Mental, not behavioral, health care: Why it matters

A colleague of mine recently pointed out a study by the Center for Health Care Strategies (CHCS) about mental health care for children. Among their findings was this: Almost 50 percent of children enrolled in Medicaid who are prescribed psychotropic medications receive no identifiable behavioral health treatment.

This is a disturbing, though not surprising, statistic given that these medications are commonly prescribed by primary care clinicians. Children living in poverty often experience greater environmental stress and may have greater mental health care needs, and the study points to Medicaid as a possible source for improved, and presumably preventive, care:

Children with significant behavioral health needs typically require an array of services to support their physical, intellectual, and emotional well-being. These children, however, are often served through fragmented systems, leading to inefficient care, costly utilization, and poor health outcomes. As a significant source of funding for children’s behavioral health care, Medicaid programs can advance fundamental improvements in care coordination and delivery for these vulnerable children.

This would certainly be a goal to work towards.

However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to “behavioral health care” rather than “mental health care.” This change in language is now common in our culture. It is significant and worrisome for two reasons.

First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.

Recently I came up against this stigma when giving a talk that included a discussion of the connection between “colic” and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.

Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a “mental health problem” is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.

Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes “call a spade a spade,” without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.

The second, and perhaps more worrisome issue related to the substitution of “behavioral” for “mental” is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior. The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.

This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant.

For example, a recent long-term follow up study of children diagnosed with “ADHD” treated with “behavior management” and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.

The CHCS study calls for “expanding access to appropriate and effective behavioral health care.” For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.