of everything my team accomplished while I had the privilege to lead TAC. I must admit that we have exceeded even my expectations. With the start of a new administration, TAC is very well positioned to build on our successes to have even more impact going forward. I am really excited about my next opportunity, working on strategic initiatives for the National Association for Behavioral Healthcare. It gives me the chance to take the lessons I’ve learned from my years and TAC and extend that reach even further with provider systems all across the nation.   

Question: What have been the major accomplishments that you personally are most proud of achieving as a CEO and what unfinished business are you leaving behind that you would most like to see resolved?

I am an advocate at heart, so the passage of 44 laws is something I will always come back to. Each of those new laws represent so much hard work by our team and by families and consumers on the ground, changing hearts and minds to ensure a better life for those they care about.

I think the most important accomplishment is how we’ve been able to shift the narrative around mental illness to bring TAC’s work squarely into the mainstream without sacrificing our core principles. It’s hard to put into words how different the conversation is today than it was when I first worked at TAC in the early 2000s.

Back then, people simply didn’t understand how broken treatment system is and couldn’t comprehend the lengths families have to go to get treatment. I’d regularly have well-meaning people say “well at least he’ll get treatment in jail” or “he just has to hit rock bottom.”

TAC was seen as bomb throwers that just wanted to lock everyone up.

I think TAC’s work and cultural touchstones like your book Crazy really began to change people’s understanding of the realities of mental health care in America. We were then able to educate people with our original research – facts like there are ten times as many people in jails and prisons as in treatment facilities or that you’re sixteen times more likely to be killed in an encounter with law enforcement if you have a mental illness.

Now when I speak to legislators or reporters, I don’t need to start by educating them on the consequences of failing to treat mental illness or why jails are terrible places to provide mental health care. I regularly have our own research quoted to me, as it’s become the bedrock for a lot of people’s understanding of these issues. In fact, we hit an amazing milestone this year – from June to October, TAC broke 1 billion media impressions. That’s how you change people’s understanding of mental illness and it’s an accomplishment I’m really proud of.

Question: You recently signed a vision statement with 13 other leading mental health CEOS that was released in December. What prompted it? Why cooperate?

The meetings had really humble origins, honestly. Like so many things these days, they began with COVID. Dan Gillison from NAMI and Tyler Norris from Well Being Trust hosted zoom conversations among mental health CEOs to see what was happening on the ground and where we needed to really be paying attention, whether it was more PPE for providers or the need to address the impact of COVID on incarcerated people with mental illness.

As we worked together on those various smaller issues, it became increasingly clear that this crisis presented us with a once-in-a-lifetime moment. The country was recognizing the need to support mental illness care in a way it hadn’t ever done before. And so we all agreed that we needed to step up and figure out how to come together with one voice.

The result was an investment of 4.25 billion of new federal dollars, the biggest investment in mental illness care in generations. At a time when state and local governments are facing devastating cuts, this funding represents a desperately needed lifeline to support the most seriously ill.

Question: Interestingly, that vision statement contains many TAC positions that once were shunned by other CEOs. This suggests that TAC not only had a seat at the table, but also has played an important role in setting priorities. Does this suggest that others are changing their views based on TAC’s success and programing or have circumstances brought them around to the obvious?

I think you’re right, the reality is that the conversation around mental illness care has really changed. Now there is a much greater recognition among everyone, me included, that there’s a great deal of room for compromise and coordination, even as we hold tight to our own priorities.

For example, TAC began to publicly embrace the need to support a full continuum of services, including treatment beds, with our report Beyond Beds. From our perspective, it didn’t change anything we were fighting for, it simply shifted how we talked about the issues and how we partnered with other groups. But by being willing to talk about the whole system and how our solutions fit within that process, we gave room for others to coordinate with us and made the conversation less adversarial.

Now issues that were once considered controversial are now widely accepted and this document reflects that fact. There was a time when things like ending the IMD exclusion or prioritizing crisis response dollars were controversial. Today, we can all understand how failing the most severely ill impacts everyone in the system and how serving their needs makes everyone better off.

Question: For the past six years, TAC has been the organization that appeared to be most quoted in articles about the inappropriate incarceration of individuals with mental illnesses.  As you just mentioned, a billion media impressions! TAC studies about a lack of hospital beds, solitary confinement, violence and, specific issues, such as the IMD exclusion, are repeatedly quoted in the mainstream press. TAC often has been a voice in the wilderness. At times it has seemed that TAC alone has focused on the seriously mentally ill and criminalization of persons with mental illnesses. Why are those two issues important to TAC?

TAC’s focus on the criminalization of mental illness and the horrors of being incarcerated with a mental illness stems from our mission to serve those with the most severe mental illness. We didn’t set out to become experts on criminalization issues, but the reality is that is where those with severe mental illness are most likely to be. We had to focus on those issues if we were going to serve our priority population.

Our system incentivizes the criminalization of mental illness. It’s an old story – families watch their loved ones deteriorate and are told there’s nothing that can be done until they’re violent. And then, once their loved one is in crisis, law enforcement is who is sent to respond.

We set everyone up for tragedy and then act like it’s a surprise when something terrible happens.

Question: Do you believe the IMD exclusion will be eliminated during the new administration?

I truly do think it’s only a matter of when not if. The public and our policymakers now understand the consequences of failing to enforce parity in a tangible, visceral way. And that’s what the IMD exclusion is: codified discrimination and a clear-cut violation of the parity law. People are denied needed care for their illness simply because of what type of care they need. It’s not that they don’t need inpatient care, it’s simply that the federal government decided it would rather not pay for that expense. And now that we are in 2020, that sort of discrimination will not stand.

My personal experience with this administration also gives me confidence they understand the need for reform. During the Iowa primaries, the state was facing a devastating psychiatric bed loss crisis. A TAC report had ranked Iowa 50^th in bed availability and advocates like Leslie Carpenter were making the case for TAC-style solutions with all of the major campaigns. As a result, we had the opportunity to work closely with the Biden and Harris campaigns and saw first-hand how much time and attention they were devoting to these issues. In fact, Vice-President Harris ultimately adopted many of TAC’s priorities in her mental health platform.

Question: Tell us about your own personal connection to severe mental illnesses. How valuable is it for CEOs of mental health organizations to have some personal connection to this issue?

I recently wrote about my own experiences with being a TAC “help call.” I don’t know if it’s necessary for every CEO to have a personal experience with these illnesses. But I will say, those experiences helped shape my understanding of these issues and grounded me in the realities of what families go through to get their loved ones help.

How do you see the too-soon passing of our mutual friend and one of TAC’s founding board members, the inimitable DJ Jaffe, impacting the mental health conversation? 

No one will ever be able to accomplish what DJ Jaffe or Dr. Torrey have done. They were trailblazers and brought the plight of those with severe mental illness into our national consciousness at a time when far too many were willing to ignore what was happening. Dr. Torrey is a genius. I truly consider it a gift to have been able to learn from him and to learn about this work from him personally.

But it isn’t our job to try and replicate what they did. They did the hard work. Our job now is to build from their accomplishments and to keep making real mental illness reform a reality at all levels.

For example, TAC has now established a longstanding partnership in Ohio with Peg’s Foundation. As a result of that partnership, Ohio has become a model for the implementation of assisted outpatient treatment. Communities from across the country have come to Ohio to learn from practitioners and see AOT programs in bloom. The federal government adopted an AOT training program that built on Ohio’s model. Now communities across the country are implementing their own programs, some may never know how influenced they were by TAC or by Ohio.

That’s how we carry on the mission – by doing the hard work on the ground to prove out Dr. Torrey, DJ Jaffe and TAC’s arguments. TAC has secured almost $100M in AOT grants for communities across the country. As those programs succeed, they seed additional programs and create a network of AOT that advocates can use to make the case for reform in their own communities.