Gary Belkin is the Director of the Billion Minds Project. Formerly Deputy Health Commissioner for New York City, he founded the Billion Minds Institute to bring policy and practical attention and change for taking on the “social climate” crisis of the climate crisis. Dr. Belkin has implemented innovative approaches to mental health, especially those that integrate with and amplify other social and community capabilities, policies, and goals at scale.
Gary Belkin spoke with Ashley Hopkinson on September 30, 2024. Click here to read the full interview with insights highlighted.
Ashley Hopkinson: Could you introduce yourself, and tell me about your journey that brought you to the work that you do?
Gary Belkin: I’m a psychiatrist. I was attracted to psychiatry because of how connected I thought it was to broader social issues, but through a public health lens. But when I became a psychiatrist, I realized that it actually had evolved to be quite distant from all those things—much more illness and biologically based. So I’ve been progressively doing different things to shift that and have held mostly public health and public policy roles. I ran large care systems. I was medical director for the New York City Health and Hospitals Corporation: twelve hospital systems and their behavioral health services. I was the Deputy Health Commissioner, which is also considered the New York City Mental Health Commissioner, for a number of years.
All of that was in parallel to working in sub-Saharan Africa and the Caribbean, where I relearned most of what I understood community mental health and public mental health to be, which is actually working cross-sectorally and ground up, with community members as co-creating partners and aim-setters.
Mental health and wellbeing and psychological strengthening become tools in their hands to pursue other aims, in addition to relieving distress and suffering, but also integral to other social purposes, problem solving, and fueling and bolstering other local and community civic priorities.
Ashley Hopkinson: Have you found that collaboration and partnerships have helped you move the work forward?
Gary Belkin: Yes. A key thing is to not start with mental health, but actually to embed, engage, and align with other institutions and efforts to meet other goals and then see where mental health fits in. That’s a new personal habit, but I also think it’s a new disciplinary habit of various mental health disciplines and how they’re operationalized, how their knowledge bases that fuel them are designed, how their business model works. So I got more concrete about that.
When I was in city government, I would meet with the heads of other city agencies: department of education, probation, homeless services, you name it. And I wouldn’t say, we’ve got some mental health ideas to sell you. Rather, the questions I would ask were, what’s hard for them? What goals have been difficult for them to achieve? What are their priorities? And within three minutes, we got to some kind of mental health or emotional wellbeing issue that was a big part of the root cause of what made those problems seemingly intractable. That’s where it began.
It was really approaching mental health as an asset to other purposes, not just intellectually but actually operationally and as more of a means to other ends than just an end in itself. Which is, I think, how most mental health assistance policies tend to work—let’s reduce depression scores, let’s give a treatment to an illness—all of which are important things, but they should be instrumental to other purposes, not just because that’s a good thing, but it will design them better by being accountable to and customized within these other purposes and civic spaces and co-owners.
Ashley Hopkinson: So mental health will naturally come up in conversations about barriers to getting things done, and then it’s a more organic part of the process.
Gary Belkin: Right, and more owned, and smarter. Whenever I’ve done this sort of process, it’s always better designed when it’s accountable to an added objective, and also because most of the work can be done in these other systems. For example, when we talk with officials at the Department of Education, [if] what’s worrying them is low graduation rates, then disruption in learning due to kids having mental health histories is a big part of that, [as is] managing the school environment, [such as whether] the school is a place that promotes mental health in terms of interpersonal social skills and managing conflict and compromise.
When we brought to them an effort to scale social-emotional learning skills for teachers, for example, it got redesigned. They know best how to reach kids and therefore how these formats need to change. There’s a model for reducing youth gang violence and gun violence called Cure Violence, which uses formerly incarcerated folks in communities to be street mediators with youth to try to interrupt retribution gun violence. And we train them in a very widely used counseling method by clinicians called motivational interviewing. We put that skillset closer to the ground—much closer to a whole set of problems that they are theoretically connected to but operationally almost never connected to. And in the process, the skillset was customized and readapted. They changed its language and its various protocols to fit that context because they’re experts of that context.
It’s a marvelous process for [delivering] what become very stale and conventionalized evidence-based strategies, whether it’s treatment or prevention or promotion of mental health. This approach really brings them to life, a whole new vitality and relevance, and a broader range of purposes.
Ashley Hopkinson: I remember when I was an education reporter and social-emotional learning became more centered. Different school districts approached it in their own unique ways, tailored to what would work for their schools. That sense of ownership really helps.
Gary Belkin: It’s critical. For example, we did another effort where we trained a peer counselor program, and the peer partner was trained in various counseling skills—asking about suicide, all sorts of very serious stuff. The 15-year-olds that they were partnered with would talk to them about this stuff that they would never talk about with a psychiatrist. It right-sizes the points of contact that have skills to meet those who most need those contacts, while using the specialist folks and skillsets that we have as backup and coaches for those front lines. Right now, it’s all the opposite.
When we think about population wellbeing, there are a lot of macro policies that are critical to that. Income security and job security and equity and political participation and just certain basic material conditions are critical. But what’s also critical, at a micro level, are these psychosocial competencies to navigate all sorts of adversity, challenges, and harms. And we don’t put those in the water. We isolate them and let mental health professionals hoard them rather than disperse them. But there’s a lot of evidence that most of the things people come to mental health clinicians for can be adapted and packaged for use by pretty much anyone.
Ashley Hopkinson: What do you think leaders and decision makers can do to advance this conversation? What have you found to be successful?
Gary Belkin: Speak to these other urgencies. It’s a different way. For example, I was just recently in a conversation with an international group of folks, [including] some big global organizations, working on early child development and trying to get it into various public policies. Because if we’re going to make any psychosocial or wellbeing investment, it’s in healthy early childhood attachment and non-traumatized life experiences. But it is hard to make the case across many sectors that the one thing they should mostly worry about is early childhood. What we can do is make the argument—and I’ve seen this work—of asking them what is hardest for them to do and what is their priority, and then show how this piece is a critical backbone to it. But to do that is a different kind of operational political practice task that needs to be intentional. The place to go is not necessarily to ask mental health systems how to do it but to ask key other leaders.
Mayors are critical in introducing the multi-solving potential of psychological-wellbeing sciences and tools and methods. There are multi-impact entry points where this can come through politically through governments and operationally in parts of civil society, where the message is not trying to sell mental health stuff but to have lots of others feel like they are buying higher graduation rates, less community violence, safer neighborhoods, and on down the line. That’s a very different dynamic. It sounds like a nuance, but it’s actually a very different dynamic and way of working and of packaging the knowledge and of acculturating the work.
Ashley Hopkinson: Can you take me back to the founding of the Billion Minds Institute? What was its purpose, and how have you seen that shift throughout the time that you’ve been a part of it?
Gary Belkin: At some point I was personally feeling like if I was not working on climate change, I was wasting my time. Maybe I was getting older. I had more children that I loved in the world. So I was trying to think, what can I contribute to that? Other than get arrested, which I did with the Extinction Rebellion, a little civil disobedience, which was immediately gratifying, but not, I thought, a long-term strategy, at least for my personal impact. A lot of the attention in climate change policy is around mitigation—reducing fossil fuel emissions, et cetera. But there was the realization, which I think most of our politicians are still not honest and forthcoming about publicly, that so much damage is already locked in. I mean, we could shut down fossil fuels today, and there is just a lot of suffering ahead of us.
So climate adaptation is urgent and is finally getting more attention as a global investment and priority. That eventually falls on communities to do the adapting, to problem solve together, to depend on each other together. I mean, the hurricanes we just saw over the last couple of days in North Carolina, it falls on people to make sure [everyone] has food and can get from point A to point B and is safe. All these transitions increasingly rely on civil society, and civil society is struggling. So the notion of community resilience had real, tangible, operational [potential].
So I thought, okay, that’s what I could bring to the table. And I brought the same approach. I got to know fairly quickly some of the key players and partners at the UN Climate Network, the UNFCCC, which sponsors and implements the global agreements on climate change, and what they call the High-Level Champions team, which mobilizes and works with civil society, and a campaign they were driving called the Race to Resilience, which is a massive effort to mobilize local capacity-building for climate adaptation for the 4 billion people most affected on the planet. And I thought, there is a channel, a distribution network, and probably eager users of incorporating this whole psychological resilience and wellbeing piece. And that proved to be the case.
Again, same strategy. Talk to folks who work across climate finance. What’s the hardest for you? That [raised] a question: can we financially measure psychological loss and damage? Loss and damage funding is growing on the global agenda, as are other forms of climate-adaptation finance. Can we calculate the value and what should be invested for that? Absolutely yes. So that became an initiative. Talk to Slum Dwellers International. They’re in 20 countries, working in informal settlements. What’s hard for you in your climate adaptation work? They mentioned that youth are their backbone of action on the ground, and they are hurting. They’re increasingly depressed, suicidal, substance using. Can we, in the way we organize them, [train them] to be peer leaders of emotional support networks for youth? Absolutely. We know how to do that.
All of these conversations informed a strategic report that we did for the UNFCCC audience and partners. But mostly it led to about a dozen of these early adopter efforts, which now involve clusters that add up to about 50 or 60 large global-reach and local NGO partners. These are the tipping point of what climate resilience could look like across sectors, across contexts, across geographies. We’re showing through them that psychological resilience can be embedded within already existing forms growing climate resilience capacity. So that’s what I’ve been up to.
Ashley Hopkinson: I live in New Orleans, climate adaptation conversations are really palpable here. After the first hurricane I went through, I really started to understand what mutual aid organizations do in terms of support on the ground.
Gary Belkin: Yeah. I learned tons from an effort after Hurricane Katrina that I got to know. I went there a couple weeks after it hit, for another reason, an effort to build a peer-to-peer network supporting the New Orleans Police Department. Officers were committing suicide at a really alarming rate. I got to know about an effort that LSU did, in a partnership with community organizations, where they took a model that is used in primary care practices for training non-mental health clinicians to pick up a lot of the tasks of depression care, screening, followup, and a basic kind of counseling. Basically, they took that model and they put it on the street. So instead of it being a social worker in a primary care office, it was a community resident knocking on their neighbor’s door, but with the healthcare system in the background to support them, coach them, and back them up as care partners to their neighbors.
It seemed like an essential idea for every community to have, and so doable. They show that the parts of the systems can assume these different roles. And I’d been seeing this even years before, all over the Global South. This is where the innovation about this whole notion is [happening]. It’s often referred to as task-sharing, where the tasks of mental health work can be widely distributed, whether it’s at the very serious deep treatment end, to prevention, promotion, wellbeing and psychological strengthening. Many if not most of those kinds of evidence-based approaches for that whole spectrum of work can be done by laypeople, especially if they’re backed up. S\o when I had my role in city government overseeing mental health, my question was—we know these models work, we know how to do them, with off the shelf manuals. How can local governments be a catalytic accelerator of those approaches becoming the new normal? That was the task I set for us. And I think we made a lot of progress.
I also learned that there are real political headwinds to that. It’s a real issue at a global level. If you take wellbeing seriously, and especially if you take it seriously in this very participatory way, you immediately face issues of all sorts of structural inequities and the interests that sustain those inequities. Any kind of community empowerment gets pushback. In this case, we got it from the more established mental health system. Even though the folks who worked in our projects loved it, others that weren’t involved felt threatened by it. To me, it gave more work and roles to everybody. There will never be enough of them. But these kinds of pushbacks really are there.
To talk about a caring economy, to talk about a wellbeing-based purpose of governance—that rubs against a lot of interests and a lot of political muscle. I ran into that and I learned a lot because of that.
Ashley Hopkinson: That has been consistent across every interview that I’ve had—this question of whether our systems are set up to operate in new or innovative ways.
Gary Belkin: Which underscores the [importance] of starting with the needs of these other systems and meeting those other needs through these methods, because then you just get more allies and buy-in rather than being alone making the argument that wellbeing is important.
We were still semi-early. We had put things a lot in place very quickly—54 initiatives at a pace of $250 million a year. The mayor at the time was a bit more resistant to this, which I think was the problem. [You have] to be super transparent about where you’re at and where you’re going, and involve not just the folks that you’re working with and that want what you have, but also these other interests. Keep them abreast.
We should have had quarterly briefings for city council members. After we set up these programs, we were about to shift to an intended transition of our work to really intensify them in five city council districts, with town halls in them, led by the city council members and ask—how do you want this stuff to work for you? What should this accomplish here to show its value? And we just didn’t get to that, unfortunately. And our mayor at the time, to be straightforward about it, paused at some of this pushback: why are you worrying about all these handholding community things when there’s still noisy homeless people on the street? As if it’s a zero-sum game, or they’re not interrelated. So he caved around that just as we were at a turning point, causing a lot of pullback. He wanted to run for president and didn’t want noise. And that really weakened it a lot. There’s still a lot of the infrastructure we built left behind, but it really set things back. More lessons learned.
Ashley Hopkinson: What teachable lessons or insights could be taken from your work that someone who’s trying to implement wellbeing initiatives can learn from?
Gary Belkin: I mentioned transparency, but I mean that in a couple of ways. One is always being transparent about the vision, because to do what I described involves mixes of partners that haven’t usually worked together.
I mentioned Slum Dwellers International. They’ve been at it for 30 years, organizing residents of informal settlements globally to be their own designers, planners, advocates, implementers. So they’re very capable of specifying what they want and need and advocating for it. So we’re bringing in some mental health content and capacity support for them to absorb that capacity. But it’s a different relationship.
And for the mental health folks, I’ve got to keep saying, this is not about you. We start getting to how we can create paths for people to get into the hospital clinics. For some people, there’s not enough of that access, absolutely. But the center of gravity that makes this work is that we’re trying to capacitate more of the community. And that’s going to be what drives and anchors all the other things to work. Because mental health systems have really floundered by having this fake zero-sum game, [this idea that] resources are going to go [only] to the most seriously mentally ill or to this prevention and promotion stuff. That whole dichotomy totally misunderstands the essentiality of human wellbeing for successful societies, period. You get to that as a whole. You don’t get to that piecemeal.
A lot of arguments came my way around, [for example], there’s not enough care for people with schizophrenia. You’re absolutely right. But with that came an accusation that we were adding to the stigma around people with more serious [mental illness]. And I would say no, actually, the stigma is that we think that people who are seriously mentally ill also don’t want a peer to talk to them, also don’t want their neighborhood to feel like a supportive place, also don’t want their pastor to have counseling skills, also don’t want to be in a school or have a kid in a school that is a social-emotional attuned environment. That stigma really fills a vacuum of limited solutions. By capacitating more of society to realize they’re part of making society a wellbeing engine, that stigma melts, because all of these things are seen as part of that.
That’s where we have to go, and that’s what we have to advocate for. What I was saying about being transparent, it’s having a transparent vision about that, in a way that doesn’t make people feel like we’re stigmatizing or leaving out [a particular treatment or illness], but the larger frame keeps it all in.
Ashley Hopkinson: What is your measure that you’re making progress?
Gary Belkin: It changes. I’ll give you a longer answer, but I’ll give you a short answer first. Since the premise is that these other places are empowered by bringing psychological, mental health, and wellbeing tools and methods to enable them to solve problems, the main outcome we want to see is that they feel that’s happening. That comes in many forms. We’re sitting down with some of these early adopter efforts I mentioned, and it’s more qualitative: What did you think this would do for you? Is that happening? How will you know that it’s happening? Then that’s where more specific measures come from.
When you talk about evaluating the whole ensemble of mental health interventions, you end up with measures that don’t tell you much. They’re very precise, and they can be standardized, but I don’t think at the end of the day they really tell you much. There are symptom scales and scores and functional scale assessments and so on, but they’re not telling us what this did for that person. Particularly at scale, which we’re talking about in Nairobi. How do we get a youth network of 1,300 to create a backbone of emotional support? Yes, we will look at how our training worked. Did the folks train and retain their competencies? That’s important from an improvement perspective. But the success of it is a whole other realm of measuring, and those people will tell us what those markers are.
Ashley Hopkinson: Given the right support and resources are there, what would you like to see grow and expand and scale?
Gary Belkin: I would say the model that we’re doing. But most of the cost of what we’re doing is to create another path for this expertise to go into these other places. I’ve been talking, for example, with health systems and insurers and policymakers at the federal level in the U.S. about how we could steer health dollars that go to mental health professionals to do one-hour office visits maybe five or six times a day, and also reimburse them to coach the staff, you know, three community-based organizations they care about. Can we shift the goals that they’re going for? We do need new training pathways to the mainstream. We need some new capacities, particularly in these grassroots and other channels, schools or education systems, all the different sectors that I talked about, to be really equal partners in planning and absorbing this wellbeing purpose, to build capacity across more of civil society and shift the expertise, or at least coach them to have a business model to do so.
Ashley Hopkinson: What does the term collective wellbeing mean to you?
Gary Belkin: You’ll hear me come from a very pragmatic place. I would use a definition that mobilizes the work. For example, the OECD endorsed this Cantril Ladder measure. I’m probably getting the specifics wrong, but it was a very simple, two-tiered question: on a scale of zero to ten, how would you rate your satisfaction with your life, and what do you think your satisfaction will be five years from now? Sounds like a very simple question. And you may disagree that that’s, in some philosophical or normative sense, the best way to define wellbeing. But the point is it tracks with almost every social indicator. So to me, that’s saying something.
But culture and reality may change [in such a way that] asking a question like that doesn’t track well.
So then we find a measure that does or a definition that does. So the way I think about psychological resilience is not as a measure or as a state of attained condition but as a process. It’s a process of applying what we know about psychological mental health and wellbeing tools and methods. It’s applying those things to help you do other things. So the question is less about what’s the perfect toolkit—the question is, what’s a good process that helps that happen? And that is a much easier question to answer. Endless arguments that I sit through, and I don’t understand the energy that goes into them, about getting the right measure and the right definition and these best practices. No, the best practices are proven when people choose to try something else and it helps them. That’s a large list, but there isn’t a process for [giving] more parts of our society access to that list. That’s the problem we should be working on. And I feel that’s the problem I’ve been working on.
It’s very critical for the climate context to be pragmatic that way. Because it’s constantly shifting. It’s very hyperlocal, because climate is very hyperlocal and shifting. Communities mature in their resilience. I mean, the emotional damage of a hurricane is different in places that have one every year versus those who are newly [experiencing] this horrific harm. And in places that have had more experience with it, there’s a certain amount of experience where it really starts to deteriorate social fabrics, which I think is what’s happening in the Southeast United States and in many other parts of the world, such as the Philippines, where there’s just too many of these cyclones.
So it is a moving target. There is no hard and fast rule about the mental health effects of hurricanes. It changes every year. And if you want to help communities have psychological resilience, you have to equip them to be much more nimble problem solvers, skill owners, and sense makers. There isn’t a measure. There’s a profusion of measures. And when we started asking these early adopters what measures they wanted, that is how we bumped up against that. They wanted tools: how can we find our own way of measuring? That led to a whole other effort that I didn’t expect, which is that we’re now forming what we’re calling a mental health and climate change observatory, where we’re going to create a pool of researchers and experts, not to evaluate their efforts but to capacitate their efforts to be self-learning enterprises and to learn across them.
Ashley Hopkinson: That is also very pragmatic. How can I help you build capacity for what’s already working for you?
Gary Belkin: Right. And help others learn about it. Maybe there are completely different contexts, but can we find threads that cross-cut at the same time we’re helping you learn what’s happening where you are?
Ashley Hopkinson: Is there anything I didn’t ask you directly that you want to add to the conversation?
Gary Belkin: I’ll put my two cents in about funders. I am really worried they’re going to destroy the climate and health space. A lot of the conversation about funding health in the face of climate change includes, yes, physical infrastructure, clinics, hospitals, et cetera to make them more climate resilient and prepared for increased incidence of certain illnesses and diseases. All true. But overall, the sense is to just double down on this belief that it’s the health system, and especially the mental health system, that is the core driver of population health or mental health. Which is just not true.
That’s why we have a mental health crisis in the U.S. now. It’s why we had a pandemic, because health systems don’t protect our health. They treat our sickness, and even then, they don’t have the capacity to do it equitably. The point is we have to capacitate communities and every other sector along with the health sector. I don’t see funders appreciating that. I don’t think they know what that means or how to do that. They’re stuck in clear, causal, legal, logical connections between climate harm and health harm, and in randomized testing of interventions. I’m going to be very frank: all of that is just not what is needed right now.
It’s really about making communities robust health and mental health systems. That means building social infrastructure and building civic muscle and capacitating clusters of partners.
We are trying to get funding for that. And it’s eye rolling, because it falls out of a paradigm that health and mental health funding has gotten used to. And it’s just got to end, or we will not have resilient people to do the work of climate resilience. That’s starting to crumble already. And a lot of the suits in philanthropy are having a conversation that is not relevant on the ground.
Ashley Hopkinson: Thank you so much for your time.
Click here to read the full interview with insights highlighted.
Ashley Hopkinson is an award-winning journalist, newsroom entrepreneur and leader dedicated to excellent storytelling and mission-driven media. She currently manages the Solutions Insights Lab, an initiative of the Solutions Journalism Network. She is based in New Orleans, Louisiana.
* This conversation has been edited and condensed.
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