Peter Fifield: Mental Health vs. Behavioral Health

Pete,

You ask great questions.  In my perspective, preference for the term mental health, behavioral health, or (I’ll add) emotional health have historically come down to one’s training and bias.  If psychology is considered a 3-legged stool made up of emotions, cognitions, and behaviors, then each leg has its own branch.  Perhaps due to the early dominance of psychoanalysis, the term mental health has long been the preferred term in our field.

Psychologists and other mental health professionals chafed against behaviorism due to the perception that it reduced humans to rats and reduced clinicians to Skinner box drivers.  I believe this perception was not shared by the medical field because they were early adopters of rigorous science and animal studies.  They have a low tolerance for the immeasurable and behavior is the most outwardly measurable aspect of psychology.

It would seem behaviorism is winning the day (reference the proliferation of B's in NCCBH, PCBH, IBH, etc) and many community mental health centers are changing their names to replace mental health with behavior health.  I support this change for a number of reasons:

It is a more broad term that easily encompasses psychopathology, addiction, and coaching

It is a better description for the lifestyle interventions that primary care clinicians offer for people with diabetes, heart disease, tobacco addiction, etc

It helps move beyond the stigma identified with mental health.

Hmm... I have always seen these two as seperate areas under psychology.  Mental Health consisting of psychopatholgy. Behavioral Health concerns issuess that can have an actual outcomes by changing "behavior" such as addictions.  You cant really change your outcome if you have something like schizophrenia by changing your behavior you can only control it with medication.  Thats just how I see it

Primary Care pragmatism tells us that we need to use best practice and have measurable outcomes.  Out of the trio of cognitions, emotions and behaviors, the latter of the three seems to be the most measurable.  The question is, how do we take out one of the legs on this three legged stool with out tipping it over.  Or do we not have to?  I think most would agree that it is almost impossible to separate these concepts.  Maybe we just attend to the body in a holistic manner--combining the three when needed, but come up with an entire new name for the process.

Behavioral health appears too isolative regarding human actions and tends to disregard (at least in its title) the other two legs of the stool.  Although mental Health has the most fitting title, it does have a marred reputation. It tends to carry a considerable stigma; it may imply that medications are necessitated for successful outcomes; it may imply that a severe and persistent issue is at hand and it leaves patients thinking long term psychotherapy is necessary.  What if we call it something so ambiguous no one knows what it means?  How about Health Stratification Treatment? 

It's an interesting topic for discussion.  Back in the day, Albert Ellis was booted from the APA for asserting that the three legged stool can be treated all at once, fairly quickly without all the psychoanalytic baloney.  Now everybody does "cognitve-behavioral therapy".  Insurance companies want therapists to use "cognitive-behavioral" techniques (but never bother to check what the heck they're really doing).  Mental health sounds like it's for crazy people.  It still scares my mother, what I do for a living.  The term "behavioral health" sounds more user-friendly.  However, the term has already been co-opted by the substance abuse megatopolis.  They even have a trade magazine named Behavioral Health.  My concern with changing the name is, it's helping the addiction treatment folks in their quest to integrate the whole shabang..mental health and substance abuse.  And they are control freaks whose main qualification to treat is they are/were a drunk or addict.  They need to make money like everyone else.  So do their suppliers.  Maybe intorduce legislation to test your hair before giving you a driver's license?

  They're currently working on the term "recovery".  They want to get that word in the mental health lexicon.  Check it out.  It's already happening. 

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While I don't share your dismissive perspective of our brothers and sisters in the substance use field, I do think you make some valid points.  By moving to one term (behavior) to describe all of mental health and one title (behaviorist) we are conflating things that aren't exactly the same.  The signifcant and subtle differences can be lost.

However, Primary care physicians are jacks-of-all-trades. Mental health clinicians are a better fit in primary care when they reflect this generalist nature.  It is helpful to have a little cognitive behavioral, a little systems thinking, a little motivational enhancement, and yes, a little substance use treatment ability.

Randall, I agree with your generalist approach to mental/behavioral health treatment in the primary care setting.  Anecdotally speaking that is, the jack of all trades approach--addressing, behaviors, cognition and emotions (with a sprinkle of MI) is what has proven most effective for most of the practitioners I am familiar with.  Regarding the integration of the "whole shabang"...mental health and substance abuse treatments--I'm not convinced that isolationism is the correct approach here either.   Aside from the PTSD Dx, most of the recent literature I have read, leans towards co-occurring substance and mental health treatment.  In my opinion, separating the two would be a regression regarding the movement towards seeing and treating the person as a whole. 

I think of behavioral health as being the overarching term for mental health, substance abuse and behavioral medicine.  Behavioral medicine is changing the body with words (well, really they all are), but behavioral medicine is health behavior change on one side and the relaxation response approaches on the other (relaxation, visualization, bio-feedback, mindfulness, hypnosis).  In fact, I have no idea how anyone in primary care, (or anywhere else) works without being in all of these areas.

I worked with a guy this week.  He is temporarily currently sober from an OTC and prescription pill addiction.  We talked about what he was learning at NA (SA) and how he stays sober day to day.  We looked at what he thinks and how that can better support his sobriety (CBT).  We looked at how he calms himself and uses breating to stay of track (RR/CBT).  We went into detail about how he got sober before and the times he thought he would fall off the wagon but didn't (Solution Focused).  We talked about how his wife has been inducted into the role of monitor for him and how their relationship when it is stuck like that holds on to the old bad boy/good gal interaction (family systems).  I asked him how much of his identity was taken up with the identy of drug addict now.  He said well over 50%.  I asked him what his goal was for the amount of his identity that would be drug addict in the future.  He said 10% (0 is not one of the options, NA).  We imagined the day when drug addict would be about as much of his identity as fisherman (all this is Narrative Therapy, a la White and Epston).  I asked him what part of his identity he would hope was taking up more space when we meet again and he said athlete.  He is going to the gym (Beh Med).  I asked him to look for times when he and his wife are having an interaction where drug addict/monitor is not in evidence.  What are the roles they like better? (Family systems, solution focused).

Why would you want to work in something as complex as human problems without a full tool box?

Sandy Blount

Sandy, Amen!