Behavioral Mental Health: An Emerging Field of Service or an Oxymoron?

Behavioral Mental Health: An Emerging Field of Service or an Oxymoron? Abstract Proliferation in the use of the terminology around behavioral mental health suggests, on one hand, an emerging field of service that integrates psychiatric, substance abuse, and related services. On the other hand, this development also raises questions about the coherence of this approach. This review explores the history, definitional issues, current trends, and available data on the impact of this field. It considers a variety of critiques of behavioral mental health, such as possibility that the field attempts to integrate fundamentally incompatible domains, that the term “behavioral mental health” is thus an oxymoron, and that it represents a co-optation by the insurance industry of traditional ideals of mental health and of behavioral medicine or as code for the implementation of a medical model that emphasizes short-term, behavioral, and psychopharmacological treatments at the expense of a truly biopsychosocial orientation. Other concerns include the focus on individual change and the effectiveness of behavioral health as a strategy for destigmatizing mental health. Recommendations for addressing the various barriers to realizing the ideals of behavioral mental health include revamping the role of managed care in oversight of treatment decisions, broadening the implementation of evidence-based treatment, and the development of treatment models that build on traditional social work practice models. Government and private mental health and substance abuse agencies have increasingly adopted the terminology of behavioral mental health. Many regard the new nomenclature with indifference, but others believe that these changes are symptomatic of an underlying and unresolved identity crisis in the mental health field, one that undermines the field’s public legitimacy and support. A common defense of the terminology suggests that “behavioral mental health” is simply a more inclusive term that integrates psychiatric, substance abuse, and related services (Backlar, 1996). It has been argued that this term destigmatizes mental health and encourages a more holistic treatment of the populations served. Skeptics, however, regard the new jargon as a code designed to encourage a focus on external behavioral manifestations of mental illness; an exclusive reliance on short-term interventions, especially psychopharmacological treatments and the medical model; and the priorities of a cost-conscious insurance industry (Taylor & Bentley, 2004). It has been suggested that the insurance industry has coopted the ideals and terminology of behavioral medicine to deemphasize those of mental health. If so, this co-optation may have inhibited the development of truly integrative biopsychosocial treatment models. A central question is whether the term “behavioral mental health” has attempted to bridge fundamentally incompatible domains, such as the cognitive and behavioral, and as such, is an oxymoron, or alternatively, whether it describes a workable solution toward integrating services. Particularly prevalent in many behavioral programs are cognitive–behavioral treatments (CBTs). Although few still subscribe to theories of classical and operant behavioral conditioning, the influence of these approaches persists, not only within specialty services such as children’s mental health, particularly developmental disabilities and autism treatment, but also in the push of the insurance industry to restrict payments for conditions that substantially diminish normative social and, specifically, behavioral functioning. Thus, one concern is that behavioral mental health represents a kind of watered-down behaviorism, making it palatable to expanded constituencies. Alternatively, some using this terminology may use it to attempt to link sociocultural, phenomenological, psychoanalytical, cognitive, and behavioral domains in a biopsychosocial conception of the whole person, in particular the substantial numbers of clients who struggle with various comorbid conditions, such as mental illness and substance abuse. As a theoretical review, this article aims to clarify these possibilities and explore the impact of their continuing lack of resolution on trends in and outcomes of behavioral mental health. Ambiguities in the meaning and implementation of behavioral mental health are critical policy issues that mask the unfinished agenda of fully integrating phenomenological, analytical, cognitive, behavioral, and biological approaches in mental health. Historical Roots Behavioral medicine is often cited as the most immediate precursor to behavioral mental health (Kennerly, 2002). Although it is debated whether behavioral medicine represented a repackaging of the older psychodynamic approaches, known as psychosomatic medicine that was associated with Franz Alexander (1965), or was a new and broader development, the terminology of behavioral medicine first appeared in Lee Birk’s,Biofeedback: Behavioral Medicine (1973). The concept of behavioral medicine was then expanded in 1978 to refer to an “interdisciplinary field concerned with the development and integration of behavioral and biomedical science, knowledge and techniques relevant to health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation” (Schwartz & Weiss, 1978, p. 249). Kennerly (2002) similarly explained that “behavioral medicine is an interdisciplinary field of research and clinical practice on the interactions of the physical and social environment, cognition, behavior and biology in health and illness” (p. 6). The overarching concern was the understanding of selected physical illnesses, with knowledge of psychopathology and substance abuse only included so far as they help explain adverse physical health outcomes. Managed care was first introduced in 1937 through experiments with health maintenance organizations by Kaiser Permanente (Fox & Kongstvedt, 2013). However, it did not see significant growth until the 1980s, and in mental health and in the public sector, by the 1990s. Early approaches to managed care typically included capitation, or set advanced payments per insured life. The resulting disincentives for service delivery stimulated considerable pushback from providers who often benefit from the linkage of payments with quantity of service provided. As a result, insurance companies developed various devices to simultaneously continue to contain costs, yet not to alienate consumers, and to provide some modicum of consumer choice. These included soft capitation and shared risk contracts, as well as preferred provider organizations (PPOs) and point of service (POS) plans. Whereas soft capitation and shared risk contracts served to minimize the disincentives for service provision that had been instituted in the first generation of managed care, PPOs and POS plans incentivized the use of a selected group of providers, yet retained some possibilities for insured individuals to go to nonpreferred providers at additional cost. These developments, apparent by the turn of the 21st century, also included a movement away from the terminology of managed care, which by then had developed considerable bad press. It was in this context that both insurance companies and their agency clients began to use the nomenclature of behavioral health or behavioral mental health to refer to their managed mental health care programs. Mowbray, Grazier, and Holter (2002) argued that, as with managed physical health care, the introduction of managed behavioral health care was driven by economic concerns, specifically, the continuing pressure for the containment of health care costs, resulting in the progressive diminution of the proportion of health care expenditures devoted to mental health and substance abuse. Mowbray and her colleagues pointed out that, in this respect, many of the forces driving the flawed policy of psychiatric deinstitutionalization also came to dominate the continued development of community mental health under the rubric of “behavioral health care.” Definitional Issues Although the term “behavioral health” is perhaps the broadest of those currently being promoted, it is usually used synonymously with “behavioral mental health.” Proposed definitions and usages of these and related terms vary considerably and range from the most inclusive to the highly targeted. They also vary based on whether they refer to a field of service, types of disabilities addressed, or the organizational auspice in which these services are provided. At its broadest, “behavioral health” is used as an umbrella term that includes all services that traditionally have been referred to as mental health and substance abuse; developmental disabilities; and those designed for less severe emotional disturbances, including stress management issues (Backlar, 1996). Warren (2011) also included psychosocial issues, such as job dissatisfaction, workplace conflict, and a lack of balance between personal life and work. But more typically, behavioral health, as Blount et al. (2007) defined the term, is used to encompass services directed at mental illness and substance abuse, and sometimes those that are characterized as behavioral medicine, defined as services designed to intervene on physical health using behavioral means. Examples are health behavior change programs; education for better coping with illness; programs to improve adherence to medical regimens; and services that access the relaxation response, such as relaxation training, biofeedback, hypnosis, visualization, and mindfulness.” (p. 297) Another approach to casting such a broad net has been to treat behavioral health as the application of behavioral science knowledge to both physical and emotional functioning (see Taylor & Bentley, 2004). Such broad definitions do not necessarily include the implication that the services are provided in any particular manner. However, some have sought to further narrow the term to specify that such services should actively integrate physical and mental health, particularly in primary care settings. For example, behavioral health has been defined as “a branch of interdisciplinary health which focuses on the reciprocal relationship between the holistic view of human behavior and the well-being of the body as a whole entity” (Healthcare Information and Management Systems Society, 2017). Such approaches have been become more common with the efforts in recent years to develop patient-centered medical homes (PCMHs) in primary care practice under the Patient Protection and the Affordable Care Act (Bao, Casalino, & Pincus, 2013). Although the integration of physical care, mental health, and substance abuse services has been pursued by some for many years now, there are few successful models (Center for Mental Health Services, 2003; Coleman et al., 2005; Dougherty, 2003; Forquer & Sabin, 2002). Too often, discussions of integration remain empty rhetoric. In many areas, behavioral health is treated as if it were synonymous with insurance-funded services, or more specifically with managed care, no doubt because most behavioral mental health agencies receive the preponderance of their funding through managed care contracts. One commentator (Sandler, 2009) complained that “finally, ‘behavioral health’ seems like a concept that was created by someone who works for an insurance company, rather than someone who has struggled with mental health issues” (para. 9). In this respect, behavioral health care is defined not only by the conditions treated or services provided, but also by the mode of their funding. A key organization that has promoted this approach is the National Committee for Quality Assurance (NCQA). They have developed an accreditation program for Managed Behavioral Healthcare Organizations (MBHOs), which they define in the following terms: Managed behavioral healthcare organizations (MBHO) can be independent organizations, can be part of a health plan or can be supported by health care providers. All have a common focus: deliver value. Key strategies for accomplishing this include network development, performance measurement, managing utilization, coordinating care and setting payment rates. (NCQA, n.d.) Although they forego the stronger notion of service integration, MBHOs emphasize service coordination, typically pursued through programs of care coordination or case management, including that for both medical and mental health care. Even more narrow, behavioral health has been assumed to be mental health or substance abuse services that are publically financed, often delivered through public managed care mechanisms, such as insurance contracted carve-out programs. Beginning in the early 1990s, managed care contracts have been issued by various governmental entities, supported by the 1915b waivers of the Social Security Act provisions that guarantee consumer choice of providers under state Medicaid programs. Only by permitting states to restrict this choice of providers has it been possible to establish some of the massive behavioral health programs that are becoming increasingly common. Behavioral mental health services have also been defined by citing particular diagnostic categories, typically those characterized by the most overt and stigmatized behaviors. Behavioral disorders, according to this view, primarily involve inattention, hyperactivity, impulsivity, deviant behavior, drug use, and criminal activity. One such definition of behavioral disorders involves “a pattern of disruptive behaviors in children that last for at least 6 months and cause problems in school, at home and in social situations” (MentalHealth.gov, n.d., para. 1). Although most behavioral mental health agencies do not restrict services to such a profile, they have been under increasing pressure to define the particular behavioral disorders that qualify for services, if only with the goal of defining “medically necessary” services. In practice, efforts to narrow the definition of behavioral mental health usually start with a list of serious mental illnesses, types of substance abuse, and related disorders. The terminology is often used to refer to large publicly funded private agencies that rely on managed care funding from private insurance companies but also, increasingly, public sources such as Medicaid and Medicare. Some suggest that such behavioral mental health services attempt to be integrative, even bridging health and mental health care. Although government agencies such as the Substance Abuse and Mental Health Services Administration have sought to promote the broader umbrella definitions (see Peek & National Integration Academy Council, 2013), these definitions have provided little guidance. One observer cynically noted, Not to be too much of a stickler here, but I don’t really know what a “behavioral health disorder” is. The most precise definition would be “whatever mental or psychiatric disorder that a managed care company has decided that they will pay for”. Behavioral health is basically a business term with no medical or psychological meaning. As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary “medical necessity” criteria. (Dawson, 2013) Trends Despite the apparent increases in the popularity of behavioral health terminology, the overwhelming preponderance of references to this field has continued to rely on the more “traditional” nomenclature of mental health. Searches of Google Scholar and the overall Google databases illustrate this pattern. Figure 1 shows that within the scholarly literature, the ratio of references to “behavioral health” or “behavioral mental health” in journal titles increased only from 2 out of 4,250 (0.05 percent) in the 1970–1974 period, to 1,579 out of 21,400 (7.3 percent) in the 2010–2014 period—although a substantial increase, still only a small proportion of the total. A search of the larger Google database, which also includes popular and agency Web sites, shows that references to “behavioral health” or “behavioral mental health” were at the 19 million level, about a 10th (10.1 percent) of the 188 million references to mental health. It is, thus, evident that although the term “behavioral health” has substantially grown in its usage, it remains considerably less prevalent than “mental health.” Figure 1: View largeDownload slide Trends in the Relative Use of Terms “Mental Health” and “Behavioral Health” in Journal Article Titles (1970–2014) Figure 1: View largeDownload slide Trends in the Relative Use of Terms “Mental Health” and “Behavioral Health” in Journal Article Titles (1970–2014) Unfortunately, as a result of a lack of any commonly agreed-on definitions for the behavioral mental health terminology, there are no reliable statistical indicators of the extent of its implementation within the larger mental health field. Identified service trends instead represent trends in mental health in general. There was a dramatic expansion of mental health services under Medicaid (Buck, 2003), such that by 2009, Medicaid was the single largest payer for mental health services (Mechanic, 2014), suggesting that its focus on services as implemented by insurance industry carve-outs may be one of the driving forces behind the expansion of behavioral health services. A related trend has been identified by David Mechanic (2014), who pointed out that the behavioral health system has been increasingly dominated by dependence on pharmaceuticals, and less so by alternative or complementary services such as psychotherapy and other evidence-based treatments (EBTs), pointing out that pharmaceuticals increased from 8.6 percent of mental health outlays in 1990 to 28.5 percent by 2009. In respect to the expansion of managed care carve-out programs that are often used for behavioral mental health, reports show that by as early as 2000, 42 states had developed some form of managed behavioral health care with 17.2 million enrolled lives. At that point 10 states—California, Maryland, Massachusetts, Michigan, New York, Oregon, Pennsylvania, Tennessee, Texas, and Washington—served 80 percent of these individuals (Coleman et al., 2005). These included both statewide and selected local, county, and regional programs. Such developments illustrate the expanded funding of behavioral mental health under Medicaid. Impact Just as the definition of behavioral mental health has been ambiguous, and the trends similarly ill defined, data on the impact of the apparent expansion of the field have been scant. Nonetheless, there are bodies of research that suggest a discernible impact, primarily on service costs; less so on service provision; and exceptionally little on service quality and effectiveness. The available research tends to conflate behavioral mental health with managed mental health care, two overlapping frames that are often used by commentators. This is especially the case with services that are publicly funded, and thus any definitive conclusions about the overall impact remain premature. There is ample evidence that behavioral mental health, at least to the extent it has been implemented through managed care mechanisms, has reduced costs. One review of 91 studies concluded that active behavioral health treatment reduced costs for overall medical care by an average of 17 percent compared with controls (Chiles, Lambert, & Hatch, 1999). Another early review reported evidence for the cost-effectiveness in each of seven different pathways for cost savings in behavioral mental health (Blount et al., 2007). It has been suggested that the more behavioral health interventions target particular medical conditions, through behavioral medicine, case management, or integrated health care, the greater have been the cost savings. In contrast, very limited savings are realized through generic behavioral health interventions such as outpatient psychotherapy. Unfortunately, there is also little evidence that the savings realized have been put toward improvement of care for people with serious mental illness (Mowbray et al., 2002). Given the apparent cost savings, it should be of little surprise that there have been reductions in service provision reported under managed behavioral mental health care. Mechanic and McAlpine (1999) reported overall reductions in mental health care regardless of diagnosis or severity of symptoms. Some studies report that the length of treatment has been reduced, particularly through programs contracted on a carve-out basis, a development not well suited for those with problems of persistent mental illness (see Mechanic, 2012, 2014; Mowbray et al., 2002). Another potential problem is that contracts for publicly funded behavioral mental health care are often only annual contracts, ill-suited for clients with persistent mental or substance abuse disorders. And finally, it is well known that capitated forms of payment are associated with incentives to minimize service delivery, as the savings can often be used for profit. Coleman et al. (2005) emphasized ongoing concerns about the incentives implicit in managed behavioral health, especially when capitation is used, to undertreat those with the most severe and expensive conditions and instead focus on acute care. Quality has been rarely examined in behavioral health care programs. However, a major study by Leff et al. (2005) involved a comparison of 958 clients in several managed behavioral health programs with 1,011 clients in traditional fee-for-service mental health programs. The modeling procedures controlled for a range of alternative explanations, standardized for the case mix differences in the various cohorts involved in the study. Some differences emerged, but none in respect to hours of service received or level of health achieved were statistically significant using a bioequivalence criterion of 5 percent. Likewise, Mowbray et al. (2002) concluded that the “efficiencies and cost-effectiveness touted by managed care proponents may be negated by current models” (p. 164). Thus, although there is evidence of cost-savings in at least publicly funded behavioral health care, along with reduced service provision, there is exceptionally little evidence for the quality and effectiveness of the services actually delivered. The challenges of developing an evidence base for such interventions, even after almost 30 years of implementation, are not unexpected given the many ambiguities in what is defined as behavioral mental health. Ongoing questions about the quality and outcomes of behavioral health services emerge in part from observations that the de facto behavioral health care system occurs within the general medical systems and does not usually involve providers trained as mental health professionals. Thus, there is often an overreliance by primary care providers on prescribing psychotropic medications, and the diversity of needed mental health services, whether psychotherapy, family therapy, day programs, or psychiatric rehabilitation, are rarely arranged (Warren, 2011). Discussion At the same time that the language of behavioral mental health is spreading, mainly with large publicly funded mental health programs, it is evident that the lack of agreement on its meaning contributes to confusion regarding the essential elements of this approach and its cohesiveness as a field of service. Concerns about the approach abound, but they are likewise varied, some of which reflect long-standing criticisms of the mental health field in general. For example, Sandler (2009) noted that the focus of behavioral health is on individual change, and that the approach minimizes work to change social and other environmental conditions, such as poverty, discrimination, and abuse, that place individuals at risk of behavioral disorders. Although the ideals of community mental health, pursued initially in the 1960s (see Caplan, 1961), were based on a holistic public health approach to address iatrogenic social conditions, the actual implementation of this ideal clearly fell short long before the advent of behavioral mental health. Others contend that the behavioral mental health nomenclature is actually a code for an intensified focus on the biological interpretation of mental illness as a brain disease or even a traditional medical model that relies on psychopharmacological treatments. This is in stark contrast to the original ideals of the field of behavioral medicine that emphasized an inclusive approach to mind–body issues (Taylor & Bentley, 2004). It is true that the last quarter century has seen an expansion in biological models of mental illness, given the many advances in neurological research made possible by new imagining technologies such as functional magnetic resonance imaging. But it is also clear that the impact of this expansion likewise goes beyond behavioral mental health, to encompass other areas of mental health and the human services. Consistent with the criticisms of behavioral mental health that involve the individual and the biological focus, others have noted that this field ignores both causes and the individual’s internal or subjective understanding, motivations, and decisions. For example, Sandler (2009) pointed out that within the field of suicide prevention it would be inappropriate to focus only on behaviors associated with suicidality, rather than the underlying causes of those behaviors. Consistent with behaviorally oriented treatments, the focus is on reducing or eliminating symptoms of disorders, rather than addressing the complex intermingling of biological and social conditions, with limited sense of individual agency that many clients experience. A related observation is that both mental health and behavioral health are used as consumerist euphemisms for mental illness and normative behavioral dysfunctions (Nidhi, 2016). Ideals of health and social functioning, along with a recognition of the strengths of clients, are obscured in the pressure to meet concrete, short-term treatment objectives. Frequent changes in terminology have often been made in response to the stigma associated with mental illness. New and less stigmatizing terms are sometimes adopted to minimize and normalize, but also as a marketing strategy to expand client demand for services. The many shifts in language and the resulting lack of definition of newer terms may be associated with a more fundamental criticism of behavioral mental health, namely, its lack of theoretical and practice integration. Many are currently arguing for a more inclusive biopsychosocial approach to social work practice, especially when comorbidities of serious mental illness, substance abuse, and physical illness are considered. However, the developments of intervention models that fulfill the ideals of service integration have been remarkably scant. The usual answers—care coordination, colocation of services, and the development of electronic medical records in the context of primary practice—have been promoted for many decades now, but with limited success. Associated with the well-known problem of lack of integration is that of poor communication among mental health professionals noted by Coleman et al. (2005). These problems—lack of definition, limited conceptual integration, poor communication, and the excessive individual and biological emphasis of much of behavioral mental health—can all be assumed to be implicated in the purported inconsistency in the implementation of behavioral mental health. Coleman et al. also pointed out that states can define eligibility and implement waiver programs for the Medicaid behavioral health programs in dramatically different ways. Despite the many actual and purported problems with the emerging interest in behavioral mental health, it clearly promotes some important ideals, though with little evidence of success. It attempts to reduce stigma by deemphasizing internal or mental states. In casting a broad net that encompasses some traditionally excluded populations, such as those with substance use disorders and developmental disabilities, it attempts to relieve problems of service access, in part through the push to restrict length of treatment and limit it to those conditions that qualify as medical necessities. It also attempts to address problems of service access through cost containment efforts that rely on a variety of managed care mechanisms. Most important is the emerging interest in service integration, in respect to the well-known prevalence of comorbid conditions such as mental illness, substance abuse, and physical ill health. Barriers to realizing these ideals include the continuing escalation of medical costs and limitations in the ability of the mental health professions to generate a sufficiently trained workforce, particularly in low-income areas. But perhaps more significant are several potential contradictions inherent in the behavioral mental health ideology. One is the conflict between the interest in taking a short-term pragmatic approach based on manifest behavioral dysfunctions, and the interest in a holistic and integrative approach that treats the whole person and intervenes in the community. Unless mental health practitioners are highly expert, this high bar potentially leads to unrealistic treatment goals and a tendency for assessment and diagnosis of the multiple comorbid conditions to minimize opportunities for treatment, a long-term problem that subscribers to the medical model have faced. In addition, efforts to limit service intensity will increase the pressure to refer (essentially, to pass) persistent, complicated, and expensive cases to other providers. Another core problem with the behavioral health ideology is that the focus on external behaviors is often at odds with work with clients on underlying dysfunctions in cognition and affect. The proliferating interest in CBTs represents a natural effort to bridge such divisions. However, any truly behavioral focus, especially that embodied in fields such as applied behavioral analysis, with its preoccupation with behavioral contingencies, rewards, incentives, and reinforcements, leaves out much that is important. Specifically, it short-shrifts underlying client motivations, beliefs, and attitudes, conscious or unconscious, based on assumptions that consciousness and self-determination are epiphenomenal and that motivation and agency are derivative and not primary in understanding behavioral dysfunction. If this is so—and it has not definitely been established whether that is the case—then the incompatibility of the behavioral and mental or cognitive dimensions in behavioral mental health would clearly support the possibility that the rubric of behavioral mental health is an oxymoron. And if this is the case, then the problems identified earlier, particularly the lack of practical approaches to service integration, can be understood as expressions of the conceptual challenges of bridging these separate dimensions. How might these concerns be addressed? One way is to support the recent trend to divest payers, particularly insurance companies, of the business of micromanaging the treatment decisions of mental health professionals, through such techniques as preauthorization, utilization review, and use of provider panels. Recent alternatives, such as accountable care organizations and PCMHs, delegate these responsibilities to providers while establishing global budgets and bundled payments to serve the need for cost containment, along with capitation rates adjusted to the level of risk (Bao et al., 2013). Another option is to support EBTs, but to adopt a more expansive approach that focuses on promoting the process of evidence-based decision making, rather than simply prescribing treatments with validated outcomes, often those that have been manualized (Hudson, 2009). Promoting a process-oriented conception of EBT entails training practitioners to actively evaluate relevant evidence as part of treatment planning rather than uncritically adopting treatments that are reputed to be empirically supported. Part of this revision of EBT involves an expanded view of what constitutes evidence, one that includes professional consensus and best practices, even if they are not always supported by randomized clinical trials (Hudson, 2009). Such an expansion should aim at striking a balance between a focus on quality processes consistent with social work values, with the achievement of demonstrable outcomes. A reconciliation is needed between process-oriented clinicians and the preoccupation with outcomes, but to achieve this, such plans need to be the basis for professional training, licensing, and accreditation. Current accreditation initiatives in behavioral mental health, particularly those embodied by the National Institute of Behavioral Health Quality and the American Board of Behavioral Healthcare Practice, which restrict them to doctoral-level psychiatrists and psychologists, are shortsighted and ignore the preponderance of master’s level clinicians, particularly social workers, in the field. Most important is the continued development and evaluation of intervention and treatment models and methods that operationalize the major approaches to service integration in particular service sectors, whether primary care or the specialty mental health sector. The professional literature abounds with rhetorical discussions of service integration, with few practical directions in this regard. Service models need to distinguish between the use of particular methods, such as CBT, dialectical behavior treatment, and the like, and establish guidelines for transition between and coordination with multiple methods, whether intensive case management, psychoeducation, case advocacy, income maintenance, supported housing, or supported employment. Such strategically oriented service models, whether some version of generalist social work practice such as the simultaneity (Jackson, Macy, & Day, 1984) or structural models (Wood & Middleman, 1989), will require the support of service agencies that transcend behavioral health boundaries. Thus, the continued expansion of the behavioral mental health field is a work in progress for which the jury is still out. 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Behavioral Mental Health: An Emerging Field of Service or an Oxymoron?

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© 2017 National Association of Social Workers
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0037-8046
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Abstract

Abstract Proliferation in the use of the terminology around behavioral mental health suggests, on one hand, an emerging field of service that integrates psychiatric, substance abuse, and related services. On the other hand, this development also raises questions about the coherence of this approach. This review explores the history, definitional issues, current trends, and available data on the impact of this field. It considers a variety of critiques of behavioral mental health, such as possibility that the field attempts to integrate fundamentally incompatible domains, that the term “behavioral mental health” is thus an oxymoron, and that it represents a co-optation by the insurance industry of traditional ideals of mental health and of behavioral medicine or as code for the implementation of a medical model that emphasizes short-term, behavioral, and psychopharmacological treatments at the expense of a truly biopsychosocial orientation. Other concerns include the focus on individual change and the effectiveness of behavioral health as a strategy for destigmatizing mental health. Recommendations for addressing the various barriers to realizing the ideals of behavioral mental health include revamping the role of managed care in oversight of treatment decisions, broadening the implementation of evidence-based treatment, and the development of treatment models that build on traditional social work practice models. Government and private mental health and substance abuse agencies have increasingly adopted the terminology of behavioral mental health. Many regard the new nomenclature with indifference, but others believe that these changes are symptomatic of an underlying and unresolved identity crisis in the mental health field, one that undermines the field’s public legitimacy and support. A common defense of the terminology suggests that “behavioral mental health” is simply a more inclusive term that integrates psychiatric, substance abuse, and related services (Backlar, 1996). It has been argued that this term destigmatizes mental health and encourages a more holistic treatment of the populations served. Skeptics, however, regard the new jargon as a code designed to encourage a focus on external behavioral manifestations of mental illness; an exclusive reliance on short-term interventions, especially psychopharmacological treatments and the medical model; and the priorities of a cost-conscious insurance industry (Taylor & Bentley, 2004). It has been suggested that the insurance industry has coopted the ideals and terminology of behavioral medicine to deemphasize those of mental health. If so, this co-optation may have inhibited the development of truly integrative biopsychosocial treatment models. A central question is whether the term “behavioral mental health” has attempted to bridge fundamentally incompatible domains, such as the cognitive and behavioral, and as such, is an oxymoron, or alternatively, whether it describes a workable solution toward integrating services. Particularly prevalent in many behavioral programs are cognitive–behavioral treatments (CBTs). Although few still subscribe to theories of classical and operant behavioral conditioning, the influence of these approaches persists, not only within specialty services such as children’s mental health, particularly developmental disabilities and autism treatment, but also in the push of the insurance industry to restrict payments for conditions that substantially diminish normative social and, specifically, behavioral functioning. Thus, one concern is that behavioral mental health represents a kind of watered-down behaviorism, making it palatable to expanded constituencies. Alternatively, some using this terminology may use it to attempt to link sociocultural, phenomenological, psychoanalytical, cognitive, and behavioral domains in a biopsychosocial conception of the whole person, in particular the substantial numbers of clients who struggle with various comorbid conditions, such as mental illness and substance abuse. As a theoretical review, this article aims to clarify these possibilities and explore the impact of their continuing lack of resolution on trends in and outcomes of behavioral mental health. Ambiguities in the meaning and implementation of behavioral mental health are critical policy issues that mask the unfinished agenda of fully integrating phenomenological, analytical, cognitive, behavioral, and biological approaches in mental health. Historical Roots Behavioral medicine is often cited as the most immediate precursor to behavioral mental health (Kennerly, 2002). Although it is debated whether behavioral medicine represented a repackaging of the older psychodynamic approaches, known as psychosomatic medicine that was associated with Franz Alexander (1965), or was a new and broader development, the terminology of behavioral medicine first appeared in Lee Birk’s,Biofeedback: Behavioral Medicine (1973). The concept of behavioral medicine was then expanded in 1978 to refer to an “interdisciplinary field concerned with the development and integration of behavioral and biomedical science, knowledge and techniques relevant to health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation” (Schwartz & Weiss, 1978, p. 249). Kennerly (2002) similarly explained that “behavioral medicine is an interdisciplinary field of research and clinical practice on the interactions of the physical and social environment, cognition, behavior and biology in health and illness” (p. 6). The overarching concern was the understanding of selected physical illnesses, with knowledge of psychopathology and substance abuse only included so far as they help explain adverse physical health outcomes. Managed care was first introduced in 1937 through experiments with health maintenance organizations by Kaiser Permanente (Fox & Kongstvedt, 2013). However, it did not see significant growth until the 1980s, and in mental health and in the public sector, by the 1990s. Early approaches to managed care typically included capitation, or set advanced payments per insured life. The resulting disincentives for service delivery stimulated considerable pushback from providers who often benefit from the linkage of payments with quantity of service provided. As a result, insurance companies developed various devices to simultaneously continue to contain costs, yet not to alienate consumers, and to provide some modicum of consumer choice. These included soft capitation and shared risk contracts, as well as preferred provider organizations (PPOs) and point of service (POS) plans. Whereas soft capitation and shared risk contracts served to minimize the disincentives for service provision that had been instituted in the first generation of managed care, PPOs and POS plans incentivized the use of a selected group of providers, yet retained some possibilities for insured individuals to go to nonpreferred providers at additional cost. These developments, apparent by the turn of the 21st century, also included a movement away from the terminology of managed care, which by then had developed considerable bad press. It was in this context that both insurance companies and their agency clients began to use the nomenclature of behavioral health or behavioral mental health to refer to their managed mental health care programs. Mowbray, Grazier, and Holter (2002) argued that, as with managed physical health care, the introduction of managed behavioral health care was driven by economic concerns, specifically, the continuing pressure for the containment of health care costs, resulting in the progressive diminution of the proportion of health care expenditures devoted to mental health and substance abuse. Mowbray and her colleagues pointed out that, in this respect, many of the forces driving the flawed policy of psychiatric deinstitutionalization also came to dominate the continued development of community mental health under the rubric of “behavioral health care.” Definitional Issues Although the term “behavioral health” is perhaps the broadest of those currently being promoted, it is usually used synonymously with “behavioral mental health.” Proposed definitions and usages of these and related terms vary considerably and range from the most inclusive to the highly targeted. They also vary based on whether they refer to a field of service, types of disabilities addressed, or the organizational auspice in which these services are provided. At its broadest, “behavioral health” is used as an umbrella term that includes all services that traditionally have been referred to as mental health and substance abuse; developmental disabilities; and those designed for less severe emotional disturbances, including stress management issues (Backlar, 1996). Warren (2011) also included psychosocial issues, such as job dissatisfaction, workplace conflict, and a lack of balance between personal life and work. But more typically, behavioral health, as Blount et al. (2007) defined the term, is used to encompass services directed at mental illness and substance abuse, and sometimes those that are characterized as behavioral medicine, defined as services designed to intervene on physical health using behavioral means. Examples are health behavior change programs; education for better coping with illness; programs to improve adherence to medical regimens; and services that access the relaxation response, such as relaxation training, biofeedback, hypnosis, visualization, and mindfulness.” (p. 297) Another approach to casting such a broad net has been to treat behavioral health as the application of behavioral science knowledge to both physical and emotional functioning (see Taylor & Bentley, 2004). Such broad definitions do not necessarily include the implication that the services are provided in any particular manner. However, some have sought to further narrow the term to specify that such services should actively integrate physical and mental health, particularly in primary care settings. For example, behavioral health has been defined as “a branch of interdisciplinary health which focuses on the reciprocal relationship between the holistic view of human behavior and the well-being of the body as a whole entity” (Healthcare Information and Management Systems Society, 2017). Such approaches have been become more common with the efforts in recent years to develop patient-centered medical homes (PCMHs) in primary care practice under the Patient Protection and the Affordable Care Act (Bao, Casalino, & Pincus, 2013). Although the integration of physical care, mental health, and substance abuse services has been pursued by some for many years now, there are few successful models (Center for Mental Health Services, 2003; Coleman et al., 2005; Dougherty, 2003; Forquer & Sabin, 2002). Too often, discussions of integration remain empty rhetoric. In many areas, behavioral health is treated as if it were synonymous with insurance-funded services, or more specifically with managed care, no doubt because most behavioral mental health agencies receive the preponderance of their funding through managed care contracts. One commentator (Sandler, 2009) complained that “finally, ‘behavioral health’ seems like a concept that was created by someone who works for an insurance company, rather than someone who has struggled with mental health issues” (para. 9). In this respect, behavioral health care is defined not only by the conditions treated or services provided, but also by the mode of their funding. A key organization that has promoted this approach is the National Committee for Quality Assurance (NCQA). They have developed an accreditation program for Managed Behavioral Healthcare Organizations (MBHOs), which they define in the following terms: Managed behavioral healthcare organizations (MBHO) can be independent organizations, can be part of a health plan or can be supported by health care providers. All have a common focus: deliver value. Key strategies for accomplishing this include network development, performance measurement, managing utilization, coordinating care and setting payment rates. (NCQA, n.d.) Although they forego the stronger notion of service integration, MBHOs emphasize service coordination, typically pursued through programs of care coordination or case management, including that for both medical and mental health care. Even more narrow, behavioral health has been assumed to be mental health or substance abuse services that are publically financed, often delivered through public managed care mechanisms, such as insurance contracted carve-out programs. Beginning in the early 1990s, managed care contracts have been issued by various governmental entities, supported by the 1915b waivers of the Social Security Act provisions that guarantee consumer choice of providers under state Medicaid programs. Only by permitting states to restrict this choice of providers has it been possible to establish some of the massive behavioral health programs that are becoming increasingly common. Behavioral mental health services have also been defined by citing particular diagnostic categories, typically those characterized by the most overt and stigmatized behaviors. Behavioral disorders, according to this view, primarily involve inattention, hyperactivity, impulsivity, deviant behavior, drug use, and criminal activity. One such definition of behavioral disorders involves “a pattern of disruptive behaviors in children that last for at least 6 months and cause problems in school, at home and in social situations” (MentalHealth.gov, n.d., para. 1). Although most behavioral mental health agencies do not restrict services to such a profile, they have been under increasing pressure to define the particular behavioral disorders that qualify for services, if only with the goal of defining “medically necessary” services. In practice, efforts to narrow the definition of behavioral mental health usually start with a list of serious mental illnesses, types of substance abuse, and related disorders. The terminology is often used to refer to large publicly funded private agencies that rely on managed care funding from private insurance companies but also, increasingly, public sources such as Medicaid and Medicare. Some suggest that such behavioral mental health services attempt to be integrative, even bridging health and mental health care. Although government agencies such as the Substance Abuse and Mental Health Services Administration have sought to promote the broader umbrella definitions (see Peek & National Integration Academy Council, 2013), these definitions have provided little guidance. One observer cynically noted, Not to be too much of a stickler here, but I don’t really know what a “behavioral health disorder” is. The most precise definition would be “whatever mental or psychiatric disorder that a managed care company has decided that they will pay for”. Behavioral health is basically a business term with no medical or psychological meaning. As far as I can tell, it was designed to disenfranchise psychiatrists and other mental health providers and yet the rationale for denying treatment was always proprietary “medical necessity” criteria. (Dawson, 2013) Trends Despite the apparent increases in the popularity of behavioral health terminology, the overwhelming preponderance of references to this field has continued to rely on the more “traditional” nomenclature of mental health. Searches of Google Scholar and the overall Google databases illustrate this pattern. Figure 1 shows that within the scholarly literature, the ratio of references to “behavioral health” or “behavioral mental health” in journal titles increased only from 2 out of 4,250 (0.05 percent) in the 1970–1974 period, to 1,579 out of 21,400 (7.3 percent) in the 2010–2014 period—although a substantial increase, still only a small proportion of the total. A search of the larger Google database, which also includes popular and agency Web sites, shows that references to “behavioral health” or “behavioral mental health” were at the 19 million level, about a 10th (10.1 percent) of the 188 million references to mental health. It is, thus, evident that although the term “behavioral health” has substantially grown in its usage, it remains considerably less prevalent than “mental health.” Figure 1: View largeDownload slide Trends in the Relative Use of Terms “Mental Health” and “Behavioral Health” in Journal Article Titles (1970–2014) Figure 1: View largeDownload slide Trends in the Relative Use of Terms “Mental Health” and “Behavioral Health” in Journal Article Titles (1970–2014) Unfortunately, as a result of a lack of any commonly agreed-on definitions for the behavioral mental health terminology, there are no reliable statistical indicators of the extent of its implementation within the larger mental health field. Identified service trends instead represent trends in mental health in general. There was a dramatic expansion of mental health services under Medicaid (Buck, 2003), such that by 2009, Medicaid was the single largest payer for mental health services (Mechanic, 2014), suggesting that its focus on services as implemented by insurance industry carve-outs may be one of the driving forces behind the expansion of behavioral health services. A related trend has been identified by David Mechanic (2014), who pointed out that the behavioral health system has been increasingly dominated by dependence on pharmaceuticals, and less so by alternative or complementary services such as psychotherapy and other evidence-based treatments (EBTs), pointing out that pharmaceuticals increased from 8.6 percent of mental health outlays in 1990 to 28.5 percent by 2009. In respect to the expansion of managed care carve-out programs that are often used for behavioral mental health, reports show that by as early as 2000, 42 states had developed some form of managed behavioral health care with 17.2 million enrolled lives. At that point 10 states—California, Maryland, Massachusetts, Michigan, New York, Oregon, Pennsylvania, Tennessee, Texas, and Washington—served 80 percent of these individuals (Coleman et al., 2005). These included both statewide and selected local, county, and regional programs. Such developments illustrate the expanded funding of behavioral mental health under Medicaid. Impact Just as the definition of behavioral mental health has been ambiguous, and the trends similarly ill defined, data on the impact of the apparent expansion of the field have been scant. Nonetheless, there are bodies of research that suggest a discernible impact, primarily on service costs; less so on service provision; and exceptionally little on service quality and effectiveness. The available research tends to conflate behavioral mental health with managed mental health care, two overlapping frames that are often used by commentators. This is especially the case with services that are publicly funded, and thus any definitive conclusions about the overall impact remain premature. There is ample evidence that behavioral mental health, at least to the extent it has been implemented through managed care mechanisms, has reduced costs. One review of 91 studies concluded that active behavioral health treatment reduced costs for overall medical care by an average of 17 percent compared with controls (Chiles, Lambert, & Hatch, 1999). Another early review reported evidence for the cost-effectiveness in each of seven different pathways for cost savings in behavioral mental health (Blount et al., 2007). It has been suggested that the more behavioral health interventions target particular medical conditions, through behavioral medicine, case management, or integrated health care, the greater have been the cost savings. In contrast, very limited savings are realized through generic behavioral health interventions such as outpatient psychotherapy. Unfortunately, there is also little evidence that the savings realized have been put toward improvement of care for people with serious mental illness (Mowbray et al., 2002). Given the apparent cost savings, it should be of little surprise that there have been reductions in service provision reported under managed behavioral mental health care. Mechanic and McAlpine (1999) reported overall reductions in mental health care regardless of diagnosis or severity of symptoms. Some studies report that the length of treatment has been reduced, particularly through programs contracted on a carve-out basis, a development not well suited for those with problems of persistent mental illness (see Mechanic, 2012, 2014; Mowbray et al., 2002). Another potential problem is that contracts for publicly funded behavioral mental health care are often only annual contracts, ill-suited for clients with persistent mental or substance abuse disorders. And finally, it is well known that capitated forms of payment are associated with incentives to minimize service delivery, as the savings can often be used for profit. Coleman et al. (2005) emphasized ongoing concerns about the incentives implicit in managed behavioral health, especially when capitation is used, to undertreat those with the most severe and expensive conditions and instead focus on acute care. Quality has been rarely examined in behavioral health care programs. However, a major study by Leff et al. (2005) involved a comparison of 958 clients in several managed behavioral health programs with 1,011 clients in traditional fee-for-service mental health programs. The modeling procedures controlled for a range of alternative explanations, standardized for the case mix differences in the various cohorts involved in the study. Some differences emerged, but none in respect to hours of service received or level of health achieved were statistically significant using a bioequivalence criterion of 5 percent. Likewise, Mowbray et al. (2002) concluded that the “efficiencies and cost-effectiveness touted by managed care proponents may be negated by current models” (p. 164). Thus, although there is evidence of cost-savings in at least publicly funded behavioral health care, along with reduced service provision, there is exceptionally little evidence for the quality and effectiveness of the services actually delivered. The challenges of developing an evidence base for such interventions, even after almost 30 years of implementation, are not unexpected given the many ambiguities in what is defined as behavioral mental health. Ongoing questions about the quality and outcomes of behavioral health services emerge in part from observations that the de facto behavioral health care system occurs within the general medical systems and does not usually involve providers trained as mental health professionals. Thus, there is often an overreliance by primary care providers on prescribing psychotropic medications, and the diversity of needed mental health services, whether psychotherapy, family therapy, day programs, or psychiatric rehabilitation, are rarely arranged (Warren, 2011). Discussion At the same time that the language of behavioral mental health is spreading, mainly with large publicly funded mental health programs, it is evident that the lack of agreement on its meaning contributes to confusion regarding the essential elements of this approach and its cohesiveness as a field of service. Concerns about the approach abound, but they are likewise varied, some of which reflect long-standing criticisms of the mental health field in general. For example, Sandler (2009) noted that the focus of behavioral health is on individual change, and that the approach minimizes work to change social and other environmental conditions, such as poverty, discrimination, and abuse, that place individuals at risk of behavioral disorders. Although the ideals of community mental health, pursued initially in the 1960s (see Caplan, 1961), were based on a holistic public health approach to address iatrogenic social conditions, the actual implementation of this ideal clearly fell short long before the advent of behavioral mental health. Others contend that the behavioral mental health nomenclature is actually a code for an intensified focus on the biological interpretation of mental illness as a brain disease or even a traditional medical model that relies on psychopharmacological treatments. This is in stark contrast to the original ideals of the field of behavioral medicine that emphasized an inclusive approach to mind–body issues (Taylor & Bentley, 2004). It is true that the last quarter century has seen an expansion in biological models of mental illness, given the many advances in neurological research made possible by new imagining technologies such as functional magnetic resonance imaging. But it is also clear that the impact of this expansion likewise goes beyond behavioral mental health, to encompass other areas of mental health and the human services. Consistent with the criticisms of behavioral mental health that involve the individual and the biological focus, others have noted that this field ignores both causes and the individual’s internal or subjective understanding, motivations, and decisions. For example, Sandler (2009) pointed out that within the field of suicide prevention it would be inappropriate to focus only on behaviors associated with suicidality, rather than the underlying causes of those behaviors. Consistent with behaviorally oriented treatments, the focus is on reducing or eliminating symptoms of disorders, rather than addressing the complex intermingling of biological and social conditions, with limited sense of individual agency that many clients experience. A related observation is that both mental health and behavioral health are used as consumerist euphemisms for mental illness and normative behavioral dysfunctions (Nidhi, 2016). Ideals of health and social functioning, along with a recognition of the strengths of clients, are obscured in the pressure to meet concrete, short-term treatment objectives. Frequent changes in terminology have often been made in response to the stigma associated with mental illness. New and less stigmatizing terms are sometimes adopted to minimize and normalize, but also as a marketing strategy to expand client demand for services. The many shifts in language and the resulting lack of definition of newer terms may be associated with a more fundamental criticism of behavioral mental health, namely, its lack of theoretical and practice integration. Many are currently arguing for a more inclusive biopsychosocial approach to social work practice, especially when comorbidities of serious mental illness, substance abuse, and physical illness are considered. However, the developments of intervention models that fulfill the ideals of service integration have been remarkably scant. The usual answers—care coordination, colocation of services, and the development of electronic medical records in the context of primary practice—have been promoted for many decades now, but with limited success. Associated with the well-known problem of lack of integration is that of poor communication among mental health professionals noted by Coleman et al. (2005). These problems—lack of definition, limited conceptual integration, poor communication, and the excessive individual and biological emphasis of much of behavioral mental health—can all be assumed to be implicated in the purported inconsistency in the implementation of behavioral mental health. Coleman et al. also pointed out that states can define eligibility and implement waiver programs for the Medicaid behavioral health programs in dramatically different ways. Despite the many actual and purported problems with the emerging interest in behavioral mental health, it clearly promotes some important ideals, though with little evidence of success. It attempts to reduce stigma by deemphasizing internal or mental states. In casting a broad net that encompasses some traditionally excluded populations, such as those with substance use disorders and developmental disabilities, it attempts to relieve problems of service access, in part through the push to restrict length of treatment and limit it to those conditions that qualify as medical necessities. It also attempts to address problems of service access through cost containment efforts that rely on a variety of managed care mechanisms. Most important is the emerging interest in service integration, in respect to the well-known prevalence of comorbid conditions such as mental illness, substance abuse, and physical ill health. Barriers to realizing these ideals include the continuing escalation of medical costs and limitations in the ability of the mental health professions to generate a sufficiently trained workforce, particularly in low-income areas. But perhaps more significant are several potential contradictions inherent in the behavioral mental health ideology. One is the conflict between the interest in taking a short-term pragmatic approach based on manifest behavioral dysfunctions, and the interest in a holistic and integrative approach that treats the whole person and intervenes in the community. Unless mental health practitioners are highly expert, this high bar potentially leads to unrealistic treatment goals and a tendency for assessment and diagnosis of the multiple comorbid conditions to minimize opportunities for treatment, a long-term problem that subscribers to the medical model have faced. In addition, efforts to limit service intensity will increase the pressure to refer (essentially, to pass) persistent, complicated, and expensive cases to other providers. Another core problem with the behavioral health ideology is that the focus on external behaviors is often at odds with work with clients on underlying dysfunctions in cognition and affect. The proliferating interest in CBTs represents a natural effort to bridge such divisions. However, any truly behavioral focus, especially that embodied in fields such as applied behavioral analysis, with its preoccupation with behavioral contingencies, rewards, incentives, and reinforcements, leaves out much that is important. Specifically, it short-shrifts underlying client motivations, beliefs, and attitudes, conscious or unconscious, based on assumptions that consciousness and self-determination are epiphenomenal and that motivation and agency are derivative and not primary in understanding behavioral dysfunction. If this is so—and it has not definitely been established whether that is the case—then the incompatibility of the behavioral and mental or cognitive dimensions in behavioral mental health would clearly support the possibility that the rubric of behavioral mental health is an oxymoron. And if this is the case, then the problems identified earlier, particularly the lack of practical approaches to service integration, can be understood as expressions of the conceptual challenges of bridging these separate dimensions. How might these concerns be addressed? One way is to support the recent trend to divest payers, particularly insurance companies, of the business of micromanaging the treatment decisions of mental health professionals, through such techniques as preauthorization, utilization review, and use of provider panels. Recent alternatives, such as accountable care organizations and PCMHs, delegate these responsibilities to providers while establishing global budgets and bundled payments to serve the need for cost containment, along with capitation rates adjusted to the level of risk (Bao et al., 2013). Another option is to support EBTs, but to adopt a more expansive approach that focuses on promoting the process of evidence-based decision making, rather than simply prescribing treatments with validated outcomes, often those that have been manualized (Hudson, 2009). Promoting a process-oriented conception of EBT entails training practitioners to actively evaluate relevant evidence as part of treatment planning rather than uncritically adopting treatments that are reputed to be empirically supported. Part of this revision of EBT involves an expanded view of what constitutes evidence, one that includes professional consensus and best practices, even if they are not always supported by randomized clinical trials (Hudson, 2009). Such an expansion should aim at striking a balance between a focus on quality processes consistent with social work values, with the achievement of demonstrable outcomes. A reconciliation is needed between process-oriented clinicians and the preoccupation with outcomes, but to achieve this, such plans need to be the basis for professional training, licensing, and accreditation. Current accreditation initiatives in behavioral mental health, particularly those embodied by the National Institute of Behavioral Health Quality and the American Board of Behavioral Healthcare Practice, which restrict them to doctoral-level psychiatrists and psychologists, are shortsighted and ignore the preponderance of master’s level clinicians, particularly social workers, in the field. Most important is the continued development and evaluation of intervention and treatment models and methods that operationalize the major approaches to service integration in particular service sectors, whether primary care or the specialty mental health sector. The professional literature abounds with rhetorical discussions of service integration, with few practical directions in this regard. Service models need to distinguish between the use of particular methods, such as CBT, dialectical behavior treatment, and the like, and establish guidelines for transition between and coordination with multiple methods, whether intensive case management, psychoeducation, case advocacy, income maintenance, supported housing, or supported employment. Such strategically oriented service models, whether some version of generalist social work practice such as the simultaneity (Jackson, Macy, & Day, 1984) or structural models (Wood & Middleman, 1989), will require the support of service agencies that transcend behavioral health boundaries. Thus, the continued expansion of the behavioral mental health field is a work in progress for which the jury is still out. 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Social WorkOxford University Press

Published: Jan 1, 2018

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