Stop Calling It Behavioral Health!
By Robert Kent JD and Charles Morgan MD 11/12/15
Does the term cause stigma and discrimination?
When somebody is treated for smoking cessation, the care will probably be provided within the behavioral health system. If that person is later diagnosed with lung cancer, that will be treated over in physical health. If she becomes depressed, that’ll be managed back over in behavioral health. But if the depression causes digestive problems, that aspect of the patient’s health and health care will be treated...you get the picture. Many “behavioral” issues are driven by biological or hereditary conditions, and yet physical and behavioral health are frequently organized, paid for and managed in two entirely different systems. Two key figures at OASAS, which oversees one of the largest addiction treatment systems in the country, argue that the divide between physical and behavioral health, and the term itself, can lead to stigmatization and discrimination against people with “behavioral disorders.” Robert Kent, J.D., the general counsel at the NYS Office of Alcoholism and Substance Abuse Services (OASAS), leads OASAS’s work to implement health care and insurance reform for the Substance Use Disorders system in New York. Charles Morgan, MD, is the medical director of OASAS and a physician who has devoted over three decades to working with people and families affected by addiction. They both want you to “STOP CALLING IT BEHAVIORAL HEALTH!”… Richard Juman, PsyD.
We believe that it is time to stop calling substance use disorder and mental health “behavioral health.” We are unabashed advocates and supporters of the substance use disorder (SUD) treatment, prevention and recovery system. We are regularly amazed by the stories of people who are now able to live their lives in recovery because of the work done by the people in our system. We need to talk about these disorders in a language that reflects their true nature; they are medical conditions, the origins of which lie in the person’s brain, and the effects of which extend into every part of that person’s life, and as with other illnesses, virtually always into the lives of the people who are touched by the patient.
The term “behavioral health” is imprecise, since it doesn’t indicate whether one is talking about a mental health condition or a substance use disorder. More importantly, the concept of “behavioral health” as separate from the rest of health care has allowed insurance and managed care companies to create rules for managing services which have denied people access to needed services. If you follow the logic of using the term “behavioral health,” then people with type 2 diabetes, heart disease and asthma could very accurately be identified as having a “behavioral health” issue, as their chronic medical condition is aggravated by their behaviors. But we would never do that with those disorders.
Constellations of behavior manifest from many chronic medical conditions, some of which are construed as “medical” and others as “behavioral.” The bifurcation is as illogical as it is stigmatizing. People aren’t expected to be able to shrink their own tumors or cure their own infections, but they are expected to control their own behavior. Consequently, calling psychiatric and substance use conditions “behavioral” puts the onus on the patient, often to his tragic detriment in the form of discrimination in housing and employment or the realm of criminal prosecution.
An individual with a substance use disorder has a natural, predictable disease course, one that is responsive to treatment, allowing for recovery. While we obviously do not want these symptoms to continue, blaming a person for their “behavioral health” issues, rather than treating them, is as counterproductive as blaming a person with epilepsy for falling down when they have a seizure, or blaming the person who is allergic to bees for disrupting the annual family reunion picnic because s/he needs emergency care when s/he is stung. Since we do not want such problems to continue or to be ignored, being judgmental or pejorative about them is harmful because it impedes treatment. In the case of the person with a bee allergy, we would instead encourage him to carry an EpiPen, and we would work to remove any barriers that might prevent him from doing so. We would also remove the bees’ nest!
With regard to the methods and rules used by the insurers and managed care companies that operate in “behavioral health,” some of our recent initiatives provide ample proof of the impact of using the term. Thanks to the leadership of New York Governor Andrew Cuomo, we now have a state law that requires insurance and managed care companies to have the decision-making criteria they use to manage substance use disorders reviewed and approved by OASAS. Our review of the criteria being used revealed that SUD level of care decisions were being significantly influenced by a person’s past failures or relapses, by whether they had “failed first” at a lower level of care before they sought a higher level of care, and by their “motivation” to seek help.
Some insurers, and even some providers of care, use the term “motivation” to exclude people from treatment. This is in contrast to the concept of motivation as described by the stages of change model, or in motivational interviewing technique, where a patient’s level of motivation is understood in order to allow for effective treatment. These types of rules would never be allowed for other chronic medical conditions like diabetes, heart disease, and asthma. Would we deny a diabetic their insulin because they ate chocolate cake the night before? Would we deny the person with heart disease medications because they ate chicken wings and french fries? Of course not, because we do not think of those other chronic medical conditions as behavioral in nature. Unfortunately, there is a bias towards thinking of SUDs as behavioral, and then allowing the punishment of the behaviors that are symptomatic of the condition.
Finally, and most importantly, we believe use of the term "behavioral health" plays a major role in the continued stigmatization of those with an SUD. Such terminology reflects a misunderstanding of SUD, and allows us to perpetuate the myth that the illness is volitional rather than based in biology. Critics of our stance tell us we are absolving people of responsibility for their actions, when in fact we are doing quite the opposite. By delineating the true nature of the illness, we can allow patients to get proper treatment for their illness. Blaming people for addiction would be like blaming people with irritable bowel syndrome for the symptoms of their disease. Acknowledging the disease of IBS allows for proper treatment, which then allows people to be more functional and self-actualized in a way that allows them to take responsibility for their recoveries and to get relief of debilitating symptoms. Similarly, when we treat SUD rationally in this way, rather than as a series of “volitional behaviors” that those afflicted should be able to stop if they were properly motivated, people affected by SUD can then take responsibility for their illness and get effective treatment.
With regard to the stigmatization of people with SUD, researchers estimate that only one in 10 people who have an SUD actually seek help. While we know there are many reasons people do not seek help, we know that the stigma associated with SUD has a significant inhibitory impact.
We should listen to the experts. The American Society of Addiction Medicine (ASAM) defines addiction as follows:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Michael Botticelli, the director of the White House Office of National Drug Control Policy, has talked recently about the language we use impacting whether people seek help for an SUD and he has encouraged us to use different language. We know that some will disagree with our viewpoint and some will dispute the basis used for making it. We also know that we can only change what we do, and we can hope others will do the same.
It is essential that we start thinking of substance use disorders and describing them by using the same language that we use when we describe other chronic medical conditions. The language is critical here: Let’s change the world by changing the way we think about, and talk about, the medical conditions formerly known as “behavioral health.”
Robert A. Kent serves as the General Counsel for the New York State Office of Alcoholism and Substance Abuse Services. In this role, Mr. Kent provides overall legal support, policy guidance and direction to OASAS Commissioner Arlene González-Sánchez, the Executive Office and all divisions of the agency. Robert is leading the OASAS efforts to implement Governor Cuomo’s Combat Heroin and Medicaid Redesign Team initiatives.
Charles W. Morgan, MD, FASAM, FAAFP, DABAM is the Medical Director of OASAS. He has worked in the field of Addiction Medicine for over three decades and is a Fellow of both the American Society of Addiction Medicine and the American Academy of Family Medicine. Dr. Morgan has expertise in all modalities of patient and family healthcare.