Suicide Prevention to ED Boarding: Applying Adaptive Leadership with Morissa Henn of the New Hampshire Department of Health and Human Services

Q: Could you describe your role at New Hampshire Health and Human Services?

Morissa Henn: The New Hampshire Department of Health and Human Services is a “super agency” under which Medicaid, public health, behavioral health, child welfare, and more roll up. My role as Deputy Commissioner is largely focused on strategy. I knit problem solving across different parts of the agency, so that if we have a behavioral health problem that also impacts childcare and Medicaid, we’re looking at leveraging those intersections.

Q: One of the things people really admire about your work is your leadership style, especially your use of adaptive leadership. How do you define adaptive leadership?

Morissa Henn: Ronald Heifetz is often seen as the father of adaptive leadership, and his work on this became a guiding principle for me.

Adaptive leadership is the practice of mobilizing people to solve problems that authority or expertise alone cannot fix. These challenges require changes in behavior, relationships, and values and developing shared responsibility.

I often joke that the best adaptive leadership exercise in my life right now is parenting my four-year-old daughter. When my husband and I struggled to get her to take a bath, we initially treated it as a technical problem: she’s filthy and needs to comply with my instructions. But the real issue was her desire to be the leader of the family when it came to deciding how and when she would take a bath. Once we gave her control over various steps in the process, such as the flavor of the popsicles that would be enjoyed in the bath, the issue resolved. She took a bath.

This experience reflects adaptive leadership in action: diagnosing the real problem, resisting the urge to rescue and mobilizing others to do the work, and regulating distress. Leaders have to create what Heifetz calls a “zone of productive equilibrium,” where there’s enough pressure to motivate change but not so much that people get overwhelmed and disconnect.

Q: What was the first time you deployed an adaptative leadership approach?

Henn: One of the earliest and most formative examples was my work on suicide prevention during my graduate studies in Utah. Utah had one of the highest suicide rates in the country, and a lot of efforts aimed at expanding mental health services weren’t moving the dial.

When we went deep into the data—analyzing death certificate and understanding the context for these tragic events—we realized the problem had been misdiagnosed as a mental health gap. Utah didn’t have higher rates of depression, anxiety, or other mental health disorders than other states. However, it did have ready access to firearms, which are extraordinarily lethal in moments of acute crisis.

Q: How did you mobilize people around this finding?

Henn: We knew immediately that a traditional public health approach—lecturing people about gun safety—would fail. In Utah, more than half of homes have at least one and often, many more, guns. It’s part of the culture of that state.

So instead of positioning public health experts as the messengers, we partnered with leaders from gun-owning and Second Amendment communities. Many of these individuals were personally affected by suicide and were deeply motivated to prevent it. Together with legislators like Steve Ellison, another Milbank Fellow, we crafted solutions build on shared values: protecting loved ones and supporting neighbors.

One intervention that resonated strongly was having a trusted friend hold onto one’s guns during stressful life events like divorce or job loss. The key was that these solutions were generated and communicated by gun owners themselves. It was not about having a gun owner come to a public health meeting where data is being presented more academically.

I’ve been so proud of how that work has continued in Utah, and in states like New Hampshire, but I would have never been part of that journey if we hadn’t gotten the definition of the problem right in the first place. While there are lots of reasons to expand mental health access in this country, doing so would have been an incomplete solution to the problem of suicide in Utah.

Q: That’s a great example of having a shared sense of the problem and not going in with pre-baked solutions. How you build trust among the different stakeholders to get there?

Henn: Adaptive leadership requires a tremendous amount of humility. It starts with acknowledging that our traditional forms of authority and expertise are inadequate to solve the problem. So, you are putting people at ease and demonstrating a willingness to experiment, and this attracts unlikely partners.

Q: Turning to New Hampshire, one of the most visible challenges you faced was emergency department (ED) boarding for behavioral health. How have you applied adaptive tools to those situations?

Henn: When I arrived in New Hampshire as Associate Commissioner overseeing behavioral health, ED boarding was a full-scale crisis. Every day, 50 to 70 people experiencing psychiatric emergencies were waiting in emergency departments—often for days or weeks—in hallways and rooms that were not designed for them. You could not describe a less therapeutic environment for patients or scarier scenario for families. And hospitals were tired of having these patients lined up in their EDs.

The state had already lost a major lawsuit related to this issue, and a court injunction had given the Department of Health and Human Services 12 months to fix it. Emotions were high.

At that time, the problem was widely defined as a lack of inpatient psychiatric beds.

Q: How did you reassess the problem?

Henn: We found the beds issue was secondary to the more upstream problem of people not having other places to go. We identified three main drivers.

• First, the front door problem: people didn’t have timely access to outpatient care or medication management, so they went to the ED.
• Second, the coordination problem: hospital social workers across 12 hospitals were independently calling inpatient facilities, creating a chaotic and inefficient system.
• Third, the back door problem: patients who were psychiatrically stable couldn’t be discharged because of other issues like medical frailty or disabilities.

We assessed roughly 30 potential interventions and ultimately focused on six that addressed these three drivers.

Q: Given the litigation and mistrust, how did you bring people together?

Henn: We did something kind of rogue. We approached the hospital association, which had helped bring the lawsuit against the state, and asked them to partner with us.

We also asked the National Alliance on Mental Illness (NAMI) New Hampshire to serve as a neutral convener. That was critical. NAMI helped keep families and lived experience at the center, rather than rehashing how things had played out in court.

We formed a steering committee that included hospitals, community mental health providers, state officials, and individuals with lived experience. It wasn’t easy sitting at the table the first day. The temperature in the room was high. But people were exhausted from conflict, and folks said, “What do we have to lose?’’

Q: What outcomes emerged from that approach?

Henn: We built data dashboards to be transparent and measure progress over time and advanced initiatives that have dramatically changed the situation in New Hampshire. We have reduced average ED boarding wait times by more than a third. On many days, the wait list hits zero.

We named the effort Mission Zero. It has built trust, credibility, and a reputation for collaborative problems solving that pays dividends beyond ED boarding. The beauty of adaptive leadership is that it just flourishes.

Q: You emphasize having very simple, clear goals. Why does that matter so much in complex systems?

Henn: When problems are complex, leaders are often tempted to make goals more complicated and abstract. In my experience, the opposite is needed.

In the case of suicide by firearm prevention, the goal is “No person in suicidal crisis should have access to a firearm.” In the case of Mission Zero, “No one in psychiatric crisis should be waiting in an emergency department.” That is the vision.

Once everyone agrees on a unifying goal, there’s room for healthy debate about how to get there. Without that goal, it’s hard to even begin talking about “the how.”

Q: How do you sustain progress when the environment keeps changing?

Henn: Continuous learning is baked into adaptive leadership. You treat your initiatives as experiments, not necessarily fixed solutions. That doesn’t mean you don’t take them on with rigor, but you are open to insights and learnings that you’re going to gain as you go. The world that we’re living in is one of constant change. With Mission Zero, we had tremendous success over two years, but with the federal Medicaid changes, there are new financial pressures on hospitals.  

Leaders have to keep “getting on the balcony,” to observe what’s changing on the dance floor and adjusting accordingly.

Q: The metaphor of the balcony resonates with all three of the adaptative leadership principles.

Henn: You’re right. Another analogy that I overuse is “hearts and minds.” The work of building relationship and admitting when you don’t know something, of holding a sense of loss for people who have been committed to something that wasn’t working, requires engaging with one’s heart as well.

That’s also what makes the work exhausting, so leaders need to have supportive communities for reflection. The Milbank Fellows is special because we can restore ourselves from what can be very exhausting cycles of problem solving.

Q: How do you build a culture of adaptive leadership across such a large organization?

Henn: First, by reinforcing the idea that leadership is a verb. I actively look for examples of adaptive leadership at all levels—right now, that’s epidemiologists and policy analysts testifying at the legislature—and I try to celebrate those efforts.

At the New Hampshire Department of Health and Human Services, the first pillar of our strategic plan is investing in people and culture. Helping people find meaning in their work and see themselves as change agents builds adaptive capacity far more effectively than top-down leadership.

Q: Finally, how does adaptive leadership hold up in today’s climate of uncertainty, constant change, and limited resources?

Henn: We’re living in an era of not knowing—about policy, funding, and what crises lie ahead. Naming uncertainty openly feels safer now, because everyone is experiencing it.

While trust in public officials is low, every day at the legislature and in our cross-agency activities, I see allies coming together in interesting ways. There is a level of creativity in crisis that we’re seeing. I wouldn’t wish this time on any leader, but I do think that it’s forcing us to be open and connect in meaningful and positive ways.

Interview condensed with use of AI.