One of the key priorities in our national healthcare crisis should be better health. While healthcare costs may be setting off the alarm bells, they will not be silenced as long as unhealthy people seek care. We know health is not up to doctors and hospitals alone, but myriad solutions focused on patients have not had positive results. Our field can be a vital part of the solution if some adjustments are made.
Our high costs don’t seem to produce top quality, at least according to most objective measures of health and mortality. It should be noted that experts long ago defined health as a state of wellbeing, not just the absence of disease. Wellbeing remains elusive, even as many diseases have been cured or controlled. Wellbeing can be enhanced, but only with behavioral healthcare as a key participant.
Three successive articles tackle these issues. The first was devoted to preventable costs. This article, the second in the series, will be dedicated to health improvement. The third will address primary care redesign. The conclusions reached are dramatic. Our field can prevent many unnecessary healthcare costs, improve the health and wellbeing of the population, and succeed most fully by becoming a primary care service.
Improving health with and without a diagnostic manual
Some of the biggest opportunities to improve the health of a population exist with problems not categorized in diagnostic manuals. We use the Diagnostic and Statistical Manual (DSM) in the U.S. in our treatment of behavioral health disorders, while the International Classification of Diseases (ICD) is the global compendium of both physical and behavioral disorders.
The ICD has been published by the World Health Organization (WHO) since its inception in 1948. It was in that inaugural year that the WHO defined health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.” In other words, they saw health as something we should aspire to achieve, more than just avoiding the diseases they categorized.
The literature on wellbeing is confusing at the level of terminology. This language needs updating. Let’s substitute our current term, wellness, for the idea of physical wellbeing. Our contemporary use of the term wellbeing best fits the WHO dimension of mental or emotional wellbeing. As will be discussed shortly, measurement clarifies what is clouded by definitions.
The WHO was ahead of its time with the declaration that health was more than the absence of disease. Many people without disease today are at high risk for disease tomorrow. For example, obese individuals are at risk for multiple diseases. So too are those living in impoverished, stressful situations. The role of a healthcare system should be to enhance health, not just fight disease.
Healthcare in our country has largely focused on helping people with the conditions found within the DSM and ICD. Professionals debate effective treatments and presume that health care is disease care. This is misguided. A focus on health obliges professionals to address wellness and wellbeing. This focus may exist outside the bounds of the diagnostic manuals, but professional attention is warranted.
Behavioral healthcare was a young field in 1948, but it has matured into one that fights disabling behavioral health disorders while also enhancing the wellness and wellbeing of populations. We help people achieve wellness when we help them change unhealthy behaviors in areas such as nutrition, movement, and use of tobacco. Wellbeing grows as coping with stress and trauma is improved.
Reliable measures of wellbeing currently exist1. Many initially criticized the WHO, believing the concept was vague and unmeasurable. Several measures exist today, and research suggests a single psychometric value can be established. Wellbeing can be assessed as a variable level of thriving or vitality. Individuals and groups can monitor their number for wellbeing, as they do blood pressure.
Some clinical services are best for diagnosable disorders, others for wellness and wellbeing, and many for both. For example, meditation and mindfulness can help people reduce anxiety or improve wellbeing. We help people become resilient and manage the stresses of everyday living, regardless of diagnosis. EAP and wellness programs reimburse for services outside the diagnostic manuals.
A leading architect of health management, Dee Edington, cautioned to “keep the healthy people healthy” once he realized decades of work had failed to rehabilitate the unhealthy. He calls for shifting some resources upstream. Our industry was minimally involved in developing historical health improvement programs. New programs should feature advances made by our behavioral experts.
We have long known that chronic conditions like diabetes and heart disease are “lifestyle diseases” that require behavior change. Wellness programs were guided by a simplistic notion of setting goals for people, supporting them in making change, and at times using incentives to build motivation. They were designed to be staffed by nurses and others without significant behavioral health training.
Corporate wellness programs may be endangered due to mediocre results and concern about incentives. We should not persist with the psychologically naïve approach of these programs. We won’t easily persuade or manipulate people into a healthier lifestyle. Programs with behavioral sophistication are emerging, but we need a new beginning, a new model for working within and without the DSM.
A new clinical model
Wellbeing and wellness promote a more comprehensive view of health. Our field embraces them in combination with its traditional focus on mental health and substance use disorders. Treating each independently is destined for failure. The consolidated behavioral health (CBH) clinical model is an integrative approach based on behavior change.
If we only view health as treating the conditions in the DSM or ICD, we are left with a stream of new unhealthy patients because we failed to implement disease prevention and health promotion activities. The many successful psychosocial strategies developed by our field can be characterized generally as behavior change, and we can help people with all manner of problems inside and outside the manuals.
We have the clinical tools to make a significant contribution to improving the health of populations, but should we wait in our offices for them to arrive? No. We cannot make this contribution as a specialty service. This comprehensive view of health and healthcare needs to function in the primary care setting. We have erred by placing these services elsewhere. These services are indeed primary.
Our field will need to make adjustments to realize this vision. We must view wellness and wellbeing as being on par with clinical improvement from behavioral health disorders. We will need to investigate modifications to our behavior change skill set. Our grounding in psychotherapy and the therapeutic alliance will serve us well. The question is how we might be greeted within the primary care setting.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.
1 Jones, et.al., “Wellbeing: A Critical Health Domain,” Journal of Health & Productivity, Volume 7, Number 1, December 2013, pp. 6-13.