Differing views of ‘behavioral health’

I enjoyed Dr. Nasrallah’s editorial regarding “behavioral health.” In New England, we have very clear delineation among psychiatry, mental health, and behavioral health. Only physicians can practice psychiatry because it is a medical specialty. Nurse practitioners and psychologists, on the other hand, are specialists in the field of mental health, as are psychiatrists, so mental health is a more encompassing term. Behavioral health encompasses all of the above plus counselors. Because insurers generally pay counselors, nurse practitioners, and psychiatrists, they use the term behavioral health because it wouldn’t be right for them to pay a counselor for a psychiatric intervention. So as a psychiatrist, I respond when being referred to as a psychiatrist, mental health specialist, or behavioral health specialist. And thankfully, per American Medical Association policy, psychiatrists are not providers.

Stu Gitlow, MD, MPH
Executive Director
Annenberg Physician Training Program in Addictive Disease
Woonsocket, Rhode Island

I was grateful for Dr. Nasrallah’s editorial regarding the misnomer of referring to psychiatry as “behavioral health.” Until this editorial, I had wondered if I was the only one bothered by the term. Many people are under the assumption that behavioral health is a politically correct term that helps to lessen stigmatism. I completely disagree. Without question, it adds to the stigmatism. The term behavioral health is belittling to our patients. For example, calling a psychiatric inpatient unit a “behavioral health unit” implies that if patients would just change their behaviors, they wouldn’t have serious biological psychiatric illness. It insinuates that the patients cause and perpetuate their illnesses, such as schizophrenia or bipolar disorder, by behaving poorly. Granted, we teach behavior modification to help manage psychiatric illness, but so, too, do our colleagues in other medical fields teach behavior modification to manage other organ-related illnesses. Some nearly ubiquitous examples include doctors advising patients to lower stress, modify diet, exercise, and take medications as prescribed. Yet, for example, in the case of a patient with diabetes, we don’t refer to diabetic ketoacidosis treatment as behavioral health treatment, though the patient’s behavior no doubt contributes to this condition. And we certainly would never call the ICU or stepdown unit the “behavioral health unit,” even though adequate holistic treatment in these settings includes counseling the patient with diabetes on changing his/her behaviors that led to the ketoacidosis. Just as in diabetes, the underlying basis of psychiatric illness is biologic processes gone awry. First and foremost, a psychiatric medical illness requires complicated and often precarious medications to treat. As in other medical specialties, modifying behavior does not treat the illness, but merely serves to help transmute the course.

In sum, I wholly agree with Dr. Nasrallah’s eloquent assessment regarding the problems with the title behavioral health in lieu of psychiatry. I also might have taken the discussion a step a further: Because psychiatric illness affects every aspect of a person’s life—such as work, social, and personal—it requires a terminology commensurate with the medical gravity it warrants. So in addition to not referring to the specialty as behavioral health, I have wondered if the name psychiatry could be replaced with a more medical-sounding term such as “cerebrology” or something of the sort. But one step at time.

Stacie Lauro, MD, ABPN
Attending in Psychiatry, Emergency Room, and Consultation Liaison
Mindcare Solutions
Tampa, Florida

The evolution within our field of the use of “behavioral health” has disturbed me to the same extent it has for Dr. Nasrallah. I founded and direct a psychiatric treatment facility in Florida. We are a teaching facility affiliated with 3 psychiatric residencies, 8 medical schools, and 60 physician assistant (PA) schools. In all of the literature (eg, evaluations) from the PA schools, they refer to their rotation with my program as “behavioral health.” I have been attempting to correct them for years! I teach all residents and students to correctly use the terms “psychiatry” and “psychiatric.” I understand there may be stigma associated with the latter terms, but the field reinforces that stigma by avoiding the use of these terms.

Robert A. Moran, MD, FAPA, FASAM
CEO and Medical Director, Family Center for Recovery
Lantana, Florida

Continue to: Pre-authorization and 'hold harmless' clauses