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Perspectives

Defining the Full Measure of the Behavioral Healthcare Field

October 13, 2020

Our field needs to be defined in comprehensive, yet succinct terms. The designation “behavioral health” has been with us for decades as the combination of mental health and substance use disorders. This label is well established and need not change, but health behaviors must be added. Unhealthy behaviors are the root cause for numerous chronic conditions, and we specialize in behavior change.

These interconnected categories have previously been described as consolidated behavioral health, and this captures the clinical scope for our field. Yet it misses an important subgroup: those with elevated, yet subclinical levels of psychological distress. People with only some symptoms of mental or substance use disorders may have intense psychological distress contributing to illness and dysfunction.

Distress not only causes dysfunction at subclinical levels, but non-diagnostic, emotionally painful distress can also lead to PCP visits for somatic complaints. What is the full measure of our field? It includes work with three types of individuals: people with global psychological distress, those with clinical disorders under the headings of mental health and substance use, and those with unhealthy lifestyle behaviors.

Why do such efforts to define our field matter? Scope helps determine the funding, location and providers of care. Funding sources include health insurance, as well as employer-sponsored programs for employee assistance, wellness and disease management. Care can be received in both specialty and primary care settings. Professionals and non-professionals have a role in care delivery.

Many stories merit telling as our field evolves, but few are as compelling as the rise of non-professional caregivers. After decades of frustration for consumers over barriers to care related to cost, access and stigma, we are witnessing the emergence of powerful new solutions. We need investment to follow in its path. Certain funding sources are ideal for redistribution to settings with new providers.

The rise of non-professional caregivers

The role of the non-professional caregiver in our field is growing. It is nothing new. Treatment programs have long included staff who excelled at engaging patients in open communication. Recognition is growing that people can be change agents based on a combination of their lived experience and natural therapeutic qualities. Certifications are being created to formalize their value.

Recovery from addiction relied on peers long before credible professionals appeared. The fellowship of others in recovery is still essential. Every day we see more people recovering from severe mental illnesses who are helping peers follow a similar path. Health improvement coaches have moved into life coaching. New products are being developed for non-professionals to provide therapy.

This description of supportive peers without a professional license is incomplete. The dissemination of digital platforms with powerful interactive tools has been a parallel development. Countless studies have found that these platforms are clinically effective, and coaches are being used to potentiate these platforms. They seem to be especially helpful at increasing levels of engagement with the digital tools.

There will always be a need for highly trained licensed professionals for certain tasks and patients, but their supply will never be sufficient. The scale of problems outstrips the supply of professionals when you consider the full measure of need from disorders to behaviors and distress. The rise of non-professional caregivers is based both on need and proven success.

Redirecting funding streams

Funding flows from payers after health conditions are recognized. Consider some milestones. The National Institute of Mental Health was founded in 1949. The AMA declared alcoholism an illness in 1956. Insurance coverage followed. EAPs began in the 1970s. Disease management (DM) needed an association by 1999. Funding flows, and it then changes direction based on treatment approaches.

Insurance funding for mental and substance use disorders was initially restricted to inpatient care, but managed care then directed patients to other levels of care. How might outpatient funding change direction? Separate funding streams support various outpatient interventions today. Is it time to redirect these funds? Let us consider how we might best use insurance, EAP, DM and wellness funding.

Change seems ripe given low rates of utilization for EAP, DM and wellness programs. Add to this fact the effectiveness of new digital and non-professional models. Existing funding is not being maximized. Business leaders will seize upon this and redirect the flow at some point. Where should funding go? Behavioral interventions belong in primary care, along with an array of care providers.

People rarely attend face-to-face EAP visits. Similarly, most decline well-intentioned nursing calls to help with chronic conditions. Wellness services are embraced by healthy people. These valuable services should be based in primary care. A licensed clinician can coordinate this so that people get digital tools, peer counselors, health coaches, and other health and wellbeing services they need.

Leaders love challenges

Behavioral healthcare executives will determine whether the field evolves as suggested here. Some might prefer trends that I neglect. Psychiatry continues to pursue new treatments for major clinical disorders. New medications sustain big hopes. Device categories like neuromodulation or brain stimulation might represent a new wave of innovation. While important, my focus is elsewhere.

Researchers are not about to produce a pill for behavior change, and this is a big problem we need to solve. Given our success helping people with depressive and addictive behaviors, we should focus on unhealthy behaviors driving chronic medical conditions. People feeling lonely appear to be the new smokers in terms of health risks. We can surely help them and many other distressed groups.

We are ready to leverage the power of psychotherapy. This is propelling new digital platforms and non-professional caregivers. We are ready to move funding from under-utilized benefit plans to more promising arrangements. We are ready to move out of the private office into the exam room next to primary care physicians. Yet only farsighted executives can make any of this actually happen.

Leaders are most likely to act based on the allure of a big goal. The size of the one imagined here is noteworthy both for its scope and height. How best to describe it? We need a healthcare system grounded in the human skills of empathy and understanding. It is big, but not grand. Every moon shot need not rest on technology. Smart leaders harness power that is plentiful and in reach.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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