Behavioral healthcare is a business that must focus on its long-term viability, even while trying to survive a steady stream of challenges every day. Sustainability requires an ability to respond to many factors, some of which are external and others internal. Two basic issues worth exploring are the endurance of our business model and our ability to impact consumer attitudes.
Our industry has a long history of its professionals and its patients struggling for validation and acceptance. Tensions remain. Behavioral healthcare is now a substantial segment of the healthcare industry, but it matters that all our services do not derive from the dominant medical model. Stigma experienced by patients has taken many forms, and elements persist today.
We cannot rely on a public outcry for mental health and substance abuse services. Barriers to the full range of treatment options are quite real, if often invisible. People consult their PCP for mental health concerns and get a prescription, rarely therapy, and only around 10% of people who could benefit from SUD treatment get it today. Increased anti-stigma efforts are not the answer.
Our field needs a new, robust business model based on the priority of changing behaviors for a diverse range of health problems. We need to expand recipients of services beyond those with mental health and substance use diagnoses. Health behaviors should be included as the third leg of our stool. Our industry’s message would then refocus on the urgency and the universality of behavior change.
A non-stigmatizing path
Albert Einstein is widely credited with saying that insanity is doing the same thing repeatedly, and yet expecting different results. How might this apply to our field? We attack stigma relentlessly as if it will rectify all public misperceptions about behavioral health issues. I would offer one troubling finding from a 2013 review1 of public surveys on this topic:
In general, the American public seems to hold positive attitudes toward seeking professional help for mental health problems and these attitudes seem to be improving over time…However, no significant changes in this time period were observed regarding the public’s perceptions of the effectiveness of mental health treatments.
Bruce Wampold has published two editions of his exhaustive review of psychotherapy research, in 2001 and 2015, and pronounced psychotherapy “remarkably efficacious.” It is not surprising that such findings don’t change public attitudes. We are encouraged by vast marketing campaigns to trust psychiatric medications, but no campaigns about psychotherapy can be found.
It would make sense that public attitudes will gradually shift about the effectiveness of treatment, but medication alone is likely to shine with that shift. Destigmatizing our field need not be synonymous with medicalization. The consolidated behavioral health or CBH clinical model offers a comprehensive understanding of our field as being about the urgent task of behavior change.
CBH can open our clinical services to a wider population with unhealthy behaviors and promote a non-stigmatizing view of our field. Social isolation, heavy drinking and overeating are all behaviors that we may need to confront at some point in our lives. This new identity for our field might provide a path to long-term growth. Yet it is not merely a new business model. It is also a moral model.
The moral model offers a choice between anti-stigma and non-stigma positions. Are you an ally for people with unique, non-universal problems? Or are you a person living with one form or another of our universal condition? Both positions point a better way forward, but one is righting a wrong, while the other is promoting a larger view of ourselves.
Our field might well thrive by underscoring how we all engage in behavior damaging to our health at some point. We can change behaviors, but some people need more help than others. The extremes shouldn’t blind us to the norm. This is as true for our moods as our weight. Behavioral healthcare is a specialty to which everyone should be able to relate. Behavior change is a universal dilemma.
Moving into the mainstream
A potential shift in the business model for our field was conceived years ago by the association of companies comprising the managed behavioral healthcare industry. The Association for Behavioral Health and Wellness (ABHW) turned its attention in 2006 to the disease management industry with the belief that its focus on health and wellness might provide growth opportunities for our field.
Excitement about the disease management industry faded years ago, yet the quest for healthy behavior remains. Employers still pay premiums to address the health behaviors that foster chronic conditions like diabetes and heart disease. Developed from a medical model, these programs are implemented by nurses and allied staff like registered dieticians. They could use the wisdom of our industry.
We should leverage knowledge gained from decades of work treating mental health and SUD to impact health behaviors. We can already see inroads in this direction. We now have smoking cessation and weight management programs based on cognitive behavioral therapy. These programs are currently inexpensive and probably useful for a subset of people. Many will need more intensive interventions.
The behavior change model is a complement to the medical model. Our industry embraces each with their defining solutions. Yet where do we seek to impact the broad range of health behaviors? While every modality of communication should be used, the foundation must be the face-to-face encounter. The most important context for that, in terms of frequency and impact, is the primary care setting.
The final aspect of this long-term business model is to assume a decision-making role alongside the primary care physician. The primacy of behavioral health warrants this. When well over half the office visits are driven by psychosocial issues, the behavioral healthcare specialist needs to embrace a significant role on a primary care team that is fully collaborative.
The vision here is to end the longstanding marginalization of our field and the stigmatizing of our patients. That can best be accomplished by leading with our unique behavioral capabilities, inserting them more prominently throughout the healthcare system, normalizing how everyone copes with unhealthy behaviors, and promoting behavioral healthcare as vital to the overall health of populations.
Our field will continue to offer services in confidential settings, while also stepping out of the shadows and into the mainstream of medical care. Anti-stigma campaigns will one day seem odd. We won’t be seeking understanding for “the other” when we know there is only us. One of the defining currents of mainstream care will then be recognized as behavior change. Targets for stigma will cease to exist.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.
1 Parcesepe, AM, et.al., “Public Stigma of Mental Illness in the United States: A Systematic Literature Review,” Adm Policy Mental Health, September 2013: 40(5).