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Beyond Behavioral Health

Recently we received a critical comment from a mental health advocate who, upon reviewing SLHI's Into the Light report on Arizona's public behavioral health system published almost ten years ago, noted that, for all of the report's lofty recommendations, very little has changed. If anything, the system has gotten worse, at least in Maricopa County.

Apparently Arizona's Office of the Court Monitor (for the Arnold v. Sarn lawsuit, still going strong after 28 years) agrees: Their most recent report cited numerous deficiencies under the current Regional Behavioral Health Authority (RBHA) in Maricopa County, worse even than the previous RBHA, which had all sorts of problems itself, and so on.

And while we're citing the local scene, let's not forget the national picture, where the National Alliance on Mental Illness gives the states an average grade of "D" for their public mental health systems, private philanthropic funding for mental health has been declining steadily as a percentage of total investment over the past decade, and polls indicate that the fear and stigma associated with mental illness haven't subsided appreciably over the past 50 years, despite better understanding of the biological basis of brain disorders.

So, why haven't things improved? Lack of leadership, communication, funding, good ideas? Fear and stigma, vested interests, provider infighting? Outmoded institutional structures, bureaucratic red tape, program fragmentation? Excessive profiteering, heavy-handed lawyers, unrealistic expectations?

Or might it be because we continue to carve out mental health from the mainstream of health care and then wonder why we have all these communication and coordination problems?

It's worth recalling how the country got to this point. As the result of "de-institutionalization" in the 1950s and 60s -- the movement from psychiatric hospital-based care to community-based care on the principle of providing care in the "least restrictive setting" -- thousands of people were discharged into a "system" of community services that was created in a crisis mode and mushroomed willy-nilly across layers of government, multiple payers and agencies. Twenty years later, when behavioral health costs were skyrocketing along with the rest of health care costs, the feds turned to the private sector for a solution: an emerging for-profit industry that carved out behavioral health services from the medical mainstream and made a killing doing it. After a decade of rapid consolidation on both the payer and provider sides in the 1990s, the Surgeon General's 1999 report concluded that the U.S. mental health system remained a fragmented, inefficient and inequitable mess, and convened a group to figure out how to "carve in" mental health care in the primary clinical care setting.

But the carve-out cat was already out of the bag. The reasons for carving in are clinical, while the reasons for carving out are primarily financial. We talked about this in our 2003 The Humpty Dumpty Syndrome report, where we made even more "lofty" recommendations. But for every step forward, it feels like two steps back. Behavioral health remains locked in the prison of a separate system, with its attendant language and culture of the "other." Millions of people won't enter it for that very reason. They don't want to be labeled as the "other." They want to be treated as the whole person they are.

Some of our friends in the behavioral health system won't find these comments to be helpful. You have to start from where you are and build on what you have. You don't just blow things up and start over. And they're right. There are things we can do under the current model that will improve communication and coordination, and lead to better outcomes. There are good people with good ideas already out there working on this.

But in the end, the behavioral health carve out perpetuates bad science, diminished care and discredited ideas. Built on the philosophical precepts of Cartesian dualism, it perpetuates the myth of mental states as separate and distinct from physical states, and the fear and stigma that go with it. By separating out 'behavior' and 'mind' from the rest of health care, it relegates the very thing it wishes to elevate to second class treatment status.

We can't very well escape from this prison until we recognize we're in it. Moving beyond the whole idea of behavioral health is a good place to start.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.