When universal education activist and Nobel Prize laureate Malala Yousafzai addressed the United Nations in 2013, she pointed out that ìwe cannot all succeed when half of us are held back.î Her words resonated with womenís rights advocates as she boldly confronted an inequity that still needs to be addressed today, especially in the behavioral health field. Success is a collective, not a zero sum game, and her words invite everyone to participate in this cooperative enterprise of equality.
The relative shortage of female executive leadership in the field presents an urgent challenge to the behavioral health community. Technological, financial, legislative, and other factors are advancing and furthering the industry, so it is critical that gender equality advances along as well. As a group representing half of the targeted treatment population, women should be strategically involved at the highest level in terms of creating new structures, modalities, and paradigms for how treatment is defined, delivered, regulated, and compensated. Women have a unique perspective that is necessary for steering the behavioral health community through these upcoming waves of change and transforming present challenges into opportunities for growth. The statistics on executive leadership in the behavioral health field reveal a major deficit in terms of roles held by women. For example, the National Council for Behavioral Health (NCBH) is comprised of 2,200 member organizations and women hold the CEO position at only eight hundred of them, despite making up a significant 75 percent of the middle management workforce (Rosenberg, 2014). Every one of the NCBH’s large corporation partners and 67 percent of their small- to mid-size corporation partners have men as CEOs. Their board is comprised of twenty-five members, yet only seven are women (Rosenberg, 2014).
Beyond Behavioral Health
This shortage of female leadership is not unique to the behavioral health field. According to business advisor Grant Thornton, the percentage of women in senior executive leadership positions has remained stagnant at 20 percent worldwide since 2004 (Williams, 2014). Less than 10 percent of businesses employ a woman as CEO, and statistics show that a majority of female employees are hired to work in finance or human resources (Williams, 2014). While it is true that women own 38 percent of businesses in the United States (American Express Open, 2016), Northwestern University professor and psychologist Alice Eagly, PhD, points out that a large number of these women are running their own small businesses as opposed to holding senior management positions in Fortune 500 companies (APA, 2006). This deficit is neither the result of lesser qualifications nor a lack of advanced education.
According to the State Street Center for Applied Research, women have earned 37 percent of all MBA degrees, yet hold only 4.6 percent of the S&P 500 CEO positions (Mitchem & McKenna, 2015). This is contradictory to evidence that woman-majority executive committees result in better financial performance, a “41 percent better return on equity and 56 percent better in terms of overall earnings before interest and taxes” (Mitchem & McKenna, 2015). Ongoing research suggests that the underrepresentation of women in senior management is not the result of any evidence-based conclusion, but instead the result of gender biases, system dynamics, organizational hierarchy, communal and agentic behavior dissonance, and other nonsensical rationales.
Adult learning specialists like Robert Kegan and Lisa Laskow Lahey work to look beyond gender gap statistics to the broader societal and organizational obstacles that prevent companies from reaching their full potential. They examine how, in the course of a workday, time and energy is often wasted when employees have to camouflage their weaknesses and play office politics to conceal or justify their inadequacies. In an attempt to correct for this waste of energy, Kegan and Lahey identified new training and development paradigms that may be more appropriate for the modern workplace. These new methods include shifting away from external leadership and development training programs that may be ineffective, costly, and limited to a select number of employees with a mind-set “so valuing the importance of developing people’s capabilities that you design a culture that itself immersively sweeps every member of the organization into an ongoing developmental journey in the course of working every day” (Kegan & Lahey, 2016). They point out that conventional incentives for hard work and promotion have changed as well: “Now we’re seeing the pursuit of new incomes: personal satisfaction, meaningfulness, and happiness” (Kegan & Lahey, 2016).
The extent to which employers can recognize that men and women both need to experience these new incomes of personal satisfaction, meaningfulness, and happiness will determine how equitably they can embark together on a path that allows for mutual development, success, fulfillment, and profitability. Though for years employers have allocated sizeable resources to foster diversity and inclusiveness during recruitment, “still in 2015, the workplace shows a slow progression toward a more diverse workforce, particularly in the higher ranks of management and leadership” (Mitchem & McKenna, 2015).
Because the behavioral health sector is “one of the hottest spaces in health care now,” it is especially important for women to be taken seriously in the workplace (Miller, 2015). PricewaterhouseCoopers reported a 24 percent increase in deal volume in the behavioral health space between 2013 and 2014, with the upward trend continuing throughout 2015 (Miller, 2015). A number of factors account for this growth. For example, legislation such as the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandate that health plans must cover behavioral health services at parity with medical/surgical treatment, which has made treatment centers with stable, consistent revenue streams newly attractive acquisition targets. Medication-assisted treatment (MAT) has become even more appealing to investors than the previously favored high-end residential centers with private pay because of MAT’s lower annual costs for insurers and their “more uniform clinical delivery process” (Miller, 2015). In addition, an increasing number of private equity firms are jumping into the addiction market and creating healthy competition, thus providing behavioral health groups with more options as far as infrastructure, portfolio acquisitions, or new ventures. Of note, however, is that these firms are voicing a significant amount of concern about the lack of solid management in the organizations they are interested in purchasing, likely related to the overwhelming absence of women in upper level executive positions.
How Women Can Make a Difference
The health care field is in a vulnerable, changing state right now and is statistically ready to accept more women into the ranks. Figures from the Bureau of Labor Statistics (2010–2011) show that the current workforce of the mental health and addiction treatment field is middle-aged, with new workers often entering the field later in life as a second career (SAMHSA, 2013). In order to right this imbalance, the Substance Abuse and Mental Health Services Administration (SAMHSA) states in its 2013 “Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues” that it has become essential to recruit students into the field “particularly from underrepresented populations” (SAMHSA, 2013). The health care field needs more female talent in order to sustain the innovation, viability, and quality of its services, as well as its financial success.
Women have the potential to revolutionize the field in a number of different areas. For example, technology is quickly becoming an integral part of the recovery experience. Mobile apps on Android and iPhone smartphones include a wide range of resources for individuals in recovery: abstinence tracking systems, relapse trigger alerts, daily meditations, sobriety calculators, audio recordings of speakers at AA meetings and NA conventions, inspirational quotes, mindfulness meditation aids, social networking platforms for the global recovery community, and even help for travelers to find the nearest AA or NA meeting. Some organizations are creating apps that become a part of their personalized continuing care, enhancing their unique program modalities while promoting their brand. Others are designing apps that guide patients through recovery to prevent relapse. Women with technological and designing experience can offer unique perspectives in terms of shaping the strategic, programmatic, and marketing decisions about how such technological innovations can assist with the integration of behavioral health care into social networks.
Women also have a lot to offer in the medical research realm. Advances in the understanding of neurobiology and brain disease along with pharmacological developments have greatly increased the number of options available for MAT and enhancements to traditional approaches to recovery. Women have the opportunity to shift conventional, institutional thinking about addiction while building partnerships with the medical community that encourage collaboration and the sharing of ideas.
In a recent survey designed to measure if and how women in the behavioral health profession are moving forward, fifty-four female participants answered questions focused on the following:
• What factors contribute most to your career success?
• What factors are holding you back?
• What do you need to make better progress?
The participants included women primarily from California, with a handful from New York, Pennsylvania, Utah, Idaho, Arizona, Michigan, Nevada, and Colorado, almost 80 percent of whom were either in management or at the executive level.
The survey results suggest that respondents overwhelmingly attribute their success to four factors: relationships, professional expertise and experience, passion for their work, and care for their clients. Building relationships and networking outside their organization has given these women opportunities to share knowledge and strategies, as well as to lend and garner support.
Within their organization, the participants feel that a solid team is crucial to empowerment, efficiency, organization, and support. Expertise, experience, training, tools, and resources are also seen as vital to success, as they enable top performance, fuel self-confidence and professionalism, and shape the skills required to practice at the highest levels. Years of education supported by ongoing training make long-term growth and the ability to initiate new ventures possible. Other important contributors to success are support systems, including supervisors and executives who give feedback and guidance, as well as the innovative and courageous spirit it takes to tackle new projects and concretize a long-range vision.
However, even though many of these women are achieving notable success in the health care field, a large number of them reported that satisfaction is only possible through self-employment or holding the position of CEO and having the freedom to create their own opportunities. These responses suggest that there is work to be done within organizational culture to make employees’ experiences at a company more satisfying, as Kegan and Lahey explored (2016). Partnering with employees in a safe and supportive environment to identify where they need more training and development, or to help them find more meaning and satisfaction in their positions, might help behavioral health organizations retain professionals who are more satisfied and productive, and consequently, able to contribute more to the company’s success. Since it may take a while for the behavioral health industry to transition to the employee training and development paradigm that Kegan and Lahey, among others, advocate, women might benefit in the meantime from learning new strategies and techniques that help them better navigate current organizational obstacles in order to stay with and benefit from working at their companies for a greater amount of their career.
When asked about the factors holding them back from achieving satisfaction in their career, the women largely reported the following:
• Dominance of men in senior management (or as owners) where women are sometimes marginalized
• No room for growth or inability to advance because titles and roles are not clearly defined, or leadership does not share control of the organization
• Lack of advanced education and training to take on new risks and responsibilities
• Lack of strategic mentoring and coaching to advance within or beyond organizations
Women who are not in senior executive positions in their organizations often experience fallout from gender disparity in leadership. Gender hierarchy studies have shown that men tend to dominate the C-Suite, and in the behavioral health field in particular, these men often do not even have the specialized training that women within their organizations have. What men do tend to have, however, are financial resources or relationships with financial institutions. Therefore, while male senior executives focus on financial issues, especially in the current hot venture capital market, women are tasked with running the organization, often without the senior executive support, vision, and leadership they need to be effective. Furthermore, not enough women are given a voice in the senior management decisions that affect both day-to-day management and long-term planning.
Other women report feeling stuck in their current positions because the path to a more satisfying role is either not clear or not available to them. This frustration does not occur as frequently in large organizations where there may be more opportunities or in start-up environments where there is often more fluidity. To navigate around the obstacles blocking their advancement, these women express a desire for more education, training, and coaching. They want to be savvier about how and where to move on while developing strategies that will give them more control and options.
Because they recognize the increasing role that the financial industry is playing in behavioral health today and how business models are changing, many women identify the need to develop an understanding of venture capital and business development while nurturing entrepreneurial instincts. They want to be able to negotiate more effectively, learn how to strategize, and/or make executive decisions. While they credit relationships for their professional success, they still place a great deal of importance on the need to network more, to develop more strategic connections, and to gain access to greater opportunities. When asked about their long-term (i.e., two- to five-year) goals, the majority of women put education and training at the top of their list—from BA to PhD as well as specialized training in fields such as organizational development.
A common theme throughout the survey was “a need to know what I do not know,” suggesting that there are not only gaps in knowledge, but also insecurities about taking on risks without having specialized training in areas that traditional degree programs may not have covered, expertise such as raising capital, mergers and acquisitions, or even billing practices and insurance. Developing leadership skills is also high on the list as a way to facilitate advancement, growth, and entrepreneurial development.
Many women have advanced theoretical skills, but have not learned how to apply them effectively in real-time environments or need help knowing how to adapt their skills to work more productively in an industry whose priorities and infrastructure are shifting rapidly. While the majority of participants believe that new skills and training maintain relevancy, sustain high levels of professionalism, and improve their chances for promotion, others emphasize that knowing how to apply skills and training is even more important. Operating and managing a business is just one of many subjects that are often not taught in an academic environment or certification program but need to be mastered.
Companies often value deliverables more than skill competency for promotion, so skills must be proven by measurable actions and initiatives. When asked about participating in programs that could improve their day-to-day experience, more than half respond favorably. One participant pointed out that executives are often more concerned with the macro, whereas the micro is where an organization lives in the day-to-day; another respondent felt that women need a program that teaches macro-focused thinking to help them compete in the male-dominated entrepreneurial space.
Coaching, as well as building self-awareness and new skills, are attractive solutions to career stagnation for many women because of the focus on their particular roadblocks to promotion. Once equipped and empowered, a frequent response for those coached is to coach others. The byproduct of advancement is clear: the desire to continue growing and learning, strategizing next steps, and mentoring and advancing staff as well as others. Success and satisfaction tend to trickle down. The most desired topics for one-on-one mentoring and coaching are entrepreneurial and strategic decision-making skills, suggesting that women who are thinking about next steps for starting or growing a business or moving up in an organization prefer to focus on the macro level.
Though statistically women behavioral health professionals are being excluded from senior management positions, the women from this sample survey are nonetheless ambitiously striving to better their services, grow in their expertise, build their businesses, open new businesses, and continue to get the education and training they need to stay on top of the latest practices and trends. They express a desire to become more involved in state policy, to oversee competency training for frontline techs, to educate and modernize the industry, to gain equity in their companies, and participate in strategic merger and acquisition decisions, along with a multiplicity of other initiatives. In other words, they remain undaunted in their quest to improve and grow the field while making themselves, their clients, and their organization or practice successful. They display the leadership, drive, and vision necessary to forge the partnerships and set the standards as new alliances are forged out of private equity and technology innovation.
It is also important to these women to have a strong moral compass, helping to keep their values and ethics at the forefront of their business. These are all solid ingredients for a management dream team, the kind of collaborative and eminently qualified executives with whom private equity firms are eager to do business but are often unable to find.
In short, the underrepresentation of women in leadership positions within behavioral health organizations can be diminished with programs that support and empower women. Women’s presence on executive teams and in boardrooms is a critical source of knowledge and experience needed to confront today’s challenges. Their leadership is crucial to help guide the industry’s choices about how clients are treated, how businesses are structured and operated to comply with legislative policy, how organizations remain healthy fiscally, and how the economical delivery of quality services can remain sustainable. Mentoring, coaching, and other immersive training courses, in partnership with organizations, would help women build on what they have learned in degree and certificate programs and what they are good at (e.g., building teams, networking, operational excellence, delivering quality services) while adding to their skill sets the entrepreneurial, management, and financial wherewithal to take their organizations and practices into the future. Their long-term goals are also in alignment with where the industry is headed; with innovation and funding heading the agenda of the top behavioral health organizations today, training and revenue are priorities. c
About the Authors
Andrea G. Barthwell, MD, DFASAM, is an internationally renowned physician who has been a pioneer in the field of addiction medicine within the American Addiction Society of Medicine (ASAM) and a contributor to the field of alcoholism and addiction treatment. Dr. Barthwell currently serves as the CMO of Treatment Management Behavioral Health and the founder and CEO of the Two Dreams facilities.
Cherlyne Short Majors, PhD, has held senior executive level positions for numerous internationally recognized behavioral health care treatment providers including the Betty Ford Center, Cirque Lodge, and most recently Constellation Behavioral Health. Dr. Majors’s experience in the fields of child/maternal health and behavioral health spans thirty years in a variety of settings, including treatment of SUDs in children and adults. Dr. Majors is a founder of The Women’s CEO Global Alliance in Behavioral Health and WILLOW Institute, which provides leadership training for emerging women leaders in behavioral health.
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American Psychological Association (APA). (2006). When the boss is a woman. Retrieved from http://www.apa.org/research/action/boss.aspx
Kegan, R., & Lahey, L. (2016). An everyone culture: becoming a deliberately developmental organization. Stanford Social Innovation Review. Reprinted by permission of Harvard Business Review Press. Excerpted and adapted from An everyone culture: becoming a deliberately developmental organization. Retrieved from https://ssir.org/articles/entry/an_everyone_
Miller, J. (2015). Three trends in behavioral health acquisitions. Behavioral Healthcare Executive. Retrieved from https://www.behavioral.net/article/3-trends-behavioral-health-acquisitions
Mitchem, K., & McKenna, K. (2015). Gender intelligence: a compendium. Bridging the gap with research, science, and relevance. Retrieved from http://www.statestreet.com/content/dam/statestreet/documents/Articles/CAR/StateStreet_Gender%20Intelligence.pdf
Rosenberg, L. (2014). Women and leadership; is leaning in enough? Retrieved from https://www.thenationalcouncil.org/lindas-corner-office/2014/03/is-leaning-in-enough/
Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Report to Congress on the nation’s substance abuse and mental health workforce issues. Retrieved from https://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf
Williams, R. (2014). Why women may be better leaders than men today. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/wired-success/201404/why-women-may-be-better-leaders-
Yousefzai, M. (2013). Malala Yousafzai’s speech at the youth Takeover of the United Nations. Retrieved from http://www.un.org/News/dh/infocus/malala_speach.pdf
Cherlyne Short Majors, PhD
Being the only woman at the executive conference table has been more the rule than the exception in my thirty-year career in behavioral health. Even after earning a place at that table, deep-seated gender inequities and discriminatory attitudes and practices have often turned the executive suite into a random game of musical chairs in which male-favored power dynamics and structures controlled how, when, and for whom the music stopped.
Like many women, it was critical for me to begin working according to my own convictions and passions, developing my strengths and talents, and collaborating with like-minded colleagues. Currently, this path to personal and professional empowerment for women aspiring to be in the C-Suite is still fraught with many obstacles.
As in every field today, political, economic, and technological disruptions are both challenging and revolutionizing behavioral health. We need 100 percent of our professionals, men and women, engaged in, committed to, and rewarded by efforts to deliver the most equitable and effective treatment solutions possible for those who are struggling. We need training to make this happen as well as advocacy to build awareness of where change needs to occur and how it can be supported at an institutional and organizational level.
Women in our field want to be leaders, and they have the talent and the drive. By creating opportunities for learning and collaboration and offering mentorship, we can help them aspire to and assume power-sharing roles that will make the field of behavioral health thrive.