‘Boss Lady’ leaves with an attitude of gratitude

By Richard Asinof, ConvergenceRI

Exit interview with Rebecca ‘Becky’ Boss, as she departs as director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, after 15 years at the agency

Rebecca Boss, director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, publicly announced her decision to leave on Wednesday, Dec. 10, 2019, at the monthly meeting of the Governor’s Task Force on Overdose Prevention and Intervention. The news stunned many members.

In response, public comment was suspended and members shared their thoughts, praising the efforts of Boss, who had served as co-chair of the Task Force.

As Boss recounted in her exit interview with ConvergenceRI the following week on Monday, Dec. 16, 2019, at her agency offices, Jonathan Goyer, one of the state’s leading advocates in the recovery community, had asked, fondly: “Who am I going to argue with now?” adding, “I’m sure I’ll find someone else.”

Boss said she responded by saying: “I am absolutely certain of that, Jonathan.” She described her relationship with Goyer as being one with a healthy tension, one of mutual respect, recognizing the need to stay connected in an ongoing conversation.

Boss’s last day at the helm of the agency was on Friday, Jan. 3, 2020. She had served at the agency for 15 years, arriving in Rhode Island in 2004.

[On Dec. 20, 2019, Gov. Gina Raimondo moved quickly in announcing her choice to replace Boss: Kathyrn Power, the former Region One administrator for the Substance Abuse and Mental Health Services who has been serving as the chair of the Governor’s Council on Behavioral Health Council since September of 2019. Raimondo will submit Power’s name to the R.I. Senate for their advice and consent in the upcoming 2020 session.]

In her interview, Boss made it clear that it was her decision to leave and she had not been forced out. “This is an opportunity for me to look for a different path for myself. I think it is probably an opportunity for the department to be led in a different way,” she said. “Change can be good.”

When asked about her future plans, Boss laughed and said: “I am going to rest. I am taking time off to rest. I am going to Costa Rica, actually for a week.”

Quite honestly, Boss continued, “I have had opportunities. I have had offers made for rejoining the private sector and doing more on the ground, working with individuals directly. I’ve had offers and opportunities for consulting, working with other states to look at some of what they are going as well as some of the national perspective about what is going on.”

Boss added: “I have not decided what I want to do.

Decades of change
In self-deprecating fashion, Boss described herself as “kind of an old dinosaur,” looking at the rapid changes occurring both in the workforce and in health policy.

“I’ve had three jobs, post-college. Three places I’ve worked, post-college. And I’ve been post-college for a long time now,” she said. “That’s not so much

[what happens]

anymore. People change positions much more fluidly than they used to. I think that kind of longevity is not necessarily representative of the workforce now.”

The workforce has changed, Boss continued. “I think today that people adapt and they get new interests and they want to go to new places. Whereas my family was more: you stay in one place and you work your way up, and you take on new responsibilities, and that’s how you evolve in a position.”

In recounting her history at BHDDH, Boss said that she had come to Rhode Island in November of 2004, moving from direct service, from working in nonprofit organization that was helping people directly, with an ability to experience the impact she had on someone else’s life.

“The reason why I came to the state,” she explained, “was because I thought I would have an ability to have a broader impact for people by making policy and program decisions, opportunities that would serve more people.”

In looking back at her 15-year tenure at the agency, Boss felt that she and her team had been able to do that.

“We’ve increased opportunities for individuals to get into treatment, especially medicated assisted treatment; we’ve created centers of excellence; and we’ve created health homes in opioid treatment programs, so that individuals who have been neglected or not well received in the medical community, are getting their holistic health needs met, where they feel most comfortable.”

Boss continued: “We created Anchor ED, which was an opportunity to get people’s “lived” experiences into an ED when someone is in crisis, and recognized the value of peers.”

Also, she said, “We’ve done a lot in peer work, a lot in recovery center development, recovery housing development, certification of peers, all of those things have happened here.”

And those accomplishments, Boss added, were just in behavioral health care work. “When you look at the developmental disability world, we have increased the number of individuals with developmental disabilities that have gotten employed; we decreased the number individuals with developmental disabilities that are living in segregated settings and increased integration into the community.”

And, in the hospital division, Boss said: “We have brought on a leadership team, and we’ve done things like reduce overtime. And we got our certification and accreditation from the Joint Commission back, improving the hospital level of care.”

Are you going to write a book now? Convergence asked.

Boss responded with laughter: “Well, I put a couple of my publications in my resume as well,” adding, “We also started BH Link.”

Connectedness
Beyond the litany of her accomplishments during her tenure at BHDDH, Boss spoke at length about some of the underlying currents at play in the world of behavioral health, including the need to listen to the voices of patients, to meet individuals where they were, engaging in one-on-one conversations, and the need to engage around despair.

She also praised her team and her colleagues in Rhode Island. “I’m leaving with an attitude of gratitude,” she said. “I am grateful for the opportunity [which I’ve had]. I look forward to whatever the next chapter is – which at this point is unwritten.”

At the end of the interview, ConvergenceRI noticed the nameplate on her desk, which said: “Boss Lady.”

Are you taking the nameplate with you? Boss’s answer: “Yes.”

Here is the ConvergenceRI interview with Rebecca Boss, the outgoing director the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, after her tenure of 15 years at the agency.

ConvergenceRI: Do you feel like there has been this huge weight that’s been lifted from you?
BOSS: It’s beginning to lift. I think it is beginning to lift.

ConvergenceRI: How do you recognize that the weight has been lifted?
BOSS: I breathe. [laughter]

ConvergenceRI: Like a yoga exercise?
BOSS: Yes. I’m allowed to breathe.

ConvergenceRI: You are not getting calls at 6 a.m. from the Governor?
BOSS: I’m not, no. Well, it could be the time of the year as well. Because things slow down naturally at this time year as well, so maybe it’s a really good time to transition.

You start to realize, as things are coming up, that these are not going to be my issues to own. It’s going to be someone else’s issue. And, there is some kind of relief in that, to be honest. There are always issues.

ConvergenceRI: I have found in working in the news biz, there are always breaking news stories, there are always crises, there will always be people demanding attention, and you have to prioritize about what is important for you.
BOSS: When you consider the population that we serve through this department, there are always going to be crises that come up. There are always going to be issues, there are always going to be problems to solve. Recognizing that we’ve done a lot, but there’s always going to be more to do.

I look orward to contributing to those solutions form a different perspective.

ConvergenceRI: Looking at the trend of what is happening in Rhode Island, there seems to be – I wouldn’t call it a turnover but an evolution – a much more positive reframe. There are a number of people in the recovery community who are, in a sense, going to the next stage, if that’s the right phrase. Tom Coderre is in Boston, Jonathan Goyer is transitioning to a new role.

Is this just a natural evolution? Is it because of burnout with the job? Is it a need to reinvent oneself?
BOSS: I would agree with a natural evolution. I’m not sure I would agree with the burnout. I think it is a natural part of the workforce evolution now that people don’t stay in one place necessarily forever.

ConvergenceRI: With the launch of the campaign, “It’s OK not to be OK,” do you find it surprising that there is so much friction around issues of diversity, and the difficulty in accepting differences? Can you talk about what’s necessary to change the narrative?
BOSS: You missed my last Task Force meeting. We talked in that meeting around the issues of stigma, but I don’t like the word “stigma.”

Because I actually think it gives permission for people, it almost gives authority to the actions that are related to stigma, which, if we are honest about it, are fear, discrimination and bias.

It is difficult to recognize, in the year almost 2020, that we still have a hard time accepting individuals with substance use disorders or mental illness, or when it is expanded to developmental disabilities. We still struggle with being an inclusive society that is open to understanding each individual’s struggles. And maybe it goes a little bit to that area, the deaths of despair.

ConvergenceRI: Do you have a prescription about how to change the narrative?
BOSS: We start to change it by education. I think the broadcast is important by getting the word out there. Mental health and substance use disorders are real conditions. They are illnesses like any other. But that only takes you so far.

I think [we need to do] more with the opportunity that we have to talk to people one on one.

We were on a call this morning with folks from Canada about safe injection facilities.

They were discovering [the best ways] to integrate the safe injection facilities in the areas that they did. They learned their lesson that having large public meetings probably wasn’t the way to go. But having one-on-one conversations was maybe more operationally effective in getting the buy-in from the community.

I think that makes a lot of sense. Working through things more one-on-one, which is hard, because we disconnect in our despair; we tend to be a society that has closed ourselves off from other people and we don’t connect, one-on-one.

Having more discussions, more personal discussions, getting out there, and that’s one of the areas that I think we have an opportunity to get out into the community.

ConvergenceRI: Face-to-face conversations, and dialogue, I have found to be the most important part of convergence.
BOSS: Absolutely.

ConvergenceRI: People want to be able to participate [and to be heard]. It’s hard to talk back to a radio or a TV.
BOSS: I think, too, you can’t underestimate the importance of [the pubic face of] individuals in recovery. For so long, kept people in recovery were kind of anonymous.

Most negative perceptions of individuals with substance use disorders are driven by people’s interactions with individuals who are active in their disease.

That their disease is very active, and when they are coming into the emergency department or engaged with law enforcement or whatever, you are seeing people who are at peak of their disease.

But [that dynamic changes] when you see that an individual can actually recover, just like with any other disease, and see other individuals in recovery who publicly announce that they are in recovery and talk about the impact of the recovery on them.

We saw that with the Anchor ED when we started that. We heard a lot about people who were going in and out of the hospital, and overdosing, and coming back in. We heard a lot of frustration on the part of the medical staff about seeing the same faces over and over again, wondering, “Do these people ever get better?”

There was never that “hope” element. When we introduced peers who were in recovery into the emergency room, what was notable, beyond the fact that people started getting help, and getting [access to] recovery and treatment, was the impact it had on the medical staff, and the staff within the emergency departments themselves, as the culture began to change and shift a bit.

I think the next evolution will be as a result of that culture shift. Folks started to see recovery and real recovery in people, and hope, and opportunity. Whether or not a peer was present, you could see it.

I’m trying to remember the exact evaluation – but the number of individuals who came through with an overdose who got a referral or were connected to treatment, even if there was no peer present, increased.

ConvergenceRI: One of the problems voiced at Task Force meetings during public comments has been concern that low reimbursements from Medicaid for providers for mental health and behavioral services have become major barrier to accessing services. There is a Senate commission now studying the rates of reimbursements.

Can you talk about how you see the issue on rates of reimbursements for mental health and behavioral health services?
BOSS: The problems with rates are complex. I think the bottom line is: You get what you pay for. And, if you want a quality system, then you need to make sure that you are reimbursing for quality service.

Part of the problem is that, you have to do one before the other. And it’s hard to invest in a quality system that has been undermined throughout the years and isn’t necessarily there.

Something has to happen first. What that is, is going to be challenging for the next administration that comes in – or leadership of this department.

There are opportunities out there. I look at what’s known as CCBHC – certified community behavioral health centers. We applied for that. I’ve heard from state colleagues in other states that it’s been a game-changer. It offers an enhanced match of federal Medicaid funds, and if that opportunity is opened again, then it would help us to establish that quality system that people want to invest in.

But, you know, it is partly a workforce issue as well. So this is a complex issue.

Working in human services, I can tell you that when I first started out, with a bachelor’s degree, and I went to work at St. Mary’s Home for Children, and made about $13,000 a year.

ConvergenceRI: And that was considered a lot of money back then.
BOSS: Well, I thought it was a lot of money.

Social services [work] does not pay a lot. And, we have a new generation of workers that want to make more money. They have an expectation of better jobs and better money than what social services has been able to pay.

You see it in substance use treatment and mental health treatment. You see it in the care of individuals with developmental disabilities in our community. It’s tough work.

Getting out there, and working with people, and being a case manager, or being a direct support professional or being a clinician, it’s pretty challenging. It’s not like you can hang up your work belt at the end of the day and not think about anything.

These are things that people who enter in the field have caring hearts and what to do good stuff.

ConvergenceRI: Is there a double edge to this issue of workforce? A lot of effort, it seems, is to push the direct services onto community health teams or outreach workers, who are not necessarily getting paid at the same rate as “professionals” and there is a disparity. As much we are attempting to create a continuum of care, it often seems to be based on outreach being done by lower wage individuals.
BOSS: It’s a really changing environment for the care of individuals in the community. When I look at the foundation of this department, you can really see that it [came from] de-institutionalization. The Ladd School closed; we moved individuals into the community, but you needed to have a system of care for those individuals to move into.

This department is the overseer of those services in the community. It is an evolution; it’s changed. We now have a number of individuals with developmental disabilities, with behavioral health care conditions, living in the community, receiving direct care.

And it has evolved over time. We changed our thinking to reflect workforce availability, but also about what the needs of the individuals really are.

Do they need [a certain] level of clinical skill In order to achieve whatever their goals are in the community? Those are things that we need to figure out. And we have, to a certain extent.

And, where do peers fit into a continuum of care. Where do community health teams and the community health workers fit, how are they different, and what are the skills they bring?

It’s a dynamic, and I don’t know if we are ever going to have a solid continuum of care.

ConvergenceRI: What are the challenges for the future?
BOSS: I think there is a value in looking at and defining what those roles are, and when individuals interact with another person in need, what are the strengths that they bring.

Peers offer hope and inspiration; clinicians can be trained in evidence-based practices, such as motivational interviewing. Knowing how to ask the questions that gets the person to make that decision that they want to change for themselves.

They represent two different ways to come at an issue. I think that they can strengthen each other.

If I have a skilled clinician who is helping me identifying the motivation that I want change in my life, and to see someone else that has done it, it gives me a glimmer of hope that there is a possibility, if I make that decision, look what I may be able to achieve.

There is room for both; both have very different skill sets.

Editor’s Note: Following the interview, Boss sent along an addendum to the conversation. Here it is:

“Since our discussion, I have been contemplating your focus on the deaths and diseases of despair. You asked for parting words of wisdom – and this came to me.

“Despair is defined as the complete loss or absence of hope. The opposite of despair is hope. The opposite of disease is health or wellness. Your message and focus on prevention is the right one. We, as a society, need to figure out how we can resurrect hope.

“BHDDH does its part in the prevention world, in communities and schools, specifically giving tools to youth to be more resilient in confronting challenges without resorting to substance use. We use our partners, the community prevention coalitions, to strengthen youth and their families, but also to outreach to other vulnerable populations. But the more primary focus of BHDDH has been in treatment and recovery aspects of behavioral health. Our emphasis has been on providing hope of wellness for those who have the disease of mental illness or substance use disorder.

“There is strength in focusing on the positive of what can be as opposed to the negative of how bad things are. We try to promote the hope of recovery and wellness in all that we do, to let people know that they do not need to suffer in silence. Peers are an important aspect of our work because they are the personification of that hope and serve as beacons of light to those still struggling in darkness. Our fight is for a system that is equitable and recognizes the many components of care needed to support those in despair.”

Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.

Here is a link to the full story:  http://newsletter.convergenceri.com/stories/boss-lady-leaves-with-an-attitude-of-gratitude,5446