Why we don’t use the term “behavioral health”

From the board of the Mental Health Association of Portland

Recently the SAMHSA has begun requiring grantees to use the term behavioral health for a bucket of illnesses and disorders. It’s an inaccurate term which diminishes black-letter science-based public health decisions going back fifty years. 

The term appeared first in 1992 in the New York Times when Travelers Insurance Company spun off a managed health care operation as US Behavioral Health. By the late nineties the term was in common use with commercial insurers. It inveigled public healthcare in the 2000s, carried by commercial insurance executives migrating into the public sectors for job security, and is now firmly couched in government lexicons and embedded in equity statements affirming a big tent orientation toward all things.  

But the term behavioral health carries a set of subtexts and qualities which you may not be aware of, and which injure the credibility and obscure the operations of treatment for mental illnesses and for addictions, thereby injuring people who have those illnesses, their friends and their families. 

Let’s first look at the word behavior, this definition from Merriam Webster.  

  1. the way in which someone conducts oneself or behaves (see BEHAVE sense 1)
    1. We were grateful for the gracious behavior of our hostess.
    2. The children were rewarded for good behavior.
    3. Be on your best behavior.
      1. also : an instance of such behavior or unacceptable social behaviors
  2. the manner of conducting (see CONDUCT entry 1 sense 2) oneself
    1. criminal behavior
    2. normal adolescent behavior
  3. anything that an organism does involving action and response to stimulation
  4. the response of an individual, group, or species to its environment
    1. They are studying the behavior of elephants in the wild.
    2. the way in which something functions or operates
    3. They tested the behavior of various metals under heat and pressure.

So the term is outside of a dictionary definition. 

In 1956 the American Medical Association declared addiction to alcohol and other drugs to be a disease and not a behavior. This is the basis for Federal and state laws requiring commercial insurers to pay for necessary medical treatment for alcoholism and addiction. Treatment of disease is covered by health insurance. Behavior, as defined above, is not.

Mental illnesses, alcoholism and addiction are not behaviors in any respect. They are for medically diagnosable and treatable illnesses. To describe them as behaviors or otherwise is intentionally misleading and ascribes a moral judgement of those who have those illnesses. It is patronizing. It belittles the clinical professions. It confuses the media. It fuels ignorance and skepticism and fear.

A disease is not misconduct, and not something changed by amending behavior. In fact the definition of an addict or alcoholic, as separate from a recreational user, is they generally cannot stop using without medical treatment and a sustained program of recovery. 

The term demeans and diminishes the experience of millions of people who struggle with their illnesses, to get effective and sufficient help from providers, including both commercial and public insurance agencies, and with the stigma and discrimination associated with the illnesses, perpetrated by profitable and diverse corporations such as the entertainment industry, in the adult beverage industry, and governments.

The term “behavioral health” implies a focus on behavioral interventions, typically meaning some type of individual or group counseling. Sometimes these interventions are important in treating many conditions, but they are neither necessary or sufficient solutions. 

The term is used for the convenience of marketing insured services, to lump together a diagnosis-related group in a shorter set of words. It is corporate-centered language, not person-centered language. Insurance marketers wanted to use fewer words than, “alcoholism, addiction, and mental illness”, to fit into their advertisements and brochures. The term is a separate nomenclature, a two-step textual distancing. There are the things themselves, the actual various illnesses, then the words for the things – such as depression or schizophrenia, then a new manufactured term for a set of words for the things.  

Mental illness has its own distinct culture, language, history, medical treatments, challenges and science. The same can be said for both addiction and for alcoholism, which are themselves equally distinct and culturally robust. These are not simply diagnosis treated by physicians, but multisystemic, intergenerational illnesses which have affected the course of world history, and require a complex highly individualized response. They are not the same things nor should they be described in the same way. 

It’s not uncommon for people to be affected by both mental illness and by addiction, or by alcoholism, or even both addiction and alcoholism. The proper terminology here is “dual diagnosis,” or using person-centered language, “persons who are dually diagnosed.” 

So what words should be used? We suggest using addiction for addiction, alcoholism for alcoholism, mental illness for mental illness, trauma for trauma. These are solid, well-defined words which mean what they mean and have no commercial agenda. 

In personal use, we suggest adopting the person-oriented language used by the identified patient or client. If a patient or client says, “I’m an alcoholic,” don’t describe them in a verbal response or in written notes as a person with a behavioral health condition. (And please don’t use “condition” to describe an illness.) 

Words have meanings and those meanings are always political.