Why I’ve Stopped Using the Term “Behavioral Health”

by Elizabeth Bowen, Ph.D.
Guest Author

 

A big part of being a social worker is critical thinking, including reflecting on the language we use to describe the people and issues with which social workers work.

 

Lately I’ve been thinking a lot about the term “behavioral health.” This term has grated on me for a while. The first problem I have is that I’m never sure exactly what it’s referring to.

Photo of white ceramic head with black grid over brain areas, labeled "individuality" "reasoning" et cetera
What is “behavioral health”?

 

 

 

Often behavioral health is used as a catch-all term for substance use and mental health-related issues.

 

 

 

 

 

Sometimes it seems to also encompass weight management, nutrition, and other efforts to promote a “healthy lifestyle.” Then there are conditions that are clearly linked to behaviors—sexually transmitted infections, for example—but that rarely seem to be included under the behavioral health umbrella.

 

This ambiguity aside, my bigger concern is that I think the term can be both misleading and stigmatizing. People who study behavioral science understand that behavior is complex and is influenced by a multitude of factors, from emotions to the environment. But in everyday use, behavior sounds like something a person should be able to readily control (how many times do we hear exasperated parents admonish their children to “just behave!”?).

 

My fear is that when we refer to mental health and substance use problems as behavioral health conditions, we may be implying that they are essentially voluntary, a matter primarily of will or self-control.

Letters on cubes like dice spell out "Bad" "Good"
It’s not just a matter of will power or self-control.

 

 

Separating substance and mental health-related conditions into their own category of behavioral health may perpetuate a sense of false dichotomy between these issues and other chronic health problems.

 

 

 

 

 

 

 

In the class that I’m teaching this semester on alcohol and other drug problems, we recently read McLellan and colleagues’ (2000) widely cited article conceptualizing drug dependence as a chronic medical condition. The authors point out that addiction has much in common with chronic conditions such as diabetes and hypertension, in that all are influenced by a range of genetic and environmental factors as well as by personal choice.

 

Treatment adherence rates are also similar across these conditions and relapse is more the rule than the exception—yet only with addictions (and I believe often with many mental health conditions as well) is relapse seen broadly as a personal failure, instead of a testament to the need for long-term support and care.

 

My final concern is that the term “behavioral health” implies a focus on behavioral interventions, typically meaning some type of individual or group counseling, often along with medication. These interventions are important in treating many conditions, but I think we need to also think bigger.

View of snowy mountain peaks with words THINK BIG in sky overhead

 

Let’s talk about strengthening families to prevent abuse, neglect, and other types of trauma that can contribute to developing a variety of problems and conditions later in life, as the ACES research shows us.

 

Let’s work on revitalizing neighborhoods to promote health and well-being at the community level, including creating opportunities for people to build relationships that foster social capital and recovery capital (those personal, social and community resources used to sustain recovery from addictions) .

 

And let’s take a critical look at transforming policies that currently stand as barriers to health and recovery—particularly the many laws that frame substance use and addiction as a criminal issue rather than a public health one and have been discriminately applied to communities of color, to devastating effect.

 

So if behavioral health is out, what new term is in? In this case I’m not sure we need a new pseudo-category. If we want to talk about mental health and substance use problems, we should just say exactly that. And if we want to refer to all conditions for which behavior is relevant, in terms of cause, progression, treatment, or management…well, I think that could include almost every known health condition.

 

I would rather see social work and our peers in other fields think about and promote health more holistically, recognizing the many factors—genetic, cognitive, behavioral, family, neighborhood, and policy-level—that contribute to our well-being.


Do we still need a term for behavioral health?  If so, what might some alternatives be?
Send us your ideas!

Photo of Elizabeth Bowen, professor. She is a young European American woman.
Elizabeth Bowen, Ph.D. 

 

Elizabeth Bowen is an Assistant Professor in the University at Buffalo School of Social Work.

Her research interests include homelessness, HIV/AIDS and addiction as intersecting epidemics; place-based health disparities; and social determinants of health and risk behaviors.

 

 

 

 

Recent publications:

Bowen, E. A. (in press). Community practice in the bulldozer’s shadow: The history and legacy of social work in urban renewal. Journal of Community Practice.

Bowen, E. A., & Walton, Q. (in press). Disparities and the social determinants of mental health and addictions: Opportunities for a multifaceted social work response. Health & Social Work.

Bowen, E. A. (2013). AIDS at 30: Implications for social work education. Journal of Social Work Education, 49, 265-276.

Bowen, E. A., Mattaini, M. A., & De Groote, S. (2013). Open access for social work research and practice. Journal of the Society for Social Work and Research, 4(1), 31-46.

 

References

Drug Policy Alliance. (2014). Race and the drug war. Retrieved from http://www.drugpolicy.org/race-and-drug-war

McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness. Journal of the American Medical Association, 284(13), 1689-1695.

White, W. L., & Cloud. W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27. (pdf download)


26 comments

  • Dr. Bowen – you make a very good case for eliminating the term ‘behavioral health’. I am glad that I am not the only one who isn’t sure what exactly the term is supposed to refer to, or how it is different from mental health and substance use.

    You focused your argument on the ‘behavioral’ side of the term, but I think it can be expanded to include a greater focus on the ‘health’ side as well. We often talk about health as though we know what it is. Fresh vegetables are healthy, salt fries with ketchup is not. But, as you say about behavior, there is a host of diverse factors that contribute to health, and the biochemical/physiological effects of certain foods is only one component. Are fries good for my health? Well, if you only look at the amount of fat in them, then probably not. But much depends on how the fries are made, how large a portion I eat, and how often I eat them.

    In addition, I typically only eat them when I am out socializing with friends. Can we measure the health benefits of quality time with loved ones against the physiological costs of the fries? What about the psychological benefits that come with eating a favorite food – there is, after all, a reason why we call certain things “comfort food”. Can we even compare these values, or are they incommensurable?

    I think that you point to some very important considerations regarding the ambiguity and problems with the term “behavioral health”. Perhaps social workers can continue this discussion and expand it to include the ambiguity which lies at the heart of the idea of “health” in all of its forms – biomedical, mental, social, as well as behavioral.

    Thanks for sharing your thoughts!

    • Thanks for your thoughtful comments! I like your analogy about the French fries. It conveys that determining what is “healthy” is really about the context–but so often that gets lost or largely left our of research, policy, and practice interventions. I hope we can continue to have an ongoing conversation as social workers about both the “health” and the “behavioral” sides of the equation and the challenges of finding an inclusive language–thank you for weighing in!

  • Very thoughtful post, thank you. I haven’t been thrilled with the term, either, and I think you’ve nailed what has been bothering me.

    • Thank you, Nancy. I realize this term is probably not going away any time soon, since it is commonly used by funders and in many practice settings. But I hope we can at least give it some critical thought as a field.

  • Language is crucial, both for discussing problems and navigating possible solutions. Finding appropriate, non-stigmatizing ways of speaking to life’s challenges is a lot of what therapy is about. Your critique of the increasingly distancing terminology in mental health is most useful. Thank you.

    • Thank you, Michael. That’s a great point that finding empowering and non-stigmatizing ways to verbalize one’s experiences is often a key focus of therapy. Finding the right words seems to be a constant and challenging process, both for individuals and for social work (and other disciplines) as a field. Thanks for adding your thoughts to the conversation!

  • I am glad to see a post on this subject. I’ve often wondered what other terms to use when referencing this in my work. I’ve tried to use the terms “mental health” or “emotional health”, but that still feels like it doesn’t quite cut it. I’ve always felt that using such simple terms to describe such a vast and varied experience has been insensitive, as well as put blame on the person who is experiencing this. It’s strange because you can ask someone what diseases they might be struggling with physically and it implies no shame, but it seems as though that leeway does not exist when it comes to emotional struggles.

    I’m still not sure what the answer is but it’s definitely something I continue to think about.

    • Thanks for your comments, Sarah. I think you hit on exactly why this is so difficult–the challenge of trying to sum up vast experiences with simple and non-stigmatizing language. I don’t know what the answer is either but I’m glad that we’re having the discussion.

    • Thanks for sharing your thoughts and these great references and resources! It is difficult to think off hand of a brief term that could reflect the tenets of trauma-informed practice, but I do hope our language will move in that direction. I also agree that the name of an organization can carry so much meaning, and this needs to be treated with great consideration and care.

  • Thank you for your thought provoking article. My take is that the term Behavioral Health was developed to facilitate billing and diagnoses in this era of solution- focused treatment. The purpose was to try to simplify treatment through measurable outcomes, totally ignoring the relationship development stage along with the psycho/social/environmental/ and physical componants. The basic tenets of social work! To address the issue of labels I always identify myself as a social worker and when pressed for clarification I go into my social work spiel!

    • Thanks for sharing your comments and experience, Sylvia. The term “behavioral health” does seem to fit with a medical model of providing services, unfortunately often to the neglect of the other developmental, psychosocial, and environmental factors that you mention. I’d like to hear more about your “spiel”–I think many of us have them!

  • Dr. Bowen, I enjoyed reading this post. I, to, have been bothered for some time by this phrase, as well as other terms such as “mental hygiene”. I work as a therapist; my organization changed their public name to a department of “behavioral health” after having “mental hygiene” for a number of years. The change was an effort to make our name more open, respectful, and less stigmatizing. I could not put my finger on what has been bothering me, but you hit the nail on the head. Reading your post also made me think about how a name can be trauma informed or not. A name/label conveys so much information. Can safety, trust, collaboration, empowerment, voice/choice, support, resilience, strength, inclusiveness, and cultural competence be conveyed with the right label (Harris & Fallot, 2001; (“Trauma informed,” 2014)? It seems that use of trauma informed language may do well to create a name such as a department of emotional and behavioral wellness and recovery. After all, healing occurs best in the context of a good relationship (Szalavitz & Perry, 2010; Bloom, 2013). The name of an organization in the community both with physical name, appearance, and reputation begins the possibility of a relationship not only with the community, but with each individual who is touched by the organizations. It will be great to hear language that conveys trauma informed principles that may work to instill more hope and identifying strengths rather than labeling the deficits that we are all working to overcome (Harris & Fallot, 2001)

    References
    Bloom, S. L. (2013). Creating Sanctuary: Toward the evolution of sane societies (revised edition ed.). New York, NY: Routledge.
    Harris, M., & Fallot, R. D. (2001). Using Trauma Theory to Design Service Systems. San Fransisco, CA: John Wiley & Sons.
    Szalavitz, M., & Perry, PhD, B. (2010). Born for Love: Why empathy is essential-and endangered. New York, New York: Harpers Publishers.
    What are the Key Principles of a Trauma-informed Care Organization?
    . (2014). Retrieved from http://www.voamn.org/Branded-Email-Headers/TIC-Article-June-2013.pdf

    • Thanks for sharing your thoughts and these great references and resources! It is difficult to think off hand of a brief term that could reflect the tenets of trauma-informed practice, but I do hope our language will move in that direction. I also agree that the name of an organization can carry so much meaning, and this needs to be treated with great consideration and care.

  • Dr. Bowen, I hold a great admiration for this post because I agree with many of the points you make. The language we use to describe people and their health conditions -whether that be mental, physical, behavioral, and/or emotional desperately calls for change. Behavioral health, in my opinion, really has no true constraints in definition, and therefore should not be limited to describing specific conditions. As a matter of fact, I believe that all aspects of health can have an overlapping effect on the other. Unfortunately, you’re right in that individuals suffering from substance abuse/mental conditions are stigmatized. Society does not fully understand the human mind and it’s functions, and therefore it seems that we want to place blame upon people who suffer from these issues -simply because we cannot solve them or give a definite explanation for them! There is so many attributing factors as you mentioned that make problems lying under “behavioral health” involuntary, yet people completely disregard them! Who really asks to be sick or incompetent in any area of life anyways? The spectrum of experiences that people have in addition to biological factors DIRECTLY influence their health, and it is hard to comprehend the idea that these factors go to great depths -especially if you are not in the same position. This is a great topic for debate, and I feel that it is something that should be addressed. It is also not fair in my opinion that resources for such “behavioral health” issues such as alcoholism and other substance abuse or mental diagnoses are so limited due to lack of funding/support.

    • Thank you for your comments, Andrea! I think it’s interesting that our society seems to often over-emphasize the role of behavior in conditions like mental health issues and addiction while under-emphasizing the importance of behavior in many physical health conditions. Perhaps that’s part of the reason why mental health problems and addictions remain so stigmatized. And thanks for pointing out the relative lack of resources for mental health and substance abuse treatment and prevention–might this be linked to stigma as well?

  • Very interesting. I often hear the term “behavioral health” but never knew quite what it was referring to either. When considering the definitions of emotional health, physical health, etc., I guess my educated guess was that its a term that describes the connection between a person’s behaviors and the well being of their mind, body and spirit. I think its important to note that behavioral health was originally used in the 70’s and 80’s to refer to behaviors that prevent illness or that promote health such as a lifestyle change to control diabetes. Now, it encompasses mental health as well. I believe this is because many mental health conditions develop largely from biological factors such as brain chemistry or one’s genetic make up. All in all, to me behavioral health is all about the behaviors that impact health.

    • Thanks for your comments and for sharing this historical perspective, Jamie. There are certainly a lot of behaviors (exercise and various ways of socializing, for example) that affect one’s physical as well as mental health, and it may be useful to have a term to refer to these. When “behavioral health” becomes used as shorthand for mental health conditions and addictions, I think it obscures this more holistic perspective. Thanks for reminding me of this!

  • Very interesting article and I am pleased to see one on this topic. I especially concur with your thoughts on substance abuse and do not believe that these abuse diagnosis’s should be considered a lack of self control.

    • Thanks for sharing, Sarah. I agree that the mis-perception that substance abuse is mainly about a lack of willpower or self-control leads to a great deal of stigma and misunderstanding about addiction. And unfortunately that stigma seems to often prevent people from getting the help they need.

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  • Dr. Bowen, I found your ideas and thoughts very interesting. I currently work at a doctor’s office where counseling is offered and it’s called Behavioral Health counseling. I’ve always wondered about a better use of terminology, but I haven’t been able to think of a better one yet. However, your point about how people make statement such as, “you better behave!,” which indicates that the individual has control over their behaviors. Which is why I agree with your views about how Behavioral Health shouldn’t be used because most of the people we are working with have a hard time controlling their behaviors, which is why they are coming to us for assistance. I think that our selection of phrases and terms are a huge factor when working with vulnerable populations. The names of our services should sound inviting to our clients and not make them feel more stigmatized than they already are. I’m glad you talked about this and hopefully we can all work together to find that appropriate phrase that gives clients more incentive to seek the help they need.

    • Thanks for sharing your insightful comments, Melissa. I don’t have a perfect solution either for what terminology we should use instead, but I agree it’s important that we think critically about how the language we use affects the populations we serve, and try to be thoughtful about this. Thanks for contributing to the conversation, which I hope will continue!

  • Great article Melissa. I think the terminology is somewhat cyclical and can vary greatly depending on where you work and live.

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