Understanding the Issues Regarding Misuse of the Term "Behavioral Health"

by Anne Donahue

IBH-PC Stakeholder Advisory Group

What is the accurate definition of “behavioral health”?

“The chronic diseases that drive the majority of mortality, morbidity and cost in America and around the globe are largely behavioral in origin or management. Tobacco, diet, physical inactivity, alcohol, substance abuse, non-adherence to treatment, insomnia, anxiety, depression, and stress are major causes of morbidity, mortality and expense, especially when chronic medical problems such as heart disease, lung disease, diabetes, or kidney disease are also present. Behavioral problems can often be effectively managed with improved outcomes for patients, their families and the health care system, but the current health care system is often unable to provide such care. Behavioral health includes mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors.” (From the study protocol for Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems)

In other words, “behavioral health care” is about health behavior, whether in relation to medical or psychological issues that are barriers to health. Behavioral health care that addresses change in behavior includes examples such as motivation to quit smoking, to exercise, to follow a diet, or to follow physical therapy routines; learning new ways to respond to stress; or addressing how to cope with past trauma. 

• Mental health and substance abuse conditions are often addressed through health behavior change, and thus many MH/SA conditions come within behavioral health care, just as many other health conditions do. 
• On the other hand, many mental health and substance abuse conditions have significant medical components and some may be mostly medical in nature, just as many other health conditions are mostly medical in nature. 

Thus behavioral health is an umbrella that includes MH/SA, but is not only MH/SA. The opposite is also true: biological and genetic health factors are an umbrella that also include MH/SA. If we recognized all of health as a holistic spectrum, we would recognize that most illnesses have biopsychosocial components, and treatment needs to align with each of those aspects, in relationship to the role each is playing in the specific person’s condition. It’s not an all or none, in any category. 

What are the problems when the terms behavioral health is (mis)used as synonymous with or as an alternative term for MH/SA?  

• Inaccuracy: The problem is not with recognizing the benefits of behavioral intervention for MH/SA; it is about failing to recognize the need for behavioral intervention for a person with heart disease. Likewise, both MH and heart disease may benefit from pharmacological or other medical interventions. In the one, if we focus only on treating the behavior we may miss an underlying illness; in the other, if we fail to address behavioral health, we might preclude medical recovery. It is a barrier to understanding the inter-relationship between behavior and all of health, and thus a barrier to fully integrated, holistic health care.
• Stigma: It is stigmatizing and hurtful to people with MH/SA conditions because the message is that the cause of the condition is a behavior (e.g., you drink too much; you are lazy; you are weak; thus you are to blame) OR that it is being called “behavioral” because the symptoms take the form of behavior that you are failing to control (e.g., you act out; you are violent; in other words, you are the problem.) It exacerbates the false separation between “mental” and “physical” health by re-categorizing them into “behavioral-fault” and “medical-not-your-fault.” 

It is a product of the inherent marginalization of persons within a stigmatized minority that the plea to avoid this hurtful language is so broadly ignored. 

Why is addressing stigma so important? 

The consequence of this historic stigma and discrimination in public attitudes is loss of successful health intervention, because:

1. It diminishes the perceived importance of access to MH/SA health care (parity)
2. It remains the single largest barrier to people seeking and accepting care

As long as people believe that if they seek help or acknowledge having an emotional crisis, they will be labelled and stigmatized in this way, we will face deep challenges in supporting individuals with these health conditions.