We tend to take for granted how healthcare specialties have been designated or categorized. I have long described myself as a mental health professional, and I have worked for many years in the behavioral healthcare industry. I can’t say that I like either of these classifications, but few people think about challenging such terminology.
As the bedrock for our specialty, we have thoughts, feelings and behaviors to choose from, and I would argue we have been going in the wrong direction from the beginning. People often ask, “How you are feeling today?” but they rarely ask, “How you are thinking or behaving today?” How you are feeling is an everyday reflection, and I would argue that it is the best foundation for classifying or organizing our field.
What led us to the ideas of mental illness and mental health? Would you credit esteemed thought leaders with giving us the concept of behavioral health? In fact, we were using the term “mental illness” when we understood astonishingly little about the various conditions comprising it, and then we created “behavioral health” as an insurance category to include benefits for both mental health disorders and substance use disorders.
There should be little wonder that, decades later, no one really embraces behavioral healthcare as a compelling or easily understood organizing concept. The nomenclature for our field is not really rooted in a clinical or research basis. It is not a proud history we should embrace for the sake of tradition or science. I propose we consider abandoning the status quo to evaluate the concept of emotional health.
Let me start with a brief history of our current terms. Mental health is a biological hypothesis from the 19th century, while behavioral heath is a fabrication of the 20th century insurance industry. Many people are ready to abandon the behavioral health classification since it appeals to no one, but the mental health designation is older, fraught with many more meanings, and closely tied to the apparently well-established concept of mental illness. However, consider this quote from a Johns Hopkins scientist on this issue.
At the turn of the nineteenth century, Darwinian thinking dominated the biological and social sciences. Within the scientific community, mental deviations, i.e., extreme variations, were conceived as having a biological basis, primarily genetic, representing mutations that were unsuccessful adaptations for survival in the environments in which they appeared. This view provided little hope for recovery of the mentally deviant. Around 1900, some physicians and psychologists became convinced that deviant behavior was an expression of illnesses that lay at the other end of a continuum from mental health.
An understanding of histories like this may turn us away from the status quo, but we are still left to question if it is worth taking on the tremendous challenges involved with changing our existing classification terms. Many institutions utilize our existing terminology, and they have little motivation to make changes. I would suggest an impolitic response, namely: “So what?”
Let’s prioritize improving the health of populations rather than the entrenched interests of institutions. I would argue we need some changes to:
1) Decrease stigma with our existing institutions and nomenclature;
2) Increase a basic understanding of what our goals are for many health improvement programs, both clinical and non-clinical in nature; and
3) Gain increased visibility for integrating with the massive healthcare system devoted to physical health.
Change in culture
People readily understand the idea of emotional health. It goes back to the simple question of how people are feeling. We judge our days emotionally, like a thermostat that tells us to what extent we have been hot or cold. We all understand this, but we have a less clear and transparent understanding of the status of our thoughts and behaviors. The concept of emotional health has not been highjacked or contaminated yet. Some health plans and large employers are embracing the concept, but we are in the early days of a new nomenclature.
Let me clarify in practical terms what I am calling for with this argument. First, let me state what I am not proposing.
The DSM is here to stay since it is a very successful institution. It may well evolve to be more clinically useful and more evidence-based over time, but my focus is best understood as a change in culture and terminology. Just as the pioneers of population health management within large employers called for developing a “culture of health” and a “culture of wellness,” I am suggesting we develop a culture of emotional health within the entire healthcare industry. Let’s abandon the mental and behavioral terms and campaign for everyone to improve their emotional health.
Some payers today embrace emotional health as a term for helping people with non-clinical or pre-clinical distress improve their lives. I would argue that it could be much broader than this since we could establish a continuum for emotional health ranging from the extremes of positive to negative emotions. We might ask what is the ideal way to classify a healthcare specialty. Should we start with the diagnostics, the specialists, the treatments, the disease origins, or the phenomenological experience of healthcare consumers? The last option may need a bit of explanation.