Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Gregg Graham says there’s a vital moment for any person experiencing a substance use disorder that can positively alter their trajectory. “It’s when their desire for change and access to care intersect,” he says. “If the first happens without the latter, you’ve lost an opportunity to save a life.” Graham is the founding partner of Behavioral Health Link, which operates the Georgia Crisis and Access Line on behalf of the Georgia Department of Behavioral Health and Developmental Disabilities and Beacon Health Options. It also answers Lifeline-988 calls in Georgia.
The fleeting convergence of will and opportunity Graham speaks of is personal to him. He witnessed the life-saving moment disintegrate before his eyes when his son, William Montgomery ‘Monty’ Graham, waited for hours at a nearby crisis center that did walk-in intakes. The hours ticked by, and Monty continued to wait. “He sat there all afternoon, waiting for someone to give him an initial screening and assessment,” says Graham. Finally, a staff member came out at 4:30 pm and told Monty he’d have to return the next day.
The staff member informed Monty they’d stopped doing intakes for the day. “Can you imagine that happening for medical emergencies?” asks Graham. “A doctor walking out and telling patients in the ER, ‘Sorry, we know you all are really sick, but we’re shot for today, so you’ll have to go somewhere else or come back tomorrow.’”
This mindset, points out Graham, is far too common in behavioral health. “Just because it’s not a medical crisis doesn’t mean the person isn’t experiencing an emergency,” he says. Like with other crises, services and supports have to be accessible and available when a person needs them. “It’s that simple.”
The lack of parity, he notes, is even more disparate for people with substance use disorders. His sentiment echoes those of Rebecca Boss, who told us in September that the emergency response for substance use disorders has long been segregated from mental health, the overall treatment system, and its development. She pointed out that the divergence, both in the medical and behavioral health fields, results from stigma and bias.
“Some still believe that because a person initially decided to use a substance, that an alcohol or opioid use disorder doesn’t equate to an organic brain disease,” she said. Boss is a senior consultant at the Technical Assistance Collaborative and the former head of Rhode Island’s Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals.
To change outcomes for those in behavioral health crises, Graham has dedicated his career to eliminating barriers and ensuring people can immediately connect to services. His son’s experience influenced how he developed Behavioral Health Link from the start. “My core objective was to answer people’s universal need to get into services at the moment they need them, or as close to that moment as possible,” he says.
The company started as a joint venture in 1995 between doctors and a large community hospital system in Georgia. In 2000, Graham approached the partnership and asked if he could buy the company. “I was running it for them,” he says. To his surprise, they said yes. “It seems they thought there was a greater risk than reward to keep it as opposed to selling it to me,” he laughs.
Today, Behavioral Health Link is known for its proprietary software that gives the Georgia Crisis and Access Line call takers real-time access to available crisis and detox beds throughout Georgia. The technological suite also provides phone, text, and chat intervention services, follow-up, and crisis counselors can make urgent and emergent appointments for callers. If needed, they can use GPS to dispatch mobile crisis teams.
In March, Debbie Atkins, director of Crisis Coordination at the Georgia Department of Behavioral Health and Developmental Disabilities, told us that the integrated technology has allowed GCAL to be far more than a hotline. Instead, it’s a comprehensive and coordinated crisis services hub that gives people “a single point of entry to the behavioral health and developmental disabilities crisis systems.”
GCAL-BHL’s care traffic control hub is an example to states across the nation that are looking to redesign their crisis systems in preparation for 988, the three-digit number for mental health, substance use, and suicidal crisis that must be live by July 16, 2022. Among them is the Greater Baltimore Regional Integrated Crisis System Partnership in Maryland. Partners include 17 hospitals, community groups, and the behavioral health authorities and local governments of Baltimore City, Baltimore County, Carroll County, and Howard County.
In February, Glenn E. Schneider shared that at GBRICS’ core is a call center modeled after GCAL. Schneider is the chief program officer for the Horizon Foundation, a health philanthropy in Howard County, Maryland. “The idea,” says Schneider, “is that care traffic control will triage all behavioral health crisis calls, determining next steps, if needed, such as dispatching mobile crisis or directing the person to a nearby walk-in clinic.”
Graham’s innovations are forward-thinking. That’s partly because of his decades in behavioral health, ranging from running a 95-bed substance use and psychiatric treatment facility to developing a crisis redesign for a large behavioral health system. His innovations have also been heavily influenced by navigating the crisis and criminal justice landscape with Monty.
As he watched his son grow up, he learned and lived the pitfalls in care for children, adolescents, and adults with behavioral or substance use challenges. “From the start,” says Graham, “the approach people took with Monty was punitive, not therapeutic or restorative.”
The family moved around quite a bit throughout much of the south, from South Carolina to North Carolina, Tennessee, and lastly, Georgia. Graham says, in retrospect, he thinks moving from place to place may have adversely impacted Monty. “Some people thrive with change,” he says, “but for Monty, it was disruptive.” At the time, working remotely wasn’t an option, and Graham and his family moved with each new career opportunity. “Our dilemma was trying to find a better professional situation with a growing family.”
When the family moved to Augusta, Monty had entered early adolescence and increasingly faced behavioral challenges. School administrators quickly responded with punishment. “He became more noncompliant,” says Graham. Unfortunately, he also began spending time with a group of boys who were similarly oppositional and acting out. “Over the years, many of the boys became involved in drugs and got in serious trouble or died.”
Monty was in middle school when his behavioral issues increased. “That’s when he began interfacing with the judicial system,” says Graham. He interacted with numerous systems—mental health, criminal justice, and school, but there was no coordination between them to develop shared goals. “It’s not that Monty shouldn’t have been held accountable, but they never took a whole-person integrated care approach to help him.”
According to Dr. Sharon Hoover, local school districts have historically defaulted to two avenues when a child is in crisis: discipline or the emergency department. She told us that taking students out of school for days at a time doesn’t address the root of the child’s crisis, and zero-tolerance policies are ineffective. They’re also discriminatory, with children of color more likely to be disciplined, noted Dr. Hoover, creating a school-to-prison pipeline.
In 2008, the American Psychological Association did an evidentiary review of zero-tolerance policies and found that school suspensions result in more disruption, not less. They predict higher future rates of misbehavior and suspensions among suspended students. “Students may not be aware that their behavior is a manifestation of an emotional or behavioral issue or trauma history,” said Dr. Hoover, “so that’s not something they’re likely to communicate to teachers or administrators.”
Monty’s probation officer’s primary tactic to keep him in line was fear. He simply repeated over and over again that he could send the middle schooler to jail. “There was no therapeutic aim,” says Graham. “He wanted to scare him straight.” The chronic threats of punishment from the assistant principal and probation officer quickly became meaningless.
Graham says he learned through Monty that a comprehensive behavioral health crisis hub is only one piece of the puzzle. To truly prevent people in crisis from justice system involvement, there must be strong collaborations and interconnections with first responders at every possible intersection. That’s why Behavioral Health Link provides mobile crisis services to divert people from jail and the emergency department and partners with Grady Health System on its 911-EMS upstream mobile crisis intervention—a diversion program that aims to deflect people in mental health crises from a typical EMS emergency response.
Last year, Megan Gleason, the metro Atlanta regional manager for Behavioral Health Link’s mobile crisis program, told us that partnering with law enforcement, fire, and EMS not only diverts people in crisis but also gives first responders “a better understanding of behavioral health crises,” de-escalation, and trauma-informed care.
Because the response to Monty’s behavior and substance use disorder was primarily punitive, Graham says his son often felt there was no hope of experiencing a different trajectory. The one moment that could have shifted his lens was the day he went to the crisis center and sat for five hours. “That was a missed opportunity,” says Graham. “Had Monty received care, it could have made all the difference.” Monty died from an opioid overdose in March 2006.
During the Covid pandemic, the predicted number of drug overdose deaths nationwide increased to more than 93,000, a 29% increase from 2019. “My family’s story isn’t unique,” says Graham. “This is happening to families all the time, 24 hours a day, all over the United States.”
As states build out their crisis system to prepare for 988, Graham hopes they incorporate a focus on substance use disorder crisis. “Communities must have a system of connection that people can reach out to 24 hours a day, at no cost, with minimal requirements,” he says, “so families and people in crisis can get the help they need at the moment they need it.”
