The consolidated behavioral health model presented here integrates three currently separate dimensions of health status into one. This cohesive, multi-dimensional construct can be put into practice to drive fundamental changes in the behavioral healthcare delivery system.
We won the legislative battle for parity in 2008 and now continue the fight to ensure regulations are implemented correctly. I don’t minimize the importance of that battle, but I reject parity as a rallying cry for today. We should be aspiring to achieve something more like authenticity. Because that might seem like a vague objective, it would help to delineate the contours of an authentic state for behavioral healthcare.
I believe it starts with healing the divisions between public and private sectors as well as between mental health and substance use disorders. Authenticity cannot mean being so divided that one side does not know what the other does. We are an industry living in hardened silos, with governmental policy and funding controlled by distinct departments, staffed by practitioners with constricted skills.
We live today with public sector clients using wraparound services to address serious mental illness, while their private sector counterparts get placed repeatedly into discreet silos called levels of care. Public sector clients addicted to opiates get methadone, while private sector doctors prescribe buprenorphine. History and economics should not determine destiny in healthcare.
We need a behavioral healthcare industry without these historical divisions. Yet the fundamental changes to be proposed in this document do not focus on healthcare services. The goal instead is to reformulate our industry’s primary health domains and how they are interconnected. This creates a new clinical model – consolidated behavioral health – that uses some familiar terms but represents a new beginning.
Consolidated behavioral health (CBH)
Physicians specialize in many areas of healthcare, and most of them can be aggregated under the simple rubric of physical health. The designation of behavioral health is much newer, and its focus less obvious. Clinical services will be explored in a follow-up article, but the foundation for that discussion will be established here by reformulating this health domain we call behavioral.
Consolidated behavioral health (CBH) is a clinical model that combines and strengthens three currently separate domains of health:
- Our level of emotional health
- Our use of addictive substances
- Our health-promoting behaviors
The behavioral healthcare industry, as we know it today, has not been structured to understand these components in a cohesive way. We have separate industries for mental health, addiction and wellness. As a clinical model for unifying these health domains, CBH can be the basis for integrating and improving the way healthcare is delivered.
While measures for physical health are well-known and incorporated into every annual physical exam, consolidated behavioral health is in the earliest stages of understanding and implementation. An annual physical may include a brief depression measure, some questions around substance use, and an evaluation of eating and exercise. This would change substantially with recognition of the importance of CBH.
We need a separate annual exam, apart from the physical exam and utilizing online assessments, to determine the consolidated behavioral health of the individual. Our objective will have been reached when a rating of one domain alone is seen as inadequate and only a three-dimensional rating is seen as evaluating one’s consolidated behavioral health.
The term “consolidated” might seem to imply that all three domains are reduced through the process of measurement into a single factor or index. CBH is not a single number. This is not the goal since it would dissolve the significance of each domain into a single, consolidated number. This would defeat the central purpose of highlighting each domain as a uniquely important indicator of behavioral health.
Understanding how CBH makes a difference
We must begin to embrace more fully the comorbidity between mental health and substance use disorders. We need to honestly state that we can’t trust changes in depressive symptoms if drinking is ignored in the background, and we might not celebrate the number of days sober with as much enthusiasm if we knew they were accompanied by painful depression.
Our clinical protocols should be as integrated as our patients. Professionals in training need to understand both MH and SUD in depth, and they must also become proficient at seeing how one can mask, mimic, or potentiate the other. Clinicians should be able to specialize in child or adult work, but there should be no choice about understanding the range of patients under MH and SUD categories.
Our understanding of the interconnectedness of these domains must go beyond diagnostic categories. We should focus less on whether specific diagnoses are comorbid or co-occurring and concentrate on how one health domain can impact the other with symptoms of any degree.
Diagnosis is a paramount concern for psychopharmacology, but health domains can have a significant impact on one another without full diagnostic criteria being met. For example, mild levels of depression can interfere with someone’s efforts to not use substances or to engage in healthy behaviors.
The wellness industry has been in existence for many years with modest results, and it is time for health-promoting behaviors to be the province of experts in behavioral health rather than nutrition and exercise specialists. Health behaviors should not be dangling somewhere on the periphery as wellness, but rather should be situated firmly within the domain of consolidated behavioral health.
Public and private sectors are distinct worlds with unique terms and acronyms, along with unequal funding streams. We have governmental divisions between mental health and addiction services at federal, state, and county levels for historical reasons. We get used to the limits within which we function each day, but a time comes to reorganize. Today may be our best opportunity to do so since the current political focus on healthcare may not endure beyond the 2020 elections.
The public must be included in new messaging about behavioral health. Parity was a classic “inside the beltway” campaign, but a CBH campaign must be broadly addressed to all stakeholders. We should aspire to having it be as revelatory as when mental illness and alcoholism were presented without the stigma and confusion long attached to them.
This proposal suggests a reform that integrates three currently separate dimensions of health status into one. The cohesive, multi-dimensional construct of CBH can be put into practice to drive fundamental changes in the behavioral healthcare delivery system. This will be the subject of the next article.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.